Totally Laparoscopic Transhiatal Middle and Lower Mediastinal Lymphadenectomy for Esophageal Cancer.

Laparoscopic transhiatal approach to esophagectomy with mediastinal lymphadenectomy usually involves hand-assisted laparoscopic surgery. However, a totally laparoscopic approach can decrease the size of the abdominal wound and curtail the impact on respiration. We present a novel, totally laparoscopic transhiatal technique that may reduce respiratory complications following thoracoscopic esophagectomy. We performed a series of combined, thoracoscopic and laparoscopic, McKeown esophagectomies via a neck-abdominal first approach. Middle and lower mediastinal lymphadenectomy, subtracheal lymph node removal, and esophageal mobilization were performed via a totally laparoscopic transhiatal approach. Subsequently, upper mediastinal lymph nodes were dissected using a thoracoscopic approach. Finally, an esophagogastric anastomosis was constructed in the neck. For the 36 patients in this series, the median values of the total operative duration and the thoracoscopic portion were 499 minutes (range, 315 to 678 min) and 106 minutes (range, 67 to 243 min), respectively. Postoperative pneumonia occurred in 3 (8.3%) patients. Totally laparoscopic transhiatal approach is feasible for esophageal surgery with acceptable short-term outcomes.