Strategies and technical key points of lymph node dissection along the left recurrent laryngeal nerve in robot-assisted esophagectomy
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摘要:
食管切除和淋巴结清扫是食管癌治疗的基石,上纵隔淋巴结清扫对于食管癌精准分期和改善病人预后具有重要价值。左侧喉返神经旁淋巴结清扫是食管外科极具挑战的操作,其解剖边界和清扫范围尚无相关共识。近年来,随着腔镜技术尤其是机器人手术系统在食管切除术中的应用,上纵隔微解剖概念的引入,笔者团队提出左侧喉返神经旁淋巴结清扫边界,以实现精准、根治性、规范化清扫。笔者结合中心经验,对机器人手术系统辅助食管切除术左侧喉返神经旁淋巴结解剖边界、清扫范围和技巧进行深入阐述。
Abstract:Esophagectomy and lymph node dissection are the cornerstones for the treatment of esophageal cancer. Upper mediastinal lymph node dissection is of great value for accurate staging and improving the prognosis of patients. Lymph node dissection along the left recurrent laryngeal nerve is the most challenging procedures in esophageal surgery, and there has been no relevant consensus on the scope and boundary of lymph node dissection. In recent years, with the application of endoscopic technology, especially robotic surgery system in esophagectomy, and the introduction of the concept of superior mediastinal microdissection, the authors have proposed the border of lymph node dissection along the left recurrent laryngeal nerve, so as to achieve precise, radical and standardized dissection. Combined with their own experiences, the authors elaborate on the anatomic boundary, extent and technique of lymph node dissection along the left recurrent laryngeal nerve.
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所有作者均声明不存在利益冲突尚晓滨, 段晓峰, 岳杰, 等. 机器人手术系统辅助食管切除术左侧喉返神经旁淋巴结清扫策略和技术要点[J]. 中华消化外科杂志, 2021, 20(5): 497-503. DOI: 10.3760/cma.j.cn115610-20210331-00160.
http://journal.yiigle.com/LinkIn.do?linkin_type=cma&DOI=10.3760/cma.j.cn115610-20210331-00160
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图 3 左侧喉返神经旁淋巴结清扫 3A:暴露左侧喉返神经旁淋巴结区域;3B:应用电钩自左主支气管处紧贴气管左侧缘将此处淋巴结连同周围组织分离;3C:电钩自下而上沿着气管左侧缘将左侧喉返神经旁淋巴结连同周围组织一并分离至左侧喉返神经上界;3D:助手尽量将气管向右侧顺时针旋转暴露,将气管左侧淋巴结及软组织一并分离;3E:自左侧喉返神经上界水平,采用机器人分离钳(MALILAND钳)在分离的淋巴结和软组织间分离喉返神经,采用旋转镂空法彻底分离喉返神经周围淋巴结和软组织;3F:自上而下分离喉返神经周围淋巴结和软组织,直至分离至主动脉弓下水平,彻底裸化左侧喉返神经;3G:分离钳和剪刀交替应用,将淋巴结自喉返神经剥离;3H:整块切除左侧喉返神经旁淋巴结及软组织
Figure 3. Techniques of lymph node dissection along the left recurrent laryngeal nerve 3A: Expose the lymph node area along the left recurrent laryngeal nerve; 3B: Use an electric hook to separate the lymph nodes and surrounding tissues from the left main bronchus close to the left edge of the trachea; 3C: Use an electric hook to separate the lymph nodes and surrounding tissues adjacent to the left recurrent laryngeal nerve from the bottom to the upper boundary along the left edge of the trachea; 3D: The assistant tries to expose the trachea clockwise to the right, and then separates the lymph nodes and soft tissues on the left side of the trachea; 3E: From the upper boundary level of the left recurrent laryngeal nerve, use the robotic separating forceps (MALILAND forceps) to separate the recurrent laryngeal nerve between the free lymph nodes and soft tissues, and use the rotation hollow method to completely separate the peripheral lymph nodes and soft tissues of the recurrent laryngeal nerve; 3F: Separate the lymph nodes and soft tissues along the recurrent laryngeal nerve from top to bottom until it is separated to the level of the sub‑aortic arch, and completely nake the left recurrent laryngeal nerve; 3G: Separating forceps and scissors are applied alternately to peel the lymph nodes from the recurrent laryngeal nerve; 3H: Completely remove the lymph nodes and soft tissues along the left recurrent laryngeal nerve
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