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Page 2 of 9 Shiozaki et al. Mini-invasive Surg 2020;4:50 I http://dx.doi.org/10.20517/2574-1225.2020.31

Keywords: Transmediastinal radical esophagectomy, laparoscopic transhiatal approach, pitfall

INTRODUCTION
Transthoracic esophagectomy with mediastinal lymphadenectomy has been the standard procedure for
[1,2]
esophageal squamous cell carcinoma . However, esophagectomy via right thoracotomy is highly invasive,
[4]
[3]
and respiratory morbidity is still one of the most common complications . Since Orringer and Sloan
reported the clinical application of transhiatal esophagectomy, it has been broadly performed because it
prevents respiratory complications. Although laparoscopic transhiatal esophagectomy, initially described
[5]
[5-7]
by DePaula et al. , has also been performed , a technique for mediastinal lymphadenectomy had not yet
been established because of the limited surgical view and difficulties associated with surgical procedures.
We began performing esophagectomy using the laparoscopic transhiatal approach for esophageal cancer in
2009 to reduce the duration of one-lung ventilation, and, to date, more than 400 patients have undergone
our method during various esophageal surgical procedures [8-11] . We noted the advantages of this approach,
and developed a novel technique for lower mediastinal lymph node dissection [8,10] . By applying the same
concept to middle mediastinum, we developed a new procedure for subcarinal lymph node dissection
using the laparoscopic transhiatal approach [12,13] . We also started using the single-port mediastinoscopic
cervical approach in 2014, and developed a simple technique for transmediastinal radical esophagectomy
without a thoracic approach (more than 200 patients) [14-17] .

We herein describe our surgical procedures for en bloc resection of the middle and lower mediastinal
lymph nodes by the laparoscopic transhiatal approach, with a focus on pitfalls for safe surgery.

SURGICAL PROCEDURES AND PITFALLS
Position, port placement, and devices
Patients were placed in the supine position, and we initially performed cervical and upper mediastinal
lymphadenectomy using the left cervical single port technique [14-16] . We recently performed middle
mediastinal lymph node dissection via the cervical approach. Abdominal surgery was conducted using
hand-assisted laparoscopic surgery (HALS), followed by lower mediastinal surgeries using the laparoscopic
transhiatal approach. In cases in which middle mediastinal lymph node dissection was difficult to perform
via the cervical approach, the laparoscopic transhiatal approach was employed.

We made an incision (70 mm) in the upper abdomen and inserted a lap disc (regular) (Ethicon, Cincinnati,
[11]
OH, USA) . We introduced three 12-mm ports (right side of the umbilicus, left hypochondrium, and left
flank), and one 5-mm port (left side of the umbilicus) for a flexible laparoscope . The surgeon stayed at
[11]
the patient’s right side, and the 12-mm port in the right side of the umbilicus was chiefly used for surgery.
The assistant stayed on the left side, and two long retractors were inserted and used from ports in the left
[11]
abdomen (UMIHIRA Co., Ltd., Japan). The scopist remained at the patient’s groin [Figure 1] .
Approach to the esophageal hiatus
Carbon dioxide was introduced into the abdominal space, and pneumoperitoneal pressure was held
at 10 mmHg [8-12] . We opened the esophageal hiatus, and carbon dioxide was introduced into the
mediastinum. The use of long sealing devices is important for the laparoscopic transhiatal approach.
The surgical view in the mediastinum was maintained by the surgeon’s left hand, two long retractors,
and pneumomediastinal pressure . The bilateral mediastinal pleura were preserved as much as possible
[11]
because pneumomediastinal pressure is essential for securing a narrow mediastinal surgical space.