Endoscopic Transesophageal Mediastinal and Thoracic Lymph Node Dissection with En Bloc Resection

This video demonstrates a novel, transesophageal endoscopic technique for mediastinal and thoracic lymph node dissection and en bloc lymphadenectomy using a Natural Orifice Transluminal Endoscopic Surgery (NOTES®) technique. Using a swine model, a double-channel gastroscope equipped with an endoscopic cap band mucosectomy device is used to create a small esophageal mucosal defect. Next, a short submucosal tunnel is created using the tip of the endoscope and closed biopsy forceps. A hook knife is then used to incise the muscular esophageal wall and to enter the mediastinum. Subsequently, endoscopic scissors are used to create a small hole in the visceral pleura and the endoscope is passed through it and into the thorax. Once in the thorax, the endoscope is carefully advanced up the thoracic wall and lymph node stations are identified high in the apex of the lung near the trachea. The parietal pleura overlying the target lymph node is then incised with the hook knife to better expose the lymph node. Prototype endoscopic Maryland dissectors are used to dissect the LN away from surrounding structures. Care is taken to preserve the lymph node architecture and to not damage the lymphovascular bundle. After lymph node dissection is complete, an electrocautery snare is placed around the entire node and closed around the lymphovascular bundle, while a second snare is used to secure the body of the lymph node and facilitate retrieval. This technique prevents the resected node from falling freely into the thoracic cavity where retrieval can be challenging. The lymph node is then removed by withdrawing the endoscope through the thorax, mediastinum, submucosal tunnel, esophagus and ultimately out of the natural orifice. Necropsy photos are shown demonstrating one of the surgical sites where a paratracheal node was removed. Histology slides also demonstrate the preserved, architecturally intact, lymph node specimens. The procedure is carried out with minimal bleeding and trauma to the lymph node. In summary, this video demonstrates that transesophageal NOTES® can accomplish mediastinal and thoracic lymph node dissection and resection and provide architecturally intact specimens for histologic examination.

Session: Podium Video Presentation

Program Number: V024

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