食道癌に対する完全腹腔鏡・縦隔鏡下経裂孔的中下縦隔郭清における手技の工夫—食道牽引と縦隔内食道離断の有用性

A method for totally laparo-mediastinoscopic transhiatal middle and lower mediastinal lymph node dissection for esophageal cancer

◆要旨：胸腔鏡下食道切除術は施設により様々な工夫がなされている．筆者らは肺の虚脱を伴う胸部操作時間の短縮を目的に，頸部および腹部操作を先行し可及的縦隔側への剝離郭清を行う術式を施行してきた．最近では完全腹腔鏡・縦隔鏡下に経裂孔的中下縦隔郭清を施行しているが，その工夫として食道牽引と縦隔内食道離断を考案し定型化した．食道を常に牽引することで，剝離層に適度な緊張が加わり，剝離や郭清操作が容易となる．さらに操作が縦隔頭側に進むにつれ，下部食道が視野の妨げとなるため，可及的口側で食道を離断することで，経裂孔的視野が広く確保され安全かつ確実に剝離および郭清操作が可能である．

Thoracoscopic esophagectomy for esophageal cancer is performed via different approaches at each hospital. In order to reduce the thoracoscopic operative time, we perform mediastinal lymph node dissection via the cervical and transhiatal approach whenever possible. Recently totally laparo-mediastinoscopic transhiatal middle and lower lymph node dissection has been performed, and we devised a method involving constant esophageal traction and esophageal transection in the mediastinum. The mediastinal operational field obtains a clear view by transecting the esophagus on the cranial side. Futhermore, towing the thread sutured the transected esophagus to outside the abdominal cavity makes it possible to achieve good visualization of the mediastinum using the assistant's two retractors. The median total operative time was 502 minutes, and the median thoracoscopic operative time was 104 minutes. It is possible to safely perform totally mediastinoscopic middle and lower lymph node dissection with this method.