In the left decubitus position, right posteriolateral thoracotomy at 5th intercostal space or anterolateral thoracotomy at 4th intercostal space is used as a standard open approach under the one lung ventilation anesthesia. After the division of the azygous arch, the posterior side of the right upper mediastinal pleura is incised up to the right subclavian artery. The right bronchial artery is then carefully isolated and preserved in case of open esophagectomy, and the dorsal and left sides of the upper esophagus are dissected from the left pleura. The thoracic duct with fat tissue is mobilized with esophagus from dorsal side to ventral side. Subsequently, the anterior side of the right upper mediastinal pleura is incised along the right vagal nerve up to the right subclavian artery, and the right recurrent laryngeal nerve is identified at the caudal end of the right subclavian artery. To prevent nerve injury, lymph nodes around the right recurrent laryngeal nerve are then carefully dissected sharply without usage of energy devices, and the anterior part of the upper esophagus is circumferentially dissected with the surrounding nodes. Posterior traction of the taped esophagus and anterior traction of the trachea provide an approach area to the left anterior side of the trachea, and the nodes around the left recurrent laryngeal nerve are dissected from the aortic arch level to the cervical area. Sharp dissection procedure without any energy devices is also essential for the lymph node dissection along the left recurrent laryngeal nerve. The left subclavian artery is then exposed to dissect the left recurrent laryngeal lymph nodes. The cranial end of thoracic duct is divided and lymph nodes along left recurrent laryngeal nerve are dissected with upper thoracic part of thoracic duct. During the dissection of the left tracheobronchial lymph nodes, the left recurrent laryngeal nerve under the aortic arch and left bronchial artery were preserved on the right side of the trunk of the left pulmonary artery.
The middle and lower mediastinal pleura are incised along the anterior edge of the vertebrae down to the hiatus, and the posterior side of the middle to lower esophagus dissected to expose the aortic arch and the descending aorta. The thoracic duct is then ligated and divided behind the lower esophagus, and resected with the esophagus. After incision of the anterior side of the middle and lower mediastinal pleura, the esophagus is divided using a linear stapler above the primary tumor, and the proximal stump of the resected esophagus and surrounding tissue are dissected up to the hiatus. Finally, the subcarinal nodes are resected separately to complete the esophageal mobilization and mediastinal lymphadenectomy.
The greater omentum is divided 4 to 5 cm from the arcade of the gastroepiploic vessels and the left gastroepiploic and short gastric vessels are divided along the splenic hilum. The lesser omentum is then opened, the right gastric vessels preserved, and the distal esophagus dissected and mobilized. The distal stump of the esophagus and the dissected mediastinal tissue are then extracted from the thorax to the abdomen. Subsequently, the lymph nodes around the celiac artery are dissected up to the hiatus and the stomach divided from the lesser curvature to the fornix using linear staplers, thus completing gastric conduit formation and abdominal lymphadenectomy.
Esophagogastrostomy was performed after the dissection of cervical paraesophageal and supraclavicular lymph nodes. In this procedure, the cervical esophagus and gastric conduit are anastomosed by circular stapling or by hand-sewing . In cases with carcinoma of the lower thoracic esophagus, lymph node metastases occur mainly in mediastinal and abdominal regions. However, metastases also occur with low frequency in cervical lymph nodes. Hence, this dissection approach is controversial; while some advocate the cervical approach, others regard the thoracic approach as the most adequate procedure.