Sternal lifting increases the operating space in esophagectomy via mediastinoscopy: a prospective cohort study

BACKGROUND: Esophagectomy with combined single-port inflatable mediastinoscopy and laparoscopy reduces the risk of postoperative respiratory complications as it obviates the need to pass through the pleural space. However, it has strict indications owing to the narrow space for operation. Therefore, we adopted a sternal lifting method using a retractor that enables the expansion of the operating space, a technique which has not been previously reported. We describe our experience and report the results of an evaluation of this new approach. METHODS: Thirty-nine patients with esophageal squamous cell carcinomas underwent esophagectomy using combined single-port inflatable mediastinoscopy and laparoscopy from March 2019 to August 2021. Among them, 20 cases received sternal suspension [sternal suspension group (SS group)], and 19 cases did not receive sternal suspension [non-sternal suspension group (NSS group)]. The short-term efficacy of the two groups was observed. RESULTS: Patients in the SS group had a shorter intramediastinal operation time (82.50 vs. 110.00 minutes; P<0.001), more dissected chest lymph nodes (14 vs. 12; P=0.036), and a lower incidence of postoperative hoarseness (2 vs. 6; P=0.235) than did those in the NSS group. There were no significant differences between the SS group and NSS group in terms of intraoperative blood loss, postoperative hospital stay, post-surgical pathologic TNM classification (pTNM), post-surgical pathologic tumor classification (pT), post-surgical pathologic extent of lymph node involvement (pN), and total number of dissected lymph nodes. There were no statistical differences in the incidence of anastomotic fistula, respiratory complications, arrhythmia, or chylothorax between the two groups. There was no mortality during hospitalization in the two groups. CONCLUSIONS: Sternal lifting increases the working space in esophagectomy via mediastinoscopy. It can make video-assisted radical esophagectomy by a transmediastinal approach with total pneumomediastinum assistance (VARETT) easier to perform, and sternal suspension in VARETT is safe and effective.