VA02.6. Systematic En-Bloc Upper Mediastinal Dissection in Robot-Assisted Minimally Invasive Esophagectomy

Abstract

Esophageal Cancer: Surgical Treatment of Esophageal Cancer We advocated for the mesenteric excision of the upper esophagus (Surg Endosc., 2019). The mesoesophagus, which is surrounded by fibrous connective tissue (visceral sheath), is an anatomical unit in the upper mediastinum that contains the esophagus, trachea, tracheoesophageal vessels, lymphatic tissue, and the recurrent laryngeal nerve (RLN). In 2012, we began performing robot-assisted minimally invasive esophagectomy (RAMIE) using the da Vinci S system. Since 2018, RAMIE using the da Vinci Xi has been the standard procedure at our institution after national health insurance coverage was approved. Our multi-center cohort study recently reported a significant reduction in postoperative RLN palsy with RAMIE compared with conventional minimally invasive esophagectomy, with comparable long-term outcomes (Ann Surg Oncol. 2026). This video demonstrates a systematic en-bloc upper mediastinal dissection based on the concept of mesenteric excision. The thoracic duct is preserved unless tumor invasion is suspected. First, the tracheoesophageal arteries within the visceral sheath over the RLN are divided, followed by lateral isolation of the RLN. Lymphatic tissue is then dissected along the trachea up to the cervical region. The right cervical paraesophageal node (101R) is dissected via the thoracic approach. The left cervical paraesophageal node (101L) is dissected from the thyroid gland via a cervical procedure under direct vision. This approach is systematically applied bilaterally for RLN nodal dissection.