Right Subtotal Thoracoscopic Oesophagectomy with Lymphadenectomy

Abstract

Blunt transhiatal oesophagectomy first reported by Grey Turner [1] and popularized by Orringer and others for both benign and malignant disease [2 – 5] carries certain advantages over the two-stage Lewis Tanner procedure [6, 7] or the three-stage oesophagectomy [8], largely due to the avoidance of a thoracotomy. There are, however, some disadvantages which are inherent to blunt dissection of the oesophagus. These include blood loss and trauma to the azygos vein, bronchi and recurrent laryngeal nerves. The procedure is particularly difficult in large tumours of the middle third of the oesophagus and the risk of damage to mediastinal structures by the blind dissection is increased if there is extramural spread of the tumour. In addition, cardiac arrhythmias are common during the retrocardiac mobilization. Nodal dissection and lymphadenectomy is not possible with blunt trans-hiatal oesophagectomy, and although this may not affect survival in the majority of patients — since most oesophageal resections are palliative — the excision of involved lymph nodes may indeed affect dysphagia-free survival. The first visually guided technique of endoscopic oesophagectomy was reported by Buess et al. [9] using a specially designed operating mediastinoscope which permits safe peri-visceral dissection of the intrathoracic oesophagus. This method is described in Vol. 1, Chap. 12 and is suitable for small tumours, preferably without extensive node involvement since the scope for lymphadenectomy is limited by this approach. The subtotal right thoracoscopic oesophagectomy [10, 11] allows dissection of large thoracic oesophageal tumours and lymphadenectomy that is equivalent in all respects to that achieved by the McKeown procedure. In addition, the dissection of the cervical oesophagus is performed largely through the thoracoscopic route.