Published in:
01-04-2017 | Original Article
Hand-assisted technique beneficial for laparoscopic transhiatal esophagectomy with en-bloc dissection of middle and lower mediastinal lymph nodes: roles of the operator’s left hand
Published in: Esophagus | Issue 2/2017
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Background
Hand-assisted laparoscopic surgery (HALS) is safe and useful in the management of gastric conduit reconstruction. By applying the HALS technique to mediastinal surgeries, we developed a novel technique for the en-bloc dissection of the middle and lower (M&L) mediastinal lymph nodes (LNs) using a laparoscopic transhiatal approach (LTHA). We describe our technique, with a focus on the roles of the operator’s left hand.
Methods
In our procedure, the operator’s hand has several important roles, such as retraction, maintenance of the route for the laparoscope, and grasping the shaft of the energy device to stabilize operability. After the esophageal hiatus was opened, the pericardium was exposed. The posterior plane of the pericardium was extended, and the anterior side of the subcarinal, main bronchial, thoracic paraaortic, and pulmonary ligament LNs was separated. The posterior side of these LNs was then separated. While lifting these LNs like a membrane, they were resected from the bilateral mediastinal pleura, main bronchi, and tracheal bifurcation. The treatment outcomes of 84 patients with esophageal cancer who underwent M&L mediastinal LN dissection by LTHA were compared with those of 75 patients who underwent their dissection by right thoracotomy.
Results
The total operative time and bleeding were significantly decreased by LTHA. The number of resected M&L mediastinal LNs in the two groups was not significantly different. Postoperative respiratory complications occurred in 14.3 % of patients treated with LTHA and 25.3 % of those treated without it.
Conclusions
In our surgical procedure, a specific technique of the operator’s left hand was essential and resulted in a good surgical view of the mediastinum, and en-bloc dissection of M&L mediastinal LNs was performed safely.