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Esophageal Stripping Creates a Clear Operative Field for Lymph-Node Dissection Along the Left Recurrent Laryngeal Nerve in Prone Video-Assisted Thoracoscopic Surgery of Esophagus(VATS-E)
Hiroshi Makino*1,2, Hiroshi Yoshida1, Tsutomu Nomura2, Takeshi Matsutani2, Nobutoshi Hagiwara2, Tadashi Yokoyama1, Atsushi Hirakata1, Masao Miyashita2, Eiji Uchida2
1Surgery, Nippon Medical School, Tama-Nagayama Hospital, Tokyo, Japan; 2Gastro-Enterological Surgery, Nippon Medical School, Tokyo, Japan
Introduction
Video assisted thoracoscopic surgery of the esophagus (VATS-E) in prone position is remarkable in Japan because the lung moves below by the gravity, and a good operative field is obtained. A clear operative view of the middle and lower mediastinum has been obtained; however, the working space in the upper mediastinum is limited.
Patients
Twenty patients in left lateral position and 17 patients in prone position, with esophageal squamous cell carcinomas underwent VATS-E since 2005 and 2009, respectively.
Methods
At first the patients are fixed at semi-prone position because both prone and left lateral positions can be set by rotating. Three 5 mm ports and two 10 mm ports are used at the 3rd, 7th, 9th and 5 th, 9th intercostal space (ICS). The pneumothorax by maintaining CO2 insufflation pressure of 6 mmHg is made, and esophagectomy is performed in prone position. In the case of emergent thoracotomy the patient will be rotated to the left lateral position. The lymph nodes around the trachea and bronchus, above the diaphragm and along the bilateral recurrent laryngeal nerves are dissected. Working space at the left upper mediastinal area for lymph nodes dissection around recurrent laryngeal nerve is limited in prone position. To obtain the space the residual esophagus is stripped in the reverse direction and retracted toward the neck after the stomach tube is removed through the nose.
Results
1. Mean estimated blood loss was 166 ml of chest procedure in prone position. 2. The rate of recurrent laryngeal nerve paralysis was 11.7% (2/17), and anastomotic leak and postoperative pneumonia was 5.8%(1/17), respectively. 3. There was no incidence of conversion to open method. 4. Lymphadenectomy along the left recurrent laryngeal nerve after esophageal stripping is available in prone position of VATS-E.
Conclusion
Our result indicates that esophageal stripping in prone VATS-E allows for safe and straight forward lymph node dissection along the left recurrent laryngeal nerve. Our technique overcame the difficulty of the lymph node dissection along the left recurrent laryngeal nerve in prone position.
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