胸腔鏡下食道切除術における縦隔左側の郭清と左迷走神経肺枝の温存手技

The procedure of lymph node dissection in the left side of the mediastinum and preservation of the pulmonary branch of left vagal nerve in thoracoscopic esophagectomy

◆要旨：胸腔鏡下食道切除術における食道のテーピングによる中下縦隔左側の郭清手技と左迷走神経肺枝の温存手技について述べる．上縦隔郭清終了後に下縦隔で胸管をクリッピング切断し，下行大動脈壁を露出するように剝離する．その後，食道を腹側に牽引し，左胸膜を露出する層で剝離する．腹側では心囊を露出するように剝離するが，背側の剝離層とは連続性がなく，左側境界の決定ができない．しかし，左下肺静脈の部位では，縦隔左側の境界が決定でき，しかもこの部分で食道をテーピングすると左迷走神経が一緒に牽引できる．このテーピングにより，迷走神経に緊張がかかり肺枝の確認が容易に行えるため，確実な温存が可能となる．

　In this paper, we described the procedure of lymph node dissection in the left side of the middle and lower mediastinum and preservation of the pulmonary branch of the left vagal nerve by taping of the esophagus in thoracoscopic esophagectomy. After the upper mediastinum dissection, the thoracic duct was ligated and cut at the lower mediastinum. From this position, we exfoliated the thoracic duct to the cranial side in the layer exposing a wall of descending aorta. We pulled the esophagus to the ventral side and exfoliated the layer that exposes the left pleura. In the ventral side of the esophagus, we exfoliated to expose the pericardium. However, this exposing layer has no continuity with the exposing layer in the dorsal side, and it is not possible for the decision of the border in the left side of mediastinum. In the site of the left inferior pulmonary vein, we can determine the border of the left side of the mediastinum and can pull up the left vagal nerve together with the esophagus by taping. After this procedure, certain confirmation and preservation of pulmonary branch of left vagal nerve is easily done by submitting tension to left vagal nerve.