Skip to main content


Log in

Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal cancer

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript



A thoracoabdominal esophagectomy for esophageal cancer is a severely invasive procedure. A thoracoscopic esophagectomy may minimize injury to the chest wall and reduce surgical invasiveness. Conventional thoracoscopic procedures are performed in the left lateral-decubitus position. Recently, procedures performed in the prone position have received more attention because of improvements in operative exposure or surgeon ergonomics. However, the efficacy of the prone position in an aggressive thoracoscopic esophagectomy with an extensive lymphadenectomy has not been fully documented.


We successfully performed a thoracoscopic esophagectomy with a three-field extensive lymphadenectomy in 43 esophageal carcinoma patients in the prone position from December 2007 to December 2009. We describe our procedures with the patients in the prone position, focusing especially on a lymphadenectomy along the left recurrent laryngeal nerve where the nodes are frequently involved and precise dissection is technically challenging. To determine further the advantages of this position, we retrospectively compared surgical outcomes in 43 patients to those of 34 patients who underwent a thoracoscopic esophagectomy in the left lateral decubitus position as a historical control from January 2006 to November 2007.


It was easier to explore the operative field around the left recurrent laryngeal nerve during a thoracoscopic esophagectomy in the prone position. The mean duration of the aggressive thoracoscopic procedure in the prone position was 307 min, which was significantly longer than in the left lateral decubitus position, but the total estimated blood loss in the prone position was significantly lower. There was no difference in the incidence of postoperative complications between the two procedures.


A thoracoscopic esophagectomy in the prone position is technically safe and feasible and provides better surgeon ergonomics and better operative exposure around the left recurrent laryngeal nerve during an aggressive esophagectomy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2
Fig. 3

Similar content being viewed by others


  1. Akiyama H, Tsurumaru M, Udagawa H, Kajiyama Y (1994) Radical lymph node dissection for cancer of the thoracic esophagus. Ann Surg 220(3):364–372

    Article  CAS  PubMed  Google Scholar 

  2. Fujita H, Kakegawa T, Yamana H, Shima I, Toh Y, Tomita Y, Fujii T, Yamasaki K, Higaki K, Noake T et al (1995) Mortality and morbidity rates, postoperative course, quality of life, and prognosis after extended radical lymphadenectomy for esophageal cancer. Comparison of three-field lymphadenectomy with two-field lymphadenectomy. Ann Surg 222(5):654–662

    Article  CAS  PubMed  Google Scholar 

  3. Watson A (1994) Operable esophageal cancer: current results from the West. World J Surg 18(3):361–366

    Article  CAS  PubMed  Google Scholar 

  4. Cuschieri A, Shimi S, Banting S (1992) Endoscopic oesophagectomy through a right thoracoscopic approach. J R Coll Surg Edinb 37(2):7–11

    CAS  PubMed  Google Scholar 

  5. Akaishi T, Kaneda I, Higuchi N, Kuriya Y, Kuramoto J, Toyoda T, Wakabayashi A (1996) Thoracoscopic en bloc total esophagectomy with radical mediastinal lymphadenectomy. J Thorac Cardiovasc Surg 112(12):1533–1540

    CAS  PubMed  Google Scholar 

  6. Smithers BM, Gotley DC, McEwan D, Martin I, Bessell J, Doyle L (2001) Thoracoscopic mobilization of the esophagus. A 6 year experience. Surg Endosc 15(2):176–182

    Article  CAS  PubMed  Google Scholar 

  7. Taguchi S, Osugi H, Higashino M, Tokuhara T, Takada N, Takemura M, Lee S, Kinoshita H (2003) Comparison of three-field esophagectomy for esophageal cancer incorporating open or thoracoscopic thoracotomy. Surg Endosc 17(9):1445–1450

    Article  CAS  PubMed  Google Scholar 

  8. Osugi H, Takemura M, Higashino M, Takada N, Lee S, Kinoshita H (2003) A comparison of video-assisted thoracoscopic oesophagectomy and radical lymph node dissection for squamous cell cancer of the oesophagus with open operation. Br J Surg 90(1):108–113

    Article  CAS  PubMed  Google Scholar 

  9. Luketich JD, Alvelo-Rivera M, Buenaventura PO, Christie NA, McCaughan JS, Litle VR, Schauer PR, Close JM, Fernando HC (2003) Minimally invasive esophagectomy. Outcomes in 222 patients. Ann Surg 238(4):486–495

    PubMed  Google Scholar 

  10. Braghetto I, Csendes A, Cardemil G, Burdiles P, Korn O, Valladares V (2006) Open transthoracic or transhiatal esophagectomy versus minimally invasive esophagectomy in terms of morbidity, mortality and survival. Surg Endosc 20(11):1681–1686

    Article  CAS  PubMed  Google Scholar 

  11. Smithers BM, Gotley DC, Martin I, Thomas JM (2007) Comparison of the outcomes between open and minimally invasive esophagectomy. Ann Surg 245(2):232–240

    Article  PubMed  Google Scholar 

  12. Berrisford RG, Wajed SA, Sanders D, Rucklidge MWM (2008) Short-term outcomes following total minimally invasive oesophagectomy. Br J Surg 95(5):602–610

    Article  CAS  PubMed  Google Scholar 

  13. Palanivelu C, Prakash A, Senthikumar R, Senthilnathan P, Parthasarathi R, Rajan PS, Venkatachlam S (2006) Minimally invasive esophagectomy: thoracoscopic mobilization of the esophagus and mediastinal lymphadenectomy in prone position - experience of 130 patients. J Am Coll Surg 203(1):7–16

    Article  PubMed  Google Scholar 

  14. Fabian T, McKelvey AA, Kent MS, Federico JA (2007) Prone thoracoscopic esophageal mobilization for minimally invasive esophagectomy. Surg Endosc 21(9):1667–1670

    Article  CAS  PubMed  Google Scholar 

  15. Cadière GB, Torres R, Dapri G, Capelluto E, Hainaux B, Himpens J (2006) Thoracoscopic and laparoscopic oesophagectomy improves the quality of extended lymphadenectomy. Surg Endosc 20(8):1308–1309

    Article  PubMed  Google Scholar 

  16. Fabian T, Martin J, Katigbak M, McKelvey AA, Federico JA (2008) Thoracoscopic esophageal mobilization during minimally invasive esophagectomy: a head-to-head comparison of prone versus decubitus positions. Surg Endosc 22(11):2485–2491

    Article  PubMed  Google Scholar 

  17. Noshiro H, Nagai E, Shimizu S, Uchiyama A, Kojima M, Tanaka M (2007) Minimally invasive radical esophagectomy for esophageal cancer. Esophagus 4(1):59–65

    Article  Google Scholar 

  18. Watanabe H, Kato H, Tachimori Y (2000) Significance of extended systemic lymph node dissection for thoracic esophageal carcinoma in Japan. Recent Results Cancer Res 155:123–133

    CAS  PubMed  Google Scholar 

  19. Shiozaki H, Yano M, Tsujinaka T, Inoue M, Tamura S, Doki Y, Yasuda T, Fujiwara Y, Monden M (2001) Lymph node metastasis along the recurrent nerve chain is an indication for cervical lymph node dissection in thoracic esophageal cancer. Dis Esophagus 14(3–4):191–196

    Article  CAS  PubMed  Google Scholar 

  20. Tsurumaru M, Kajiyama Y, Udagawa H, Akiyama H (2001) Outcomes of extensive lymph node dissection for squamous cell carcinoma of the thoracic esophagus. Ann Thoracic Cardiovasc Surg 7(6):325–329

    CAS  Google Scholar 

  21. Nishimaki T, Suzuki T, Tanaka Y, Nakagawa S, Aizawa K, Hatakeyama K (1997) Evaluating the rational extent of dissection in radical esophagectomy for invasive carcinoma of the thoracic esophagus. Surg Today 27(1):3–8

    Article  CAS  PubMed  Google Scholar 

  22. Lerut T, Nafteux P, Moons J, Coosemans W, Decker G, De Leyn P, Van Raemdonck D, Ectors N (2004) Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: impact on staging, disease-free survival, and outcome: a plea for adaptation of TNM classification in upper-half esophageal carcinoma. Ann Surg 240(6):962–974

    Article  CAS  PubMed  Google Scholar 

  23. Snedecor GW, Cochran WG (1980) Statistical methods. Iowa State University Press, Ames

    Google Scholar 

  24. Cuschieri A (1994) Thoracoscopic subtotal oesophagectomy. Endosc Surg Allied Technol 2(1):21–25

    CAS  PubMed  Google Scholar 

  25. Isono K, Sato H, Nakayama K (1991) Results of nationwide study on the three-field lymph node dissection of esophageal cancer. Oncology 48(5):411–420

    Article  CAS  PubMed  Google Scholar 

  26. Igaki H, Tachimori Y, Kato H (2004) Improved survival for patients with upper and/or middle mediastinal lymph node metastasis of squamous cell carcinoma of the lower thoracic esophagus treated with 3-field dissection. Ann Surg 239(4):483–490

    Article  PubMed  Google Scholar 

  27. Peracchia A, Rosati R, Fumagalli U, Bona S, Chella B (1997) Thoracoscopic dissection of the esophagus for cancer. Int Surg 82(1):1–4

    CAS  PubMed  Google Scholar 

  28. Swanson SJ, Batirel HF, Bueno R, Jaklitsch MT, Lukanich JM, Allred E, Mentzer SJ, Sugarbaker DJ (2001) Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma. Ann Thorac Surg 72(6):1918–1924

    Article  CAS  PubMed  Google Scholar 

  29. Gluch L, Smith RC, Bambach CP, Brown AR (1999) Comparison of outcomes following transhiatal or Ivor Lewis esophagectomy for esophageal carcinoma. World J Surg 23(3):271–275

    Article  CAS  PubMed  Google Scholar 

  30. Orringer MB, Marshall B, Iannettoni MD (1999) Transhiatal esophagectomy: clinical experience and refinements. Ann Surg 230(3):392–400

    Article  CAS  PubMed  Google Scholar 

  31. Crozier TA, Sydow M, Siewert JR, Braun U (1992) Postoperative pulmonary complication rate and long-term changes in respiratory function following esophagectomy with esophagogastrostomy. Acta Anaesthesiol Scand 36(1):10–15

    Article  CAS  PubMed  Google Scholar 

  32. Ferguson MK, Martin TR, Reeder LB, Olak J (1997) Mortality after esophagectomy: risk factor analysis. World J Surg 21(6):599–603

    Article  CAS  PubMed  Google Scholar 

Download references


The authors are grateful for the technical training and ongoing advice on the prone procedures by Professors Ichiro Uyama and Seiichiro Kanaya in the Department of Surgery of Fujita Health University School of Medicine.


Drs. Hirokazu Noshiro, Tomonori Iwasaki, Kiitiro Kobayashi, Akihiko Uchiyama, Yoshihiro Miyasaka, Toshihiro Masatsugu, Kenta Koike, and Koji Miyazaki have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations


Corresponding author

Correspondence to Hirokazu Noshiro.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Noshiro, H., Iwasaki, H., Kobayashi, K. et al. Lymphadenectomy along the left recurrent laryngeal nerve by a minimally invasive esophagectomy in the prone position for thoracic esophageal cancer. Surg Endosc 24, 2965–2973 (2010).

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: