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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

尚晓滨, 段晓峰, 岳杰, 马钊, 陈传贵, 张辰, 屈大望, 姜宏景

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
引用本文: 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
Shang Xiaobin, Duan Xiaofeng, Yue Jie, et al. Strategies and technical key points of lymph node dissection along the left recurrent laryngeal nerve in robot-assisted esophagectomy[J]. Chinese Journal of Digestive Surgery, 2021, 20(5): 497-503. DOI: 10.3760/cma.j.cn115610-20210331-00160
Citation: Shang Xiaobin, Duan Xiaofeng, Yue Jie, et al. Strategies and technical key points of lymph node dissection along the left recurrent laryngeal nerve in robot-assisted esophagectomy[J]. Chinese Journal of Digestive Surgery, 2021, 20(5): 497-503. DOI: 10.3760/cma.j.cn115610-20210331-00160

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

基金项目: 

京津冀三地基础研究项目 20JCZXJC00050

中国临床肿瘤学会(CSCO)临床肿瘤学研究基金 Y-MSD2020-0346

天津市卫生健康科技人才培育项目 KJ20135

详细信息
    通讯作者:

    姜宏景,Email:jianghj@vip.163.com

Strategies and technical key points of lymph node dissection along the left recurrent laryngeal nerve in robot-assisted esophagectomy

Funds: 

Basic Research Program of Beijing-Tianjin-Hebei Region 20JCZXJC00050

Clinical Oncology Research Fund of Chinese Society of Clinical Oncology Y-MSD2020-0346

Tianjin Health Science and Technology Talent Cultivation Project KJ20135

More Information
  • 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.

  • 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

  • 图  1   左侧喉返神经旁淋巴结清扫边界示意图

    Figure  1.   Schematic diagram of the boundary of lymph node dissection along the left recurrent laryngeal nerve

    图  2   术中左侧喉返神经旁淋巴结清扫边界图

    Figure  2.   Intraoperative boundary diagram of lymph node dissection along the left recurrent laryngeal nerve

    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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  • [1]

    ChenW, ZhengR, BaadePD, et al. Cancer statistics in China,2015[J]. CA Cancer J Clin,2016,66(2):115‑132. DOI: 10.3322/caac.21338.

    [2]

    StraatmanJ, van der WielenN, CuestaMA, et al. Minimally invasive versus open esophageal resection: three‑year follow‑up of the previously reported randomized con-trolled trial: the time trial[J]. Ann Surg,2017,266(2):232‑ 236. DOI: 10.1097/SLA.0000000000002171.

    [3]

    WekslerB, SullivanJL. Survival after esophagectomy: a propensity‑matched study of different surgical approa-ches[J]. Ann Thorac Surg,2017,104(4):1138‑1146. DOI: 10.1016/j.athoracsur.2017.04.065.

    [4]

    YamashitaK, WatanabeM, MineS, et al. Minimally invasive esophagectomy attenuates the postoperative inflammatory response and improves survival compared with open esophagectomy in patients with esophageal cancer: a propensity score matched analysis[J]. Surg Endosc,2018,32(11):4443‑4450. DOI: 10.1007/s00464-018-6187-z.

    [5]

    KauppilaJH, HelminenO, KytöV, et al. Short‑term out-comes following minimally invasive and open esophagec-tomy: a population‑based study from finland and sweden[J]. Ann Surg Oncol,2018,25(1):326‑332. DOI: 10.1245/s10434-017-6212-9.

    [6]

    LengX, HeW, YangH, et al. Prognostic impact of postoperative lymph node metastases after neoadjuvant chemoradiotherapy for locally advanced squamous cell carcinoma of esophagus: from the results of neocrtec 5010, a randomized multicenter study[J]. Ann Surg,2019[Oline ahead of print]. DOI: 10.1097/SLA.0000000000003727.

    [7]

    WangZ, MaoY, GaoS, et al. Lymph node dissection and recurrent laryngeal nerve protection in minimally invasive esophagectomy[J]. Ann N Y Acad Sci,2020,1481(1):20‑29. DOI: 10.1111/nyas.14427.

    [8]

    RiceTW, IshwaranH, HofstetterWL, et al. Recommen-dations for pathologic staging (pTNM) of cancer of the esophagus and esophagogastric junction for the 8th edition AJCC/UICC staging manuals[J]. Dis Esophagus,2016,29(8):897‑905. DOI: 10.1111/dote.12533.

    [9]

    Japanese Classification of Esophageal Cancer, 11th Edition: part Ⅰ[J]. Esophagus,2017,14(1):1‑36. DOI:10.1007/s10 388-016-0551-7.

    [10]

    MatsudaS, TakeuchiH, KawakuboH, et al. Three‑field lymph node dissection in esophageal cancer surgery[J]. J Thorac Dis,2017,9(Suppl 8):S731-S740. DOI: 10.21037/jtd.2017.03.171.

    [11]

    WangZ, LinS, WangF, et al. Salvage lymphadenectomy for isolated cervical lymph node recurrence after curative resection of thoracic esophageal squamous cell carcinoma[J]. Ann Transl Med,2019,7(11):238. DOI:10.21037/atm. 2019.04.64.

    [12]

    TachimoriY, OzawaS, NumasakiH, et al. Efficacy of lymph node dissection by node zones according to tumor location for esophageal squamous cell carcinoma[J]. Esophagus,2016,13:1‑7. DOI: 10.1007/s10388-015-0515-3.

    [13]

    WuJ, ChenQX, ZhouXM, et al. Does recurrent laryngeal nerve lymph node metastasis really affect the prognosis in node‑positive patients with squamous cell carcinoma of the middle thoracic esophagus?[J]. BMC Surg,2014,14:43. DOI: 10.1186/1471-2482-14-43.

    [14]

    ParkSY, KimDJ, SonT, et al. Extent of mediastinal lymphadenectomy and survival in superficial esophageal squamous cell carcinoma[J]. J Gastrointest Surg,2017,21(10):1584‑1590. DOI: 10.1007/s11605-017-3471-5.

    [15]

    TanZ, MaG, ZhaoJ, et al. Impact of thoracic recurrent laryngeal node dissection: 508 patients with tri‑incisional esophagectomy[J]. J Gastrointest Surg,2014,18(1):187‑ 193. DOI: 10.1007/s11605-013-2411-2.

    [16]

    SudaK, IshidaY, KawamuraY, et al. Robot‑assisted thoracoscopic lymphadenectomy along the left recurrent laryngeal nerve for esophageal squamous cell carcinoma in the prone position: technical report and short‑term outcomes[J]. World J Surg,2012,36(7):1608‑1616. DOI:10. 1007/s00268-012-1538-8.

    [17]

    ChenJ, LiuQ, ZhangX, et al. Comparisons of short‑term outcomes between robot‑assisted and thoraco-laparos-copic esophagectomy with extended two‑field lymph node dissection for resectable thoracic esophageal squamous cell carcinoma[J]. J Thorac Dis,2019,11(9):3874‑3880. DOI: 10.21037/jtd.2019.09.05.

    [18]

    YangY, ZhangX, LiB, et al. Short‑and mid‑term outcomes of robotic versus thoraco‑laparoscopic McKeown esopha-gectomy for squamous cell esophageal cancer: a pro-pensity score‑matched study[J]. Dis Esophagus,2020,33(6):doz080. DOI: 10.1093/dote/doz080.

    [19]

    ChaoYK, HsiehMJ, LiuYH, et al. Lymph node evaluation in robot‑assisted versus video‑assisted thoracoscopic esophagectomy for esophageal squamous cell carcinoma: a propensity‑matched analysis[J]. World J Surg,2018,42(2):590‑598. DOI: 10.1007/s00268-017-4179-0.

    [20]

    DengHY, LuoJ, LiSX, et al. Does robot‑assisted minimally invasive esophagectomy really have the advantage of lymphadenectomy over video‑assisted minimally invasive esophagectomy in treating esophageal squamous cell carcinoma? A propensity score‑matched analysis based on short‑term outcomes[J]. Dis Esophagus,2019,32(7):doy110. DOI: 10.1093/dote/doy110.

    [21]

    LiXK, XuY, ZhouH, et al. Does robot‑assisted minimally invasive oesophagectomy have superiority over thoraco-laparoscopic minimally invasive oesophagectomy in lymph node dissection?[J]. Dis Esophagus,2021,34(2):doaa050. DOI: 10.1093/dote/doaa050.

    [22]

    GongL, JiangH, YueJ, et al. Comparison of the short‑term outcomes of robot‑assisted minimally invasive, video-assisted minimally invasive, and open esophagectomy[J]. J Thorac Dis,2020,12(3):916‑924. DOI:10.21037/jtd.2019. 12.56.

    [23]

    DuanX, YueJ, ChenC, et al. Lymph node dissection around left recurrent laryngeal nerve: robot‑assisted vs. video‑assisted McKeown esophagectomy for esophageal squamous cell carcinoma[J]. Surg Endosc,2020,26:1‑9. DOI: 10.1007/s00464-020-08105-2.

    [24]

    Japan Esophageal Society. Japanese classification of esophageal cancer, 11th edition: part Ⅱ and Ⅲ[J]. Esophagus,2017,14(1):37-65. DOI: 10.1007/s10388-016-0556-2.

    [25]

    CuestaMA, WeijsTJ, BleysRL, et al. A new concept of the anatomy of the thoracic oesophagus: the meso-oeso-phagus. Observational study during thoracoscopic eso-phagectomy[J]. Surg Endosc,2015,29(9):2576‑2582. DOI: 10.1007/s00464-014-3972-1.

    [26]

    TsunodaS, ShinoharaH, KanayaS, et al. Mesenteric excision of upper esophagus: a concept for rational anatomical lymphadenectomy of the recurrent laryngeal nodes in thoracoscopic esophagectomy[J]. Surg Endosc,2020, 34(1):133‑141. DOI: 10.1007/s00464-019-06741-x.

    [27]

    FujiwaraH, KanamoriJ, NakajimaY, et al. An anatomical hypothesis: a "concentric‑structured model" for the theoretical understanding of the surgical anatomy in the upper mediastinum required for esophagectomy with radical mediastinal lymph node dissection[J]. Dis Esophagus,2019,32(8):doy119. DOI: 10.1093/dote/doy119.

    [28]

    ShirakawaY, NomaK, MaedaN, et al.Microanatomy-based standardization of left upper mediastinal lymph node dissection in thoracoscopic esophagectomy in the prone position[J]. Surg Endosc,2021,35(Suppl 1):349-357. DOI: 10.1007/s00464-020-07407-9.

    [29]

    ShirakawaY, NomaK, KunitomoT, et al. Initial introduc-tion of robot-assisted, minimally invasive esophagectomy using the microanatomy-based concept in the upper mediastinum[J]. Surg Endosc,2020[Online ahead of print]. DOI: 10.1007/s00464-020-08154-7.

    [30] 段晓峰,岳杰,陈传贵,等.机器人辅助McKeown食管癌切除术近期疗效分析[J].机器人外科学杂志:中英文,2020,1(5):355-363. DOI: 10.12180/j.issn.2096-7721.2020.05.007.
    [31] 李辉,章智荣.食管癌根治术淋巴结清扫的争议与共识[J]. 中华消化外科杂志,2019,18(1):39-42. DOI: 10.3760/cma.j.issn.1673-9752.2019.01.009.
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  • 收稿日期:  2021-03-30
  • 网络出版日期:  2024-07-18
  • 刊出日期:  2021-05-19

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