Fujiwara Hitoshi, Shiozaki Atsushi, Konishi Hirotaka, Otsuji Eigo
Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan.
J Vis Surg. 2016 Jul 26;2:125. doi: 10.21037/jovs.2016.07.08. eCollection 2016.
Mediastinoscope-assisted transhiatal esophagectomy (MATHE) is a minimally invasive option for thoracic esophageal cancer with the potential benefit of decreasing pulmonary complications by avoiding one-lung ventilation or a transthoracic procedure. However, the conventional MATHE procedure is less radical than transthoracic esophagectomy due to operative view limitations and insufficient mediastinal lymphadenectomy. In upper mediastinal dissection, the conventional MATHE procedure only provides esophageal mobilization with or without lymph node sampling. We developed a novel MATHE procedure with en bloc mediastinal lymphadenectomy by introducing a single-port laparoscopic technique.
The patient was placed in a supine position with bilateral lung ventilation. The upper mediastinal dissection, using a left cervical approach, was performed with a single-port mediastinoscopic technique. A laparoscope was used as a 'mediastinoscope'. The lymph nodes along the right recurrent laryngeal nerve (RLN) were dissected under direct vision using a right cervical approach. Bilateral cervical approaches were followed by hand-assisted laparoscopic transhiatal esophagectomy.
A single-port technique provides a favorable expansion of the mediastinal space by carbon dioxide insufflation, and improves the visibility and handling in the deep mediastinum around the aortic arch, allowing for en bloc lymphadenectomy in the upper mediastinum including the subaortic arch lymph nodes. In addition, a hand-assisted laparoscopic transhiatal procedure allows for en bloc lymphadenectomy in the middle and lower mediastinum including the subcarinal and bilateral main bronchial lymph nodes. Cervical and transhiatal procedures were performed safely and carefully under video-assisted magnified vision according to the standardized procedure with an appropriate operative field expansion using retractors.
Single-port MATHE is feasible as a novel minimally invasive surgery for esophageal squamous cell carcinoma (ESCC) or thoracic esophageal cancer.
纵隔镜辅助经裂孔食管切除术（MATHE）是治疗胸段食管癌的一种微创术式，具有避免单肺通气或开胸手术从而降低肺部并发症的潜在优势。然而，由于手术视野受限和纵隔淋巴结清扫不充分，传统的MATHE手术不如开胸食管切除术彻底。在上纵隔清扫中，传统的MATHE手术仅能在有或没有淋巴结采样的情况下游离食管。我们通过引入单孔腹腔镜技术开发了一种新型的MATHE手术，可进行纵隔淋巴结整块切除。
患者取仰卧位，双侧肺通气。采用左颈入路，运用单孔纵隔镜技术进行上纵隔清扫。将腹腔镜用作“纵隔镜”。通过右颈入路在直视下清扫右喉返神经（RLN）周围的淋巴结。双侧颈入路后，进行手辅助腹腔镜经裂孔食管切除术。
单孔技术通过二氧化碳气腹可良好地扩展纵隔空间，并改善主动脉弓周围深纵隔的视野和操作，从而能够对上纵隔包括主动脉弓下淋巴结进行淋巴结整块切除。此外手辅助腹腔镜经裂孔手术能够对中纵隔和下纵隔包括隆突下和双侧主支气管淋巴结进行淋巴结整块切除。根据标准化操作流程，在视频辅助放大视野下，使用牵开器适当扩大手术视野，安全、细致地完成颈部和经裂孔手术。
单孔MATHE作为一种新型的微创食管癌手术，对食管鳞状细胞癌（ESCC）或胸段食管癌是可行的。
