All attendant surgeons stand on the right side of the patient at chest level and a high-quality video monitor is placed on the opposite side (Fig. 16.1a). A 12-mm blunt trocar is carefully inserted in the fifth intercostal space (ICS) on the lateral side of the right scapula to confirm the absence of pleural adhesion. Another three trocars are inserted under thoracoscopic control: a 12-mm trocar in the ninth ICS on the scapular angle line for the thoracoscope during surgery, a 5-mm trocar in the seventh ICS behind the posterior axillary line, and a 12- or sometimes 5-mm trocar in the third ICS on the posterior axillary line. A 5- or 3-mm trocar in the eighth ICS on the posterior axillary line is added for dissection of the lower mediastinum if necessary (Fig. 16.1b). A smaller trocar is more advantageous for smooth movement of the forceps in patients with narrow ICSs, despite the fact that an endoscopic linear stapler or gauze cannot be passed through it. Carbon dioxide pneumothorax is achieved at a pressure of 8 mmHg (6–12 mmHg) to collapse the right lung and to expand the mediastinum in all patients. To maintain a clear operative fields, surgical mist or fog produced by energy devices must be removed using an exhaust pump.

Our actual procedures in the prone position are basically the same as the conventional right thoracotomic open or thoracoscopic procedures in the left lateral decubitus position during three-staged esophagectomy for thoracic esophageal cancer [2]. The surgeon uses a grasper in the left hand and a monopolar or bipolar electrocautery, ultrasonic-activated device or tissue-fusion system in the right hand. First, the mediastinal pleura overlying the anterior aspect of the esophagus is opened. The pleura along the azygos in the middle mediastinum is cut, avoiding injury to the thoracic duct, and the pleura from the lower to upper mediastinum is then opened. The arch of the azygos vein is isolated and divided after ligation and clipping, and the posterior stump is sutured to the back to exposé the operative field around the right bronchial artery. The right bronchial artery is usually divided after the bifurcation of the third intercostal branch to expand the later operative views. However, in cases of salvage surgery for recurrent disease after chemo-radiation therapy with curative intent, the right bronchial artery must be carefully preserved to avoid tracheal or bronchial ischemia. Conversely, in such cases, the third intercostal branch must be divided to elongate the right bronchial artery for later assessment of the left aspect of the trachea.

The thoracic duct is usually preserved except patients with a stage T3 or higher tumor of the upper esophagus (Fig. 16.2). Keeping the preparation plane on the thoracic duct, mobilization of the esophagus can be performed in the upper mediastinum. However, the preparation plane is obscure around the azygos arch and right bronchial artery, where numerous nerve branches from the thoracic ganglia of the sympathetic nervous system cross the preparation plane. Thus, careful dissection in this area is necessary to avoid injury to the thoracic duct. In addition, some large collecting ducts that course from the esophagus or more anterior mediastinal organs and drain into the thoracic duct are often observed there. To obtain a safe circumferential surgical margin in patients with stage T3 or higher upper thoracic esophageal cancer, the thoracic duct is divided at the lower mediastinum and behind the left subclavicular artery and dissected as an attachment to the esophagus.

Except for patients with upper thoracic esophageal cancer, pretracheal nodes are not dissected systematically because of the lower metastatic rate and lower effectiveness of dissection [3]. Therefore, the dissection is limited tithe posterior aspect of the right vagus nerve and around the right recurrent laryngeal nerve (RLN). The right RLN is identified and isolated around its bifurcation from the vagus nerve at the right subclavicular artery. Although many small vessels and nerves are involved in this region, careless use of energy devices should be avoided because of the risk of damaging the right RLN (Fig. 16.3a). On the right face of the trachea, the nodes along the right RLN must be dissected completely; portion of the pretracheal nodes is thus often dissected in this region. During this dissection, the vascular network on the cartilaginous portion of the trachea must be preserved to avoid impairing the blood supply to the trachea [4]. While some esophageal branches of the right RLN are divided, the lymph nodes around the right RLN can be dissected in an enbloc fashion nearly below the thyroid gland, which cannot be confirmed visibly during the chest procedures (Fig. 16.3b).

After dissection around the right RLN, a couple of esophagocardial branches of the right vagus nerve are divided after the pulmonary branches of this nerve. Otherwise, sufficient counter traction cannot be obtained during the dissection around the right RLN. The preserved lower pulmonary branches are prepared and isolated from the subcarinal nodes and the nodes below the right bronchus, which will be dissected in a later step.

This step is considered to be the most complicated procedures. After dissection along the right RLN, the esophagus is prepared from the membranous portion of the trachea, extending as far toward the cervical esophagus as possible. The trachea is strongly but carefully rolled back to the right and ventrally by a grasper holding a small piece of gauze to explore the left aspect of the trachea and the left bronchus (Fig. 16.4) [5]. During this manipulation, the use of a single-lumen endotracheal tube provides much better operative fields. After the esophagus has been released from the trachea toward the neck to allow the lymph nodes up to the thoracic inlet to be dissected, the tissue including the left RLN and lymph nodes is dissected just along the trachea and the left bronchus to create the ventral dissection border. The esophagus is strongly lifted posteriorly to facilitate pulling out the target tissue from the left aspect of the trachea. The posterior aspect, which is the left dissection border, is dissected on a vascular sheath of the dense connective tissue covering the aortic arch, left subclavicular artery and left carotid artery, which is supposed to be developed the pericardium caudally. This dense connective tissue includes a couple of superior cardiac branches of the sympathetic nervous system arising at the neck and running down along the left subclavicular artery. This tissue including lymph nodes and the left RLN, are recognized as a lymphatic chain on the vascular sheath overlying the aortic arch, subclavicular artery, and carotid artery. During isolation of the lymphatic chain to be dissected from the trachea and vascular sheath, the lymphatic chain should be attached with the esophagus to pull out the tissue on the left aspect of the trachea because of the esophageal branches of the left RLN. Next, the upper esophagus is mobilized circumferentially, and the esophagus is divided at a higher level of the aortic arch by linear stapling to facilitate subsequent lymph node dissection at the left aspect of the esophagus (Fig. 16.5). The tissue including lymph nodes and the left RLN attached to the divided proximal esophagus must be carefully detached from the esophagus, and the proximal esophagus is then fixed by suturing it to the anterior inner chest wall to facilitate exposure of the superior upper mediastinum between the chest and neck. Within the lymphatic tissue chain including lymph nodes and the left RLN, the left RLN can be easily identified without splitting the lymphatic chain only on the vascular sheath of the aortic arch because the RLN is embriologically descended concomitantly with the downward development of the aortic arch (Fig. 16.6a). In other words, the left RLN must be identified and isolated after splitting this lymphatic chain above the aortic arch toward the neck. Around the thoracic inlet, the lymphatic chain disconnected mainly to the pretracheal tissue and partially with the tissue along the neck portion of the left RLN and left supraclavicular tissue including the respective nodes [6]. Therefore, the ventral aspect of the left RLN has been considered to be important for dissection. Of course, complicated dissection procedures in this region can be performed during subsequent neck procedures. However, such dissection cannot be performed enbloc.

Dissection along the left RLN must be adequately performed according to the surgical anatomy described above. Dissection along the left RLN is carried out while some esophageal or tracheal branches of the identified left RLN are divided, and the dissection ends at the thoracic inlet. The left RLN is sharply isolated from the explored tissue without an electric device to avoid injury by electricity or heat, and the lymph nodes are consequently dissected in an enbloc fashion with the divided distal esophagus. The thoracic duct is also divided behind the left subclavicular artery at the thoracic inlet when it is excised. On the vertebral side of the posterior aspect of this dissection, a vascular sheath covering the aortic arch and left subclavicular artery is transected if the sheath has been prepared with the divided esophagus on the descending aorta at the posterior face (Fig. 16.6b).

Below the aortic arch, the recurrent portion of the left RLN also has a couple of esophageal branches, which are sharply cut. Lymph node dissection around the left RLN is then finished. During dissection below the aortic arch, one or two left bronchial arteries are identified and preserved on the face of the trunk of the right pulmonary artery (Fig. 16.7). This dissection is somewhat complicated. It is limited to the anterior aspect of the left vagus nerve, along the left bronchus, below the aortic arch and on the face of the pulmonary artery trunk. Using the same technique as that used for dissection around the left RLN, the right bronchus is adequately rolled back and the window below the aortic arch is opened widely.

Dissection along the left RLN and below the aortic arch is followed by dissection of the subcarinal nodes and nodes below the bilateral bronchi. The dissection extends from the right to left pulmonary hilum. When the right bronchial artery and pulmonary branches of the right vagus nerve are preserved, the procedures are complicated as mentioned above. The esophageal branches of the left vagus nerve are divided after the pulmonary branches. Around the left bronchus and left inferior pulmonary vein in the left pulmonary hilum, dissection must be carefully performed to avoid injury to these structures (Fig. 16.8). A proper dissecting plane comprising the pericardium, left pleura, descending aorta and diaphragm is then established to perform sufficient paraesophageal, middle and lower posterior mediastinal, and supradiaphragmatic lymph node dissection. Dissection is performed on the vascular sheath of the descending aorta without exposure of the adventitia of the aorta to avoid hemorrhage. In addition, the surrounding tissue on the face of the esophagus can be pulled out and dissected easily in this manner (Fig. 16.9). It is important to dissect the nodes below the left inferior pulmonary vein and along the left esophago-pulmonary ligament. In most cases, the left pleura is opened to facilitate dissection along the left esophago-pulmonary ligament and around the supradiaphragm region. In this situation, pneumothorax can influence the left lung ventilation, but the effects of this left pleurotomy on anesthesia are minimal or ignorable. Around the esophageal hiatus, dissection is carried out thoroughly on the bilateral crus preserving the sheath of the esophagus proper. Because both conjunctions of the bilateral crus are visible on the ventral and dorsal sides in all patients, the prone position is considered to provide the best operative view of the lower mediastinum (Fig. 16.10).

After thoracoscopic procedures have been completed, the divided distal esophagus is inserted into a vinyl bag to avoid spreading cancer cells. Both stumps of the divided esophagus are connected with a long string for the purpose of later reconstruction via the posterior mediastinal route. A chest tube is inserted in a standard manner. The patient is then placed in the supine position. Laparoscopic surgery using five ports is performed as in an abdominal procedure. The stomach is mobilized and the abdominal lymph nodes are dissected, and a gastric conduit is created extracorporeally through the small laparotomic incision at the umbilical port site. Reconstruction of an alimentary tract between the cervical esophagus and a gastric conduit pulled up through the posterior mediastinum is performed at the neck using the triangular stapling technique in our hospital [7]. Pyloroplasty is not performed and a feeding jejunostomy tube is not usually placed.

The results published in the literature, including our results, are summarized in Table 16.1. In spite of better operative exposure, the operative time in our previous series was not shortened. A long duration of time was required to preserve the mediastinal organs and structures, including recurrent nerves, bronchial arteries, thoracic duct, cardiac branches of the sympathetic nervous system and pulmonary branches of the vagus nerves. We recently began dividing the right bronchial artery to facilitate easier performance of the other procedures. As a result, the mean thoracoscopic time of our recent series was shortened by more than 70 min compared with that of the previous cases. Nevertheless, the operative time was still long because meticulous dissection along the RLNs was required. The numbers of retrieved mediastinal lymph nodes were correlated with the chest operative time of the thoracic procedure, as shown in Table 16.1.