With the continuous promotion and popularization of thoracoscopy, thoracic surgeons continue to perform breakthroughs based on previous surgical techniques, and incisions are becoming smaller. Especially in lung resection, the previous four-port surgery has gradually transitioned to three-, two-, and single-port surgery, which is now widely available[8]. A multicenter open-label randomized control trial showed that there is a lower incidence of postoperative short-term pulmonary infections, shorter hospital stay, and better short-term quality of life in patients undergoing MIE than those undergoing open esophagectomy[9]. How to find a breakthrough in previous mature MIE to further reduce the patient’s trauma under the premise of radical treatment of esophageal tumors put forward a request to our thoracic surgeons.
Recently, an increasing number of general surgeons have completed cholecystectomy, appendectomy, radical resection of colon cancer, and even radical resection of gastric cancer with a 3–4-cm incision at the lower umbilical margin, thus resulting in less trauma, less pain, faster recovery, and better aesthetics[10, 11]. However, because the laparoscope and operator’s instruments penetrate the abdominal cavity through a single-hole puncture device, the operator’s manipulation will cause the endoscope to shake, resulting in unstable screen display, so the mirror holder should firmly support the endoscope with both hands, keep the lens stable, flexibly adjust the lens angle, avoid the operator’s instruments, prevent collisions, and keep the operator’s instruments located in front of the endoscope, avoid frequent lens swing, and reduce the operator’s dizziness and eye fatigue. The laparoscopic assistant should be familiar with the surgical steps and have long-term experience in cooperation with the surgeon. To avoid obstruction of visual field by the liver, purse suture is often used to lift the liver lobes and fix them in vitro to provide good exposure for dissociating the stomach and dissecting abdominal lymph nodes.
In common MIE abdominal procedure, a 4-cm incision is made in the middle epigastrium of the subxiphoid to remove the esophageal tumor, make a tubular stomach, and guide the placement of the duodenal nutrient tube. Therefore, in this study, combined with the relevant experience of the general surgeon and characteristics of esophageal surgery in the thoracic cavity, we attempted to make full use of the existence of a small incision and put all operation holes, except the endoscopic observation holes, into the small incision. During the surgery, the instrument and lens can be freely converted between the two ports according to the surgical area and operative requirements, which reduced the difficulty of the surgery. Previously, the endoscopic observation port was usually placed at the lower margin of the umbilicus, but in the “two-port method”, the observation port was selected at 3 cm to the left of the umbilicus, which avoided the interference of the endoscope and operating instrument, and simultaneously, the ultrasonic knife could be inserted into the observation port to more conveniently dissect the short gastric vessels. If necessary, a latex drainage tube can also be placed using the observation port. In the end, we achieved the same effect of laparoscopy with the two-port method as with the traditional five-port method without extending the operative time, reducing patient trauma.
During the abdominal surgery, we first establish a small incision in the epigastric abdomen, which can detect whether there is adhesion in the abdominal cavity under direct vision; then, a disposable multichannel single-port laparoscopic puncture device was placed to establish pneumoperitoneum, avoiding the risk of intestinal injury and bleeding caused by the pneumatic needle or direct penetration of the puncture. Simultaneously, the operation can be quickly converted to open surgery. Although the position of the three puncture ports on the airtight cover is relatively fixed, we can rotate the airtight cover according to the needs of the operation and adjust the relative position of each puncture port to facilitate the operation. During the surgery, we selected a disposable multichannel single-hole laparoscopic puncture device with a diameter of 7 cm, which was slightly larger than the abdominal incision of 4 cm, making the puncture device and surgical incision difficult to detach, establishing a more reliable pneumoperitoneum and expanding the operating space for surgery. After laparoscopic surgery was completed, the airtight cover was removed, and the esophageal tumor and stomach were dragged out under the protection and extension of the incision by a laparoscopic puncture instrument, thus avoiding the possibility of abdominal incision implantation of the tumor, making it easier to release the adhesion connective tissue around the pylorus and place the prepared tubular stomach into the abdominal cavity. When the surgery was completed, the airtight cover was applied again to quickly establish a pneumoperitoneum, and the abdominal cavity was examined for active bleeding by laparoscopy.
The modified McKeown procedure with two-port laparoscopy for esophageal cancer may have a certain degree of difficulty in the initial application. We have optimized the surgical ideas and methods according to our own experience: 1. We adjusted the previous operation sequence of the abdomen and then the neck, first disconnecting the esophagus in the neck and then performing abdominal surgery. In this way, the lower esophagus and cardia can be fully dissociated after abdominal dissociation of the stomach and when the short gastric or posterior gastric vessels encounter difficulties, thus dragging the lower esophagus into the abdominal cavity and then treating the blood vessels from the rear will greatly reduce the difficulty of the surgery and risk of bleeding. 2. Instead, of the entire palm, the right middle and index fingers were used to guide the nasoenteral feeding tube through the small abdominal incision.
The following problems should also be noted: First, patients should be carefully selected in the early stage of the technology. It is recommended to select patients with no history of abdominal surgery, thinness, and long epigastric length to reduce the difficulty and requirements of surgery. Second, in case of difficulties, laparotomy should be performed in time or an operative port should be added. The quality and time of surgery should not be sacrificed to complete it. During our procedure, a 12-mm auxiliary port was added to the right side of the umbilicus in one patient due to extensive adhesion in the abdominal cavity after previous open cholecystectomy. For patients with obesity or severe adhesions near the pylorus, the small incision in the abdomen can be appropriately extended to 5 cm to achieve direct vision to separate the remaining parts, which is convenient for exposure, avoid injury to the right gastroomental artery, and sufficiently release the adhesions.
In summary, this study found that the abdominal “two-port method” in MIE has good operability and safety in lymph node dissection and gastric dissociation, and surgical trauma is less under the premise of following the principle of tumor-free operation and standard lymph node dissection. Single-port and reduced-port laparoscopy is the most popular minimally invasive technology at present, which not only is the inheritance and innovation of traditional five-port laparoscopic technology but also represents the direction of the development of precision minimally invasive technology. Moreover, single-port and reduced-port laparoscopic techniques meet the development needs of the contemporary concept of ERAS. However, this technique is extremely difficult and needs to be performed by surgeons, especially thoracic surgeons, who are skilled in laparoscopic techniques, and the long-term efficacy needs to be further confirmed by prospective and multicenter clinical studies.