A 50-year-old man presented to the hospital with difficulty swallowing. Physical examinations, including heart rate and bleed pressure, were normal. The gastroscopy tips showed an ulcerative esophageal tumor 34–38 cm from the upper incisors, and biopsy results indicated squamous cell carcinoma. Preoperative computed tomography (CT) showed：thickening of the middle esophagus wall, consistent with malignant tumor (MT), and slight chronic inflammation of the right middle lung. During the operation, the patient underwent radical resection of esophageal cancer with bilateral thoracoscopic approach and the intraoperative pathological staging , according to the UICC-TNM classification (7th edition), indicated stage IIIB (pT3, pN2, cM0).
Surgical method: First, the patient was placed in the prone position on the left side. Under 7mmHg pneumothorax pressure, a 30° thoracoscopy was placed between the mid-posterior axillary line in the 7th intercostal space of the right chest. Then we took the subscapular line of the right posterior chest and two incisions at the mid-axillary line of the fourth intercostal space of the right chest as the main and auxiliary operation holes to free the thoracic esophagus. During the freeing process, we found that the esophageal mass was huge with extrapleural invasion and one of the irregularly enlarged lymph nodes invaded the thoracic aorta. Trial separation found it was frozen. Considering the risk of hemorrhage with forced separation, it was changed to local titanium clip marking for postoperative adjuvant radiotherapy（Figure 1）. We cleared subcarinal nodes, thoracic paraesophageal lymph nodes and bilateral paratracheal lymph nodes Simultaneously. After the inventory was correct, a drainage tube was inserted, and the four holes of the right chest were closed and sutured one by one. The patient took the left side elevated position by 30°, re-sterilized the drape, cut off the anterior abdomen of the scapula hyoid muscle through an incision on the inner edge of the left cervical sternocleidomastoid muscle. Then we cut the scapula hyoid muscle anterior abdomen and free the cervical esophagus through an incision on the inner edge of the left cervical sternocleidomastoid muscle. Then we freed the cervical esophagus, broke and sutured the esophagus at the entrance to the thoracic cage of the neck. The umbilical incision was placed into a thoracoscopy. Four operation holes were made under the xiphoid process, bilateral costal arch and right upper abdomen to explore the chest cavity and free the stomach, and then the esophagus was pulled into the abdominal cavity. Take the midline incision of the upper abdomen to raise the gastric body, excise the cardia and part of the lesser curvature of the stomach, stretch the gastric body into a tube, and suture three stitches of the marking thread on the fundus of the stomach. The sixth intercostal space of the left thorax was inserted into the thoracoscope, and the anterior axillary incisions of the fourth and fifth intercostal spaces of the left thorax were taken as the operating holes (Figure 2). The silicone tube was guided under the laparoscope and pulled from the left thoracic aortic arch into the abdominal cavity through the mediastinum through the esophageal hiatus. After connecting with the tubular stomach marking line, guide the tubular stomach through the left thoracic aortic arch to the left neck, and perform an esophageal-tubular stomach anastomosis on the left neck (Figure 3a,b). During the operation, an anesthesiologist was asked to insert the duodenal nutrition tube and gastrointestinal decompression tube from the nasal cavity and suture the incision layer by layer.