Surgica/ Oncology 1993; 2: Supplement 1,3-l 1 Endoscopic subtotal oesophagectomy for cancer using the right thoracoscopic approach A. CUSCHIERI Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dondee DDl9SV, UK The technique of right thoracoscopic oesophagectomy and our experience with this approach are reviewed. The procedure enables resection of middle and lower third tumours with lymphadenectomy which is equivalent to that achieved by the standard McKeown operation. Thoracoscopic inspection with biopsy detects small pleural deposits which are missed by the standard preoperative tests including CT scanning. The initial experience with endoscopic oesophagectomy has been favourable in terms of recovery and time spent in the intensive care unit, although the procedure takes significantly longer than the equivalent open dissection of the thoracic oesophagus. Surgical Oncology 1993; 2: Suppl. 1,3-l 1. Keywords: endoscopic oesophagectomy, right thoracoscopic approach. INTRODUCTION Blunt transhiatal oesophagectomy, first reported by Grey Turner [I] and popularized by Orringer and others for both benign and malignant disease [2-51, carries certain advantages over the two-stage Lewis-Tanner procedure [6, 71 or the three-stage oesophagectomy [8], largely due to the avoidance of a thoracotomy. There are, however, some disadvan- tages which are inherent to blunt dissection of the oesophagus. These include blood loss, trauma to the azygos vein, bronchus and recurrent laryngeal nerves. The procedure is particularly difficult in large tumours of the middle third of the oesophagus and the risk of damage to mediastinal structures by the blind dissection is increased if there is extramural spread of the tumour. In addition, cardiac arrythmias are common during the retrocardiac mobilization. Nodal dissection and lymphadenectomy is not possible with blunt transhiatal oesophagectomy and although this may not affect survival in the majority of patients as most oesophageal resections are palliative, the excision of involved lymph nodes may prolong the dysphagia-free survival. The first visually guided technique of endoscopic oeso- Correspondence: Dr A. Cuschieri, Department of Surgery, Ninewells Hospital and Medical School, University of Dundee, Dundee DDl 9SY, UK. phagectomy was reported by Buess eta/. [9] using a specially designed operating mediastinoscope which permits safe perivisceral dissection of the intra- thoracic oesophagus. This technique is suitable for small tumours preferably without extensive node involvement as the scope for lymphadenectomy is limited by this approach. The subtotal right thoracoscopic oesophagectomy [I 0] allows dissec- tion of large thoracic oesophageal tumours and lym- phadenectomy that is equivalent in all respects to that achieved, by the McKeown procedure. In addi- tion, the dissection of the cervical oesophagus is performed largely through the thoracoscopic route. The following account is based on a consecutive series of 27 patients (aged 49-81 years) with histo- logically proven oesophageal cancer worked up for subtotal thoracoscopic oesophagectomy. MATERIALS AND METHODS Indications and contraindications Right subtotal thoracoscopic dissection of the oeso- phagus is indicated for intra-thoracic oesophageal tumours (middle and lower third). It is inadvisable for tumours involving the gastro-oesophageal junc- tion as these require resection of the upper third of the stomach to ensure distal clearance. The proce- 3