title: Surgical anatomy of the supracarinal esophagus based on a minimally invasive approach: vascular and nervous anatomy and technical steps to resection and lymphadenectomy.
abstract: During esophageal dissection and lymphadenectomy of the upper mediastinum by thoracoscopy in prone position, we observed a complex anatomy in which we had to resect the esophagus, dissect vessels and nerves, and take down some of these in order to perform a complete lymphadenectomy. In order to improve the quality of the dissection and standardization of the procedure, we describe the surgical anatomy and steps involved in this procedure.
  
  
  
  We retrospectively evaluated twenty consecutive and unedited videos of thoracoscopic esophageal resections. We recorded the vascular anatomy of the supracarinal esophagus, lymph node stations and the steps taken in this procedure. The resulting concept was validated in a prospective study including five patients.
  
  
  
  Seventy percent of patients in the retrospective study had one right bronchial artery (RBA) and two left bronchial arteries (LBA). The RBA was divided at both sides of the esophagus in 18 patients, with preservation of one LBA or at least one esophageal branch in all cases. Both recurrent laryngeal nerves were identified in 18 patients. All patients in the prospective study had one RBA and two LBA, and in four patients the RBA was divided at both sides of the esophagus and preserved one of the LBA. Lymphadenectomy was performed of stations 4R, 4L, 2R and 2L, with a median of 11 resected lymph nodes. Both recurrent laryngeal nerves were identified in four patients. In three patients, only the left recurrent nerve could be identified. Two patients showed palsy of the left recurrent laryngeal nerve, and one showed neuropraxia of the left vocal cord.
  
  
  
  Knowledge of the surgical anatomy of the upper mediastinum and its anatomical variations is important for standardization of an adequate esophageal resection and paratracheal lymphadenectomy with preservation of any vascularization of the trachea, bronchi and the recurrent laryngeal nerves.
authors.affiliation: Department of Surgery, VU Medical Center, De Boelelaan 117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands. ma.cuesta@vumc.nl.
authors.forename: Miguel A
authors.initials: MA
authors.lastname: Cuesta
authors.affiliation: Department of Surgery, VU Medical Center, De Boelelaan 117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands.
authors.forename: Nicole
authors.identifier: 0000-0002-6166-0382
authors.initials: N
authors.lastname: van der Wielen
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Teus J
authors.initials: TJ
authors.lastname: Weijs
authors.affiliation: Department of Anatomy, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Ronald L A W
authors.initials: RL
authors.lastname: Bleys
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Suzanne S
authors.initials: SS
authors.lastname: Gisbertz
authors.affiliation: Department of Surgery, Gelre Hospital, Apeldoorn, The Netherlands.
authors.forename: Peter
authors.initials: P
authors.lastname: van Duijvendijk
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Richard
authors.initials: R
authors.lastname: van Hillegersberg
authors.affiliation: Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
authors.forename: Jelle P
authors.initials: JP
authors.lastname: Ruurda
authors.affiliation: Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands.
authors.forename: Mark I
authors.initials: MI
authors.lastname: van Berge Henegouwen
authors.affiliation: Department of Surgery, VU Medical Center, De Boelelaan 117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Straatman
authors.affiliation: Department of Surgery, Osaka University, Osaka, Japan.
authors.forename: Harushi
authors.initials: H
authors.lastname: Osugi
authors.affiliation: Department of Surgery, VU Medical Center, De Boelelaan 117, ZH 7F020, 1081 HV, Amsterdam, The Netherlands.
authors.forename: Donald L
authors.initials: DL
authors.lastname: van der Peet
mesh_terms: D000230:Adenocarcinoma / Q000601:surgery*; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D004210:Dissection / Q000379:methods; D004938:Esophageal Neoplasms / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods*; D004947:Esophagus / Q000033:anatomy & histology* / Q000601:surgery; D006801:Humans; D008197:Lymph Node Excision / Q000379:methods*; D008482:Mediastinum; D011446:Prospective Studies; D012189:Retrospective Studies; D013906:Thoracoscopy / Q000379:methods*; D016896:Treatment Outcome; D014741:Video Recording
keywords: Bronchial arteries; Esophagus; Lymphadenectomy; Recurrent laryngeal nerve; Thoracoscopy; Upper mediastinum