Esophageal cancer is one of the malignant tumors treated by thoracic surgery 5.
However, surgical treatment of esophageal cancer is traumatic. This is mostly due to the deep anatomical location of esophageal cancer, which is in close proximity to vital organs like the aorta and trachea. Therefore, intraoperative risk is high6.
The advantages associated with inflatable mediastinoscopy synchronized laparoscopic esophagectomy is its avoidance of entry into the pleural cavity. This characteristic allows for the prevention of compression on pulmonary tissue and the displacement of surgical instruments, which are common occurrences in traditional thoracoscopic surgery7.However, at present, surgery for inflatable mediastinoscopy synchronized laparoscopic esophagectomy lacks popularity both domestically and internationally, with just a decade of use observed even in prominent local medical institutions. With effective collaboration between the Department of Anesthesiology and the surgical operating team, the surgical team employs mediastinoscopy to dissect the esophagus via the neck, and laparoscopy to dissect the stomach and lower esophagus through the abdomen. Ultimately, the mediastinoscopy and laparoscopy procedures will be integrated in the thoracic region, resulting in the full removal of the esophagus. Additionally, a cervical anastomosis was performed8.
Our surgical team believes that the utilization of inflatable mediastinoscopy synchronized aparoscopic esophagectomy not only results in a notable reduction in operation time, but also facilitates lymph node excision with comparable efficacy to the widely accepted McKeown approach. This surgical approach enables surgeons to achieve a learning curve of over 50 cases. It is particularly applicable to patients with esophageal cancer who have impaired lung function, significant tuberculosis-related alterations in the thoracic cavity, and extensive thoracic adhesions. By opting for surgical treatment, these patients can potentially attain a longer survival period.
Our team proposed that mediastinoscope and laparoscope are performed simultaneously. During the operation, the patient's position does not need to be changed, and the patient only needs to rotate the neck around and around to cooperate with the operation, which significantly reduces the total operation time (generally completed within 2.5-3.0 hours). The simultaneous execution of operations by two groups of surgeons and two groups of instrument nurses resulted in several benefits. These included a reduction in anesthesia time and intraoperative blood loss, as well as a decrease in the waiting time for patient postural changes and re-disinfection of towels. Therefore, this technique significantly shortened the overall operation time, the patient's surgical trauma time, and the occurrence of postoperative complications. In addition, the absence of a thoracic incision and thoracic vascular damage resulted in little surgical bleeding and a reduction in the duration of the procedure due to decreased need for repeated hemostasis. Furthermore, the utilization of this technique in current clinical practice extended the surgical indications of the widely accepted McKeown procedure for the comprehensive treatment of esophageal cancer. This was due to its ability to avoid the need for single-lung ventilation, without damaging the intercostal nerves, and provide notable benefits in terms of patient comfort and expedited postoperative recovery. Hence, our surgical team maintained that the selection criteria for surgical patients should encompass the following indications: 1) early-stage esophageal cancer (stage 0 and stage I); 2) patients diagnosed with upper esophageal cancer exhibiting a lesion length measuring less than 3.0 cm, middle esophageal cancer with a lesion length less than 5.0 cm, and lower esophageal cancer with a lesion length less than 7.0 cm, all falling under stage II and III of esophageal cancer, and displaying no evident external invasion of the tumor; 3) some patients diagnosed with stage III esophageal cancer, presenting preoperative external invasion, who demonstrated favorable health status subsequent to preoperative induction radiotherapy. The contraindications for surgery should encompass the following criteria: 1) The cancer exhibits extensive invasion or demonstrates evident external infiltration, or its removal becomes unfeasible due to invasion of nearby vital organs. 2) The esophagus presents symptoms of penetration or distant metastasis. 3) Patients with serious heart, lung, liver, and kidney dysfunction cannot tolerate surgery. In addition, patients with severe cachexia are also unable to undergo surgery.
Two transverse neck incisions effectively excised 101 or 104 bilateral lymph nodes. The surgical procedure relied upon the exposure and dissection of the left recurrent laryngeal nerve via the incision made on the left side of the neck. It is advised to exercise caution when dissecting and exposing the left recurrent laryngeal nerve, as excessive manipulation might lead to demyelination damage of the nerve and subsequent postoperative hoarseness. The utilization of specialized upper and lower mediastinal retractors was imperative for conducting dissections within narrow anatomical regions. Maryland forceps were used to separate and excise tissues during operation, which generate minimal smoke during thermal conduction, hence preserving the visual clarity of the surgical field. The inflation pressure of artificial mediastinal emphysema was controlled at 10–12 mmHg, and the abdominal inflation pressure was controlled at 12–14 mmHg 9.It not only facilitated the visualization of the surgical region, but also mitigated the risk of significant CO2 accumulation 10.
The creation of an artificial environment for mediastinal inflation resulted in several benefits, including improved eyesight, enlarged operating area, and enhanced visibility of the intact exposed trachea, thoracic duct, and other structures11.
The utilization of inflatable mediastinoscopy demonstrated efficacy in overcoming challenges associated with a constricted mediastinal area, restricted surgical maneuverability, and intricate lymph node excision. At the same time, it completely removed the surrounding lymph nodes, including: mediastinal lymph nodes, recurrent laryngeal nerve lymph nodes, subcarinal lymph nodes, periesophageal lymph nodes, diaphragm and abdominal lymph nodes above the upper edge of the pancreas. Currently, there is a significant debate about the completion of regional lymph node dissection in the context of inflatable mediastinoscopy synchronized laparoscopic esophagectomy. The number of lymph nodes excised in the middle and upper mediastinum is few, especially the lymph nodes along the right recurrent laryngeal nerve 12. Our team suggested the utilization of inflated mediastinoscopy synchronized laparoscopic esophagectomy, employing a pair of transverse incisions in the neck. Under direct visualization, it was possible to perform dissection of the lymph nodes located along the right recurrent laryngeal nerve. Additionally, the lymph nodes situated beneath the aortic arch, namely those adjacent to the left tracheobronchial region, could be visualized in a more unobstructed vertical manner, devoid of interference from the aortic arch. Furthermore, it had the potential to successfully perform a thorough excision of the left paratracheobronchial lymph nodes (No.106tbL group), which are typically considered inoperable, with a single incision on the left side. The right cervical approach enabled the execution of a comprehensive excision of the right middle and upper mediastinal lymph nodes under direct visualization. This technique offered a wide visual field, facilitating the dissection of para-esophageal and bilateral recurrent laryngeal nerve lymph nodes with relative ease. One notable advantage of employing this method was its ability to avoid the need for thoracotomy, hence preserving the structural integrity of the thoracic cavity. Additionally, this strategy entailed reduced surgical trauma, diminished pain, and expedited postoperative recuperation. After surgeons successfully completing the learning curve of 50 cases, the surgeon could completely achieve the same effect as the mainstream McKeown's approach. In certain cases, inflatable mediastinoscopy synchronized laparoscopic esophagectomy may be considered as an alternative treatment option for patients with esophageal cancer, particularly those who have cardiopulmonary dysfunction and for whom the conventional McKeown technique is not appropriate.
In summary, the technique of inflatable mediastinoscopy synchronized laparoscopic esophagectomy involved the creation of a mediastinal tunnel to complete the procedure. Additionally, a tubular stomach was constructed through a minor incision in the upper abdomen, followed by an anastomosis in the left neck. Notably, this approach has been found to be associated with a minimal risk of chest complications. Therefore, the proposed surgical procedure can serve as a supplementary procedure to the existing McKeown esophagectomy technique, and can be effectively implemented in clinical practice.