Techniques for Upper Mediastinal Lymph Node Dissection in Robot-Assisted and Thoracoscopic Minimally Invasive Esophagectomy

Background Our institution introduced thoracoscopic minimally invasive esophagectomy (MIE) in the prone position in 2013 and robot-assisted minimally invasive esophagectomy (RAMIE) in August 2023. As with other robotic gastrointestinal surgeries, RAMIE has been expected to contribute to an increase in overall survival. Therefore, RAMIE will be the first choice in our institution as long as the patient tolerates the procedure. We are also trying to avoid postoperative recurrent laryngeal nerve (RLN) palsy by standardizing the technique of upper mediastinal lymph node dissection in RAMIE and MIE. In this study, we report on the development of a unified this surgical technique. Methods We examined postoperative RLN palsy in 25 of 28 patients who underwent MIE or RAMIE for esophageal cancer between August 2023 and December 2024, excluding those who underwent total laryngectomy and combined resection of t the RLN. It is important to two-dimensional membrane of the RLN to preserve the sympathetic plexus around the artery. Specifically, preserving the plane where the branches of the right thoracic sympathetic ganglion fix the left side of the thoracic duct and esophagus, the left esophageal mesentery was recognized and the lymph nodes from the left RLN was able to be dissected completely. Results Postoperative recurrent nerve palsy of Clavien-Dindo (: CD) classification Grade I or higher was observed in 8 of 33 (24.0%) cases performed from 2019 to 2022. In this study, postoperative recurrent nerve palsy of CD classification Grade I or higher was observed in 4 (16.0%) of 25 cases with devised superior mediastinal lymph node dissection technique, with no significant difference (p = 0.44), but a decreasing trend over time was observed. Conclusion The results of this study suggest that the use of a uniform technique for upper mediastinal lymph node dissection in RAMIE and MIE may reduce postoperative recurrent nerve palsy. We will continue to improve the short-term and long-term outcomes by accumulating more cases in the future.