2．食道癌に対する縦隔鏡下手術

Transmediastinal Esophagectomy for Esophageal Cancer

縦隔鏡下食道切除術は狭い術野での深部操作を要し，効果的な視野展開，長いデバイスの有効利用，頸部・経裂孔両方向からの立体的縦隔解剖の把握がきわめて重要である．われわれが定型化したen blocな縦隔郭清手技について概説する．

We started performing esophagectomy by a laparoscopic transhiatal approach in 2009. Further, we started performing single-port mediastinoscopic cervical approach in 2014, and developed a technique for total mediastinal lymph node dissection. The upper and middle mediastinal lymph node dissection including lymph nodes along the left recurrent laryngeal nerve, using a left cervical approach, was performed with a single-port technique. This approach with pneumomediastinum improved the visibility and handling in the deep mediastinum around the aortic arch. We recently performed intraoperative monitoring of the recurrent laryngeal nerve using nerve integrity monitor system. For dissection of upper and middle mediastinal lymph nodes, the left recurrent laryngeal nerve was sometimes compressed by the shaft of the sealing device or the retractor. We used continuous monitoring with the automatic periodic stimulation electrode for the left recurrent laryngeal nerve, and immediately recognized dangerous procedures. Furthermore, to understand the anatomy of bilateral bronchial arteries, we performed 3-dimensional computed tomography angiography preoperatively, which was crucial to avoid intraoperative bleeding. Our surgical procedure resulted in a good surgical view, safe en-bloc mediastinal lymph node dissection, and the decrease of postoperative respiratory complications.