Name: low-cost single-port (locosp) device for a transcervical approach in minimally invasive transhiatal esophagectomy
Uploaded: 2021-09-11T15:00:00
Description: Watch this Scientific Journal Video about Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy at JoVE.com

The surgical procedure and the protocol were explained to the patients, and they signed a consent form. This study was approved by the local ethics committees of the institutional review board and informed consent were collected from patients, register number 1688/20. Patients who underwent transhiatal esophagectomy were included in the protocol, while those patients who underwent a transthoracic approach were excluded.
1. Production of low-cost single-port device
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	<li>Use a nasogastric...

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	<li>Borggreve, A. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+treatment+of+esophageal+cancer+in+the+era+of+multimodality+management.">Surgical treatment of esophageal cancer in the era of multimodality management.</a> Annals of the New York Academy of Sciences. 1434 (1), 192-209 (2018).</li><li>Kato, H., Nakajima, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatments+for+esophageal+cancer:+a+review.">Treatments for esophageal cancer: a review.</a> General Thoracic and Cardiovascular Surgery. 61 (6), 330-335 (2013).</li><li>Rice, T. W., Patil, D. T., Blackstone, E. H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=8th+edition+AJCC/UICC+staging+of+cancers+of+the+esophagus+and+esophagogastric+junction+application+to+clinical+practice.">8th edition AJCC/UICC staging of cancers of the esophagus and esophagogastric junction application to clinical practice.</a> Annalsof Cardiothoracic Surgery. 6 (2), 119-130 (2017).</li><li>Hulscher, J. B., Tijssen, J. G., Obertop, H., van Lanschot, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transthoracic+versus+transhiatal+resection+for+carcinoma+of+the+esophagus:+a+meta-analysis.">Transthoracic versus transhiatal resection for carcinoma of the esophagus: a meta-analysis.</a> Annals of Thoracic Surgery. 72 (1), 306-313 (2001).</li><li>Rentz, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transthoracic+versus+transhiatal+esophagectomy:+a+prospective+study+of+945+patients.">Transthoracic versus transhiatal esophagectomy: a prospective study of 945 patients.</a> Journal of Thoracic and Cardiovascular Surgery. 125 (5), 1114-1120 (2003).</li><li>Tokairin, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mediastinoscopic+subaortic+and+tracheobronchial+lymph+node+dissection+with+a+new+cervico-hiatal+crossover+approach+in+thiel-embalmed+cadavers.">Mediastinoscopic subaortic and tracheobronchial lymph node dissection with a new cervico-hiatal crossover approach in thiel-embalmed cadavers.</a> International Surgery. 100, 580-588 (2015).</li><li>Fujiwara, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Single-port+mediastinoscopic+lymphadenectomy+along+the+left+recurrent+laryngeal+nerve.">Single-port mediastinoscopic lymphadenectomy along the left recurrent laryngeal nerve.</a> Annals of Thoracic Surgery. 100 (3), 1115-1117 (2015).</li><li>Gupta, V., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Major+airway+injury+during+esophagectomy:+experience+at+a+tertiary+care+center.">Major airway injury during esophagectomy: experience at a tertiary care center.</a> Journal of Gastrointestinal Surgery. 13 (3), 438-441 (2009).</li><li>Hulscher, J. B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Injury+to+the+major+airways+during+subtotal+esophagectomy:+incidence,+management,+and+sequelae.">Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae.</a> Journal of Thoracic and Cardiovascular Surgery. 120 (6), 1093-1096 (2000).</li><li>Fermin, L., Arnold, S., Nunez, L., Yakoub, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Extracorporeal+membrane+oxygenation+for+repair+of+tracheal+injury+during+transhiatal+esophagectomy.">Extracorporeal membrane oxygenation for repair of tracheal injury during transhiatal esophagectomy.</a> Annals of Cardiac Anaesthesia. 20, 67-69 (2017).</li></ol>

The LoCoSP device allows for safer surgery using a transcervical approach in minimally invasive THE. This is accomplished by improving the recognition and dissection of the esophagus, trachea, and the aortic arch under magnified vision. The advantages of THE are amplified. In addition to allowing surgery with less morbidity and fewer pulmonary complications, this technique can improve the dissection of left paratracheal and recurrent lymph nodes. Another advantage of this technique is that it is possible to reduce the ri...

There are multiple options for the treatment of esophageal cancer, which involve endoscopy, surgery1, neoadjuvant, and definitive treatment with chemoradiotherapy2. Esophagectomy is the most important element in the curative treatment of patients with advanced esophageal cancer3, and the two main approaches currently used for surgical treatment are transthoracic esophagectomy (TTE) and transhiatal esophagectomy (THE). However, the choice of approach remains controversial. Since TTE requires pulmonary collapse during surgery, more frequent pulmonary complications are to be expected than in a transhiatal approach. Minimally invasive techniques are used to reduce access trauma to the lungs and others structures of the thorax, but they do not decrease the morbidity in comparison to THE. Thus, minimally invasive THE has become a more attractive option; however, the upper esophagus and upper mediastinum are difficult areas to dissect due to blind areas, and cervical incision might be not enough to allow a safe dissection of the upper part.
Laparoscopic THE reduces morbidity4 and enhances postoperative recovery with no compromise in cancer recurrence or survival5. THE has been shown to decrease the hospital stay, hospital mortality, surgical time, and blood loss. Furthermore, TTE has a higher risk of pulmonary complications. The patient's stay in the intensive care unit is significantly longer after transthoracic resection, and hospital stay is also significantly prolonged. 
However, there is an issue with THE regarding the lymph node dissection, particularly in the upper mediastinum, which is a blind area. This results in a risk of tracheal and vascular lesions during the surgery. Tokairin6 et al. and Fujiwara et al. described a single-port mediastinoscopic method for upper mediastinal dissection in esophageal cancer surgery. This technique enabled clear visualization of the structures around the aortic arch and safe lymphadenectomy7. A low-cost single-port device was developed to improve upper mediastinal dissection using a left transcervical mediastinoscopic approach, which was used to improve the visibility and dissection in the upper mediastinum around the aortic arch. The aim of this project is to describe the step-by-step process of a laparoscopic THE completed using a mediastinoscopy cervical approach with a low-cost single-port device in a rendezvous technique.

low-cost single-port (locosp) device for a transcervical approach in minimally invasive transhiatal esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

The LoCoSP device is a useful tool for safely dissecting the structures of the upper mediastinum. Direct visualization of the cervical and upper thoracic esophagus allows for safe dissection with less risk of tracheal injury and hemorrhage from tearing of the larger vessels, in addition to improving the lymphadenectomy of the left recurrent laryngeal and paratracheal nodes.
From 2018 to 2020, 12 patients with distal esophageal carcinoma (2 squamous cell carcinoma and 10 adenocarcinoma) were su...

Watch this Scientific Journal Video about Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy at JoVE.com

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

We developed a low-cost single-port device to improve upper mediastinal dissection using a left transcervical mediastinoscopic approach, which was used to improve the visibility and dissection in the upper mediastinum around the aortic arch. The aim of this project is to describe the step-by-step process of a laparoscopic transhiatal esophagectomy, completed using a mediastinoscopy cervical approach with a low-cost single-port device in a rendezvous technique. The materials used are a nasogastric tube, one sterile number eight glove, a sterile sponge, three permanent five millimeter trocars and surgical suture materials.One cylinder with a sterile sponge is made. Three glove fingers are used to triangulate the trocars. Little finger, middle finger and thumb.The three trocars pierce the sponge and perform the triangulation. One ring with the nasogastric tube is made. The sponge, the trocars and the glove are placed between the ring to seal the air leak and to stabilize the sutures.The glove is used to cover all the sutures to prevent air leak again. This is the final aspect of the single-port, low-cost device. The operation starts with the laparoscopic access to the peritoneal cavity and inspection to evaluate any possible of liver metastasis, peritoneal carcinomatosis or free fluid.After this inspection, we start to open up the greater curvature with the division of the gastrocolic ligament, preserving the arterial arcade of the right gastroepiploic artery. The left gastroepiploic artery and vein were dissected and divided, after that, they were clipped. Then, we begin the lymphadenectomy of the lesser epiploic cavity, performing the dissection of the lymph nodes around the common hepatic artery and the celiac trunk.We dissect cranially to the origin of the left gastric vein and isolated it from the left gastric artery. We usually use one clip proximally and other distally in the left gastric vein before sealing it. We use two Hem-o-locks proximally and one distally in the left gastric artery before sealing it.After that, we retrieve all lymph nodes around the left gastric artery. We continue the lymphadenectomy through the hiatus. Then we initiate the dissection of the lower mediastinum with the opening of the diaphragmatic crus.Distal esophagus is dissected from the both left and right pillar. We start at the posterior part of the esophagus between the descending aorta and the esophagus. After that, we dissect anterior, lower mediastinal lymphadenectomy with the dissection of the pericardial lymph nodes.We dissect the periesophageal lymph nodes close to the right pleura and left too. We stop the dissection in the transition of the middle to upper mediastinal up to the carina and started dissection with a single-port mediastinoscope surgical approach, using a rendezvous technique. Left cervicotomy is performed with the isolation of the cervical esophagus.We insert the single-port device into the cervical wound and create a pneumomediastinum by carbon dioxide insufflation. We use a five millimeter arch and a harmonic scalpel for esophagus dissection along with a laparoscopic grasper. We dissect the esophagus over the aortic arch and behind the superior portion of the trachea.The dissection of the lymph nodes is performed along the left recurrent laryngeal nerve and parathyroid. After this stage, the esophagus is completely mobilized and we will reach the transhiatal dissection. The cervical esophagus is divided, and the esophagus with the tumor is removed by abdominal incision.Stapling is performed along the greater curvature for the propose of making the gastric tube, which will be drawn for anastomoses in the cervical region. This is the final appearance of the surgical specimen. Cervical anastomosis was performed with gastric tube and esophageal stent.From 2018 to 2020, 12 patients with this type of esophageal carcinoma, two is squamous cell carcinoma and 10 adenocarcinoma, were submitted to laparoscopic transhiatal esophagectomy with transcervical access to cervical esophagus dissection and lymphadenectomy. The low-cost single-port device is a useful tool for safely dissecting the structures of the upper mediastinum. Direct visualization of the cervical and upper thoracic esophagus allows for safe dissection with less risk of tracheal injury and hemorrhage from tearing of the larger vessels.In addition to improving the lymphadenectomy of the left recurrent laryngeal and paratracheal nodes.

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