We developed a low-cost single-port device to improve upper mediastinal dissection using a left transcervical mediastinoscopic approach, which was used to improve the visibility and dissection in the upper mediastinum around the aortic arch. The aim of this project is to describe the step-by-step process of a laparoscopic transhiatal esophagectomy, completed using a mediastinoscopy cervical approach with a low-cost single-port device in a rendezvous technique. The materials used are a nasogastric tube, one sterile number eight glove, a sterile sponge, three permanent five millimeter trocars and surgical suture materials.
One cylinder with a sterile sponge is made. Three glove fingers are used to triangulate the trocars. Little finger, middle finger and thumb.
The three trocars pierce the sponge and perform the triangulation. One ring with the nasogastric tube is made. The sponge, the trocars and the glove are placed between the ring to seal the air leak and to stabilize the sutures.
The glove is used to cover all the sutures to prevent air leak again. This is the final aspect of the single-port, low-cost device. The operation starts with the laparoscopic access to the peritoneal cavity and inspection to evaluate any possible of liver metastasis, peritoneal carcinomatosis or free fluid.
After this inspection, we start to open up the greater curvature with the division of the gastrocolic ligament, preserving the arterial arcade of the right gastroepiploic artery. The left gastroepiploic artery and vein were dissected and divided, after that, they were clipped. Then, we begin the lymphadenectomy of the lesser epiploic cavity, performing the dissection of the lymph nodes around the common hepatic artery and the celiac trunk.
We dissect cranially to the origin of the left gastric vein and isolated it from the left gastric artery. We usually use one clip proximally and other distally in the left gastric vein before sealing it. We use two Hem-o-locks proximally and one distally in the left gastric artery before sealing it.
After that, we retrieve all lymph nodes around the left gastric artery. We continue the lymphadenectomy through the hiatus. Then we initiate the dissection of the lower mediastinum with the opening of the diaphragmatic crus.
Distal esophagus is dissected from the both left and right pillar. We start at the posterior part of the esophagus between the descending aorta and the esophagus. After that, we dissect anterior, lower mediastinal lymphadenectomy with the dissection of the pericardial lymph nodes.
We dissect the periesophageal lymph nodes close to the right pleura and left too. We stop the dissection in the transition of the middle to upper mediastinal up to the carina and started dissection with a single-port mediastinoscope surgical approach, using a rendezvous technique. Left cervicotomy is performed with the isolation of the cervical esophagus.
We insert the single-port device into the cervical wound and create a pneumomediastinum by carbon dioxide insufflation. We use a five millimeter arch and a harmonic scalpel for esophagus dissection along with a laparoscopic grasper. We dissect the esophagus over the aortic arch and behind the superior portion of the trachea.
The dissection of the lymph nodes is performed along the left recurrent laryngeal nerve and parathyroid. After this stage, the esophagus is completely mobilized and we will reach the transhiatal dissection. The cervical esophagus is divided, and the esophagus with the tumor is removed by abdominal incision.
Stapling is performed along the greater curvature for the propose of making the gastric tube, which will be drawn for anastomoses in the cervical region. This is the final appearance of the surgical specimen. Cervical anastomosis was performed with gastric tube and esophageal stent.
From 2018 to 2020, 12 patients with this type of esophageal carcinoma, two is squamous cell carcinoma and 10 adenocarcinoma, were submitted to laparoscopic transhiatal esophagectomy with transcervical access to cervical esophagus dissection and lymphadenectomy. The low-cost single-port device is a useful tool for safely dissecting the structures of the upper mediastinum. Direct visualization of the cervical and upper thoracic esophagus allows for safe dissection with less risk of tracheal injury and hemorrhage from tearing of the larger vessels.
In addition to improving the lymphadenectomy of the left recurrent laryngeal and paratracheal nodes.
