Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
Department of Gastroenterological Surgery, Hyogo Medical University, 1-1 Mukogawa-cho, Nishinomiya, Hyogo, 663-8501, Japan.
Surg Oncol. 2022 Aug;43:101793. doi: 10.1016/j.suronc.2022.101793. Epub 2022 Jun 16.
Due to the limited number of landmark structures, it is difficult to standardize the surgical procedures for advanced esophagogastric junction cancer such as Ivor Lewis esophagectomy that require transhiatal lower mediastinal lymph node dissection (TH-LMND). We demonstrate an easily reproducible procedure for TH-LMND, wherein four body cavities, namely, the abdominal cavity, infracardiac bursa (ICB), and left and right thoracic cavities are interconnected.
First, the dissection between the right crus and the esophagus was used to connect the abdominal cavity to the ICB - a lower mediastinal cavity separated from the omental bursa during embryonic development [1,2]. Second, the right thoracic cavity was opened with the shortest distance by dissecting the cranial side of the ICB. The right pulmonary ligament was dissected from the right lung. Third, the dissection to the contralateral side while exposing the aorta and the pericardium connected the left and right thoracic cavities. Then, the left pulmonary ligament was dissected from the left lung. The dissected tissues, including the lymph nodes, were subsequently peeled from the esophagus.
Between April 2018 and August 2021, 14 patients underwent laparoscopic or robotic TH-LMND via the procedure above. The median time required to complete the dissection was 75 min. None of the procedures were converted to open surgery, and none of the patients experienced intraoperative complications such as pericardial injury, lung injury, or massive bleeding.
The surgical concept of interconnecting four body cavities made the procedure more accessible and reproducible while achieving en bloc TH-LMND.
由于 landmarks 结构数量有限，对于需要经膈肌食管裂孔下纵隔淋巴结清扫术（TH-LMND）的食管胃交界部癌的 Ivor Lewis 食管切除术等先进手术程序，难以标准化。我们展示了一种易于复制的 TH-LMND 程序，其中四个体腔，即腹腔、心下囊（ICB）和左右胸腔相互连通。
首先，通过对右骼嵴和食管之间的解剖，将腹腔与 ICB 连接起来 - ICB 是胚胎发育过程中与大网膜囊分开的下纵隔腔[1,2]。其次，通过解剖 ICB 的颅侧以最短的距离打开右胸腔。从右肺解剖右肺韧带。第三，在暴露主动脉和心包的同时向对侧解剖，将左右胸腔连接起来。然后，从左肺解剖左肺韧带。随后将包括淋巴结在内的解剖组织从食管上剥离。
2018 年 4 月至 2021 年 8 月，14 名患者通过上述程序接受了腹腔镜或机器人 TH-LMND。完成解剖所需的中位数时间为 75 分钟。没有一个程序被转换为开放性手术，也没有一个患者发生术中并发症，如心包损伤、肺损伤或大出血。
连接四个体腔的手术概念使该程序更容易获得和复制，同时实现了整块 TH-LMND。
