Laparoscopic transhiatal lymphadenectomy in the lower mediastinum for adenocarcinoma of the esophagogastric junction

Abstract

Laparoscopic transhiatal esophagogastrectomy is difficult because the lower mediastinum is so deeply located that the operative field is narrow and restricted by surrounding organs. Therefore, we performed lymphadenectomy with opening of the bilateral mediastinal pleura to maintain safety and obtain better exposure of lymph nodes and important organs. We will present our technique for laparoscopic lower mediastinal lymphadenectomy and reconstruction for cancer of the esophagogastric junction. Five abdominal ports were used. Retraction of the left lobe of the liver exposed the esophageal hiatus. A long, narrow gastric tube (3 cm wide) was formed, and regional abdominal lymph nodes (No. 1, 2, 3a, 7, 8a, 9, 19, and 20) were resected. The diaphragmatic hiatus was widely split and the opened bilateral mediastinal pleura enabled better exposure for lymph node dissection and reconstruction. The level where the inferior vena cava passed through the diaphragm into the chest was used as a landmark to identify supradiaphragmatic (No. 111) and lower thoracic paraesophageal nodes (No. 110), which were completely retrieved with this procedure. The posterior mediastinal nodes (No. 112pulR, 112pulL, and 112aoA) were also retrieved with bilateral opening of the mediastinal pleura and dissection of the inferior pulmonary ligaments. An esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis. This approach enabled safe and accurate laparoscopic lower mediastinal nodal dissection. With the advantage of a narrow gastric tube, the good working space made tension-free anastomosis possible.

Electronic supplementary material

The online version of this article (10.1007/s13691-018-0318-1) contains supplementary material, which is available to authorized users.

Introduction

Adenocarcinoma of the esophagogastric junction reportedly often involves lymph nodes in the lower mediastinum [1, 2]. Therefore, a technique for lower mediastinal nodal dissection is necessary. In our institution, laparoscopic proximal gastrectomy and lymphadenectomy for adenocarcinoma of the esophagogastric junction have been performed according to guidelines of the Japanese Gastric Cancer Association [3]. Nodal metastases commonly occur in lower mediastinal paraesophageal nodes (No. 110), supradiaphragmatic nodes (No. 111), and posterior mediastinal nodes (Nos. 112pulR, 112pulL, and 112aoA). According to Japanese guidelines, we adopted lymphadenectomy of these lymph node stations using the transhiatal approach as follows: the location of adenocarcinoma less than 40 mm diameter, with the dominant area of invasion E (proximal 2 cm segment of the esophagogastric junction), EG, E = G (both areas equally involved).

Laparoscopic transhiatal lymphadenectomy remains difficult because the lower mediastinum is so deeply located that the operative field is narrow and restricted by surrounding organs [4]. To overcome technical difficulties and establish a standardized lower mediastinal lymphadenectomy technique, we performed a procedure with open bilateral mediastinal pleura to maintain safety and obtain better lymph node exposure. This video article demonstrates our standard laparoscopic transhiatal lower mediastinal lymphadenectomy for adenocarcinoma of the esophagogastric junction (Video 1).

Technique

Under general anesthesia, patients were placed in reverse Trendelenburg position with their legs apart. After pneumoperitoneum was established using an open technique at the umbilicus, a flexible electrolaparoscope was introduced through the umbilical trocar. Five abdominal ports were used. For reconstruction after proximal gastrectomy, a long, narrow gastric tube (3 cm wide) was formed, and regional abdominal lymph nodes (Nos. 1, 2, 3a, 7, 8a, 9, and 19) were resected. After complete exposure of the abdominal esophagus with division of the anterior and posterior vagal trunks, a tape for retraction and no-touch manipulation was passed around the lower end of the esophagus. The left lateral segment of the liver was mobilized by dividing the left triangular ligament (with care taken to avoid injuring the inferior phrenic vein and left hepatic vein), then retracted with a Nathanson liver retractor to expose the esophageal hiatus. The diaphragmatic hiatus was widely split and open bilateral mediastinal pleura enabled better exposure for lymph node dissection and reconstruction.

Transhiatal dissection was performed between the pericardium and esophagus, then between the aorta and esophagus and right pleura and esophagus; finally, the remaining left side of the esophagus was dissected. The level where the inferior vena cava passed through the diaphragm into the chest was used as a landmark to identify supradiaphragmatic (No. 111) and lower thoracic paraesophageal nodes (No. 110), which were completely retrieved with this procedure. We defined the caudal surface of the inferior pulmonary vein as cranial landmark of the No. 110. The posterior mediastinal nodes (Nos. 112pulR, 112pulL, and 112aoA) were also retrieved with bilateral opening of the mediastinal pleura and dissection of the inferior pulmonary ligaments. A loose connective tissue between aorta and thoracic esophagus can be identified easily, and separate this preaortic space, we identified soft tissue right side of the aorta. We retrieve the ventral soft tissue as No. 112aoA and preserve the dorsal tissue around thoracic duct and azygos vein to minimize surgical invasion. The proximal margin of the specimen was examined pathologically when necessary before reconstruction. When reconstruction had to be performed in the deeper mediastinum, laparoscopic opening of the left diaphragm was helpful to obtain better exposure. If sufficient remnant intra-abdominal esophagus was preserved, esophagogastrostomy was performed after proximal gastrectomy. If the anastomotic site was located in the lower mediastinum, an esophagogastric tube anastomosis with pseudo-fornix was made with a no-knife linear stapler to prevent postoperative reflux esophagitis [5]. Esophagojejunostomy was performed using an overlap method after total gastrectomy [6]. After the reconstruction, we closed the hiatus with interrupted 3–0 prolene sutures, and wall of the remnant stomach or jejunal tube near the anastomosis was sutured to the crus of the diaphragm to prevent hiatal hernia.

Results

From June 2013 to October 2016, transhiatal, lower mediastinal lymphadenectomy was performed in four patients (two men and two women). Laparoscopic total gastrectomy for remnant gastric cancer was performed in one patient, and laparoscopic proximal gastrectomy was performed in three patients. Operative time was 247–391 min, operative blood loss was 5–99 ml, and 15–26 lymph nodes were retrieved per case. To examine the effect of this procedure on the total number of lymph nodes retrieved, 16 consecutive patients with histologically proven primary esophageal cancer who underwent transthoracic esophagectomy in our institution during the same period were also reviewed. There was no difference between the procedures (Table 1). The TNM stage of disease was IA in all patients. Anastomotic leakage of the esophagojejunostomy occurred in remnant gastric cancer patients. No anastomotic stenosis was observed.

Table 1.

Comparison of total number of lower mediastinal lymph node (No. 110 + 111 + 112) retrieved between transhiatal lower mediastinal lymphadenectomy and thoracoscopic esophagectomy

Variable	Transhiatal approach (n = 4)	Thoracoscopic esophagectomy (n = 16)
Mean (± SD)	5.75 ± 4.3	5 ± 3.6
Median (range)	4.5 (2–12)	4.5 (0–11)

Conclusion

This approach enables safe and accurate laparoscopic lower mediastinal nodal dissection. With the advantage of a narrow reconstructive gastric tube, the good working space made a tension-free anastomosis possible.

Electronic supplementary material

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Compliance with ethical standards

Conflict of interest

The authors declare that there are no conflicts of interest.