Prone Esophageactomy with Rope Way Technique Intending Complete Removal of Mediastinal Lymph Nodes

Haruhiro Inoue, MD PhD, Hitoshi Satodate, MD PhD, Michitaka Suzuki, MD, Noriko Odaka, MD PhD, Horoaki Itoh, MD PhD, Shin-ei Kudo, MD PhD. Digestive Dissease Center

[Background] In surgical treatment of esophageal squamous cell carcinoma, usefulness of 3-field lymph node dissection has been advocated for a long time. In order to complete lymph node dissecction during thoracoscopic esophagectomy “rope way technique in prone position” was developed by present authors. Prone esophagectomy was reported by Cushieri et al. and then highlighted again by Paranivelu et al. Prone position offers us better view of surgical field of mediastinum and then further additional technique of complete lymph node dissection was expected.

[Techniques] Firstly a patient is position in supine. Bilateral recurrent laryngeal nerves are exposed and taped with vascular tape at the level of lower margin of thyroid. Cervical lymph nodes are dissected and removed. Then keep a patient in prone position and perform thoracoscopic esophagectomy. Four trocars are intubated and esophageactomy with extensive lymph node dissection is carried out. Bilateral recurrent laryngeal nerve are carefully exposed and lymph nodes along both nerves are extensively dissected. In that procedure tapes on recurrent laryngeal nerve are used to idnetify nerve and tapes on the nerves are moved from cervical area to the analomical begining of them (right subclavian artery in right side and aortic arch in the left side). In order to complete mediastinal lymph node dissection thoracic duct in thorax is totally excised with surrounding lymph nodes.

[Results] We applied above mentioned technique to 35 consecutive cases recently (from April 2009 to September 2010). Recurrent laryngeal nerve palsy was evaluated by endoscopic observation of vocal cord movement. Recurrent laryngeal nerve palsy was identified in 16%. Hoarseness (recurrent nerve palsy) was less common after introduction of rope way technique. Most of them are palsy of left side. Tape on recurrent nerve is effective to identify recurent laryngeal nerve in the mediastinum and to dissect lymph node alongside recurrent laryngeal nerve. Total excision of thoracic duct was done in 86% of cases. Others were high risk patients including liver cirrhosis.

[Conclusion] Prone esophagectomy with rope way technique was developed and performed intending complete removal of mediastinal lymph node. In this procedure thoracic duct through the thorax was also totally excised. Clinical Impact of this technique onto survival rate should be evaluated in the future.

Session: Poster
Program Number: P276
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