Thoracoscopic Esophagectomy While in a Prone Position for Esophageal Cancer: A Preceding Anterior Approach Method

Soji Ozawa, MD DMSc, Eisuke Ito, MD, Akihito Kazuno, MD, Osamu Chino, MD DMSc. Department of Gastroenterological Surgery, Tokai University School of Medicine

INTRODUCTION: Although many esophageal surgeons are interested in thoracoscopic esophagectomy for esophageal cancer, the rate of thoracoscopic esophagectomy was about 20% in Japan in 2009. This low rate may be due to the difficulty in both maintaining a good surgical field and the meticulous procedures that are required. The purpose of this study was to establish and evaluate a new procedure for thoracoscopic esophagectomy in a prone position using a preceding anterior approach to make esophagectomy easier to perform.
METHODS AND PROCEDURES: We have performed thoracoscopic esophagectomy while the patient was in a prone position for 44 patients with esophageal cancer between September 2009 and September 2011. The indications for this operation were the absence of severe pleural adhesion, cases with T1b to T3 cancer, and cases without preoperative chemoradiotherapy. Patients were placed in a prone position, and five trocars were inserted into the right thoracic cavity; only the left lung was ventilated, and pneumothorax was maintained with 6 mmHg of CO2 gas. The anterior pleura of the upper posterior mediastinum was incised between the esophagus and the trachea. The lymph nodes around the right recurrent laryngeal nerve and the upper esophagus were dissected. The esophagus was mobilized from the trachea in the first step and from the posterior structure in the second step. The middle and lower esophagus was also mobilized in the same manner as that for the upper esophagus; the lymph nodes around the esophagus were then dissected anteriorly in the first step and posteriorly in the second step. After the esophagus was transected, the lymph nodes around the left recurrent laryngeal nerve were dissected. The time and blood loss associated with the thoracoscopic procedure and the adverse events were evaluated.
RESULTS: The median operation time for the thoracoscopic procedure was 220 minutes, and the median blood loss was 20 g. The median operation time of the latter 22 cases (210 min) was shorter than that of the former 22 cases (259 min) (p=0.012). The median blood loss of the latter 22 cases (15 g) was also less than that of the former 22 cases (27 g) (p=0.026). No intraoperative incidents occurred. We did not convert the procedure from thoracoscopic surgery to open surgery in any of the cases. There were no operative deaths in this series. As postoperative complications, pneumonia occurred in 8 cases (18%), recurrent laryngeal nerve palsy occurred in 6 cases (14%), and chylothorax occurred in 1 case (2%).
CONCLUSIONS: A thoracoscopic esophagectomy in a prone position for esophageal cancer using a preceding anterior approach is a safe and feasible procedure. After experiencing more than 20 cases, the performance of the procedures stabilized. The advantages of this method were that the mediastinal organs are shifted downwards as a result of gravity and that the surgical field for the posterior mediastinum eventually becomes wide open. This method, which is performed while the patient is in a prone position, seems to make esophagectomies easier to perform.