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Background Retrosternal reconstruction is associated with a lower risk of mediastinitis, gastro-tracheal fistula, and hiatal hernia. Historically, traumatic manual creation of the retrosternal tunnel has been performed using one's fist. We report a novel and atraumatic laparoscopic procedure to create the retrosternal route. Methods We have laparoscopically created the retrosternal route in 25 thoracoscopic, mediastinoscopic, or robot-assisted minimally invasive esophagectomies since August 2019. Specifically, a peritoneal incision is started at the dorsal side of the xiphoid process. Through a 12-mm port inserted slightly to the right of and superior to the umbilical camera port, we dissect loose connective tissues from the caudal to the cranial side using behind the sternum and inside the internal thoracic vessels as landmarks. The time required to create the route was calculated. Then, the cumulative sum (CUSUM) method and the simple moving average of five cases were used to evaluate the learning curve of this novel procedure. Operative outcomes were analyzed according to the learning curve results and also compared with 25 cases of postmediastinal reconstruction counterparts. Results Twenty-five patients were divided into the early group (six patients) and late group (19 patients) based on the peak of the CUSUM chart. The time required for route creation was 28.5 min (median) in the early and 15 min in the late group, indicating a significant difference (P = 0.038). The overall incidence of pleural injury was 20% (5 of 25 patients), with no significant difference between the groups. There was no significant difference in the incidence of perioperative complications. Also, there were no significant differences in perioperative complications or gastric conduit functions 1 year after surgery between the retrosternal and the postmediastinal reconstruction. Conclusion Laparoscopic creation of a retrosternal route for gastric conduit reconstruction is safe and feasible and has a short learning curve.

Despite the increasing utilization of transanal total mesorectal excision as a promising approach for low rectal cancer, the feasibility and safety of transperineal minimally invasive abdominoperineal resection (tp-APR) remain unclear. In total, 25 patients who underwent tp-APR between April 2017 and May 2020 (tp-APR group) and 27 patients who underwent conventional laparoscopic APR between May 2009 and September 2016 (lap-APR group) for low rectal cancer were enrolled in this retrospective study. Clinical outcomes were compared between the groups before and after propensity score matching. The primary outcome was the incidence of the overall postoperative complications with Clavien–Dindo grade II or above. Standardized technique of tp-APR was also demonstrated. On comparison, operative time, intraoperative blood loss, and overall postoperative complications with Clavien–Dindo grade II or above were significantly less in the tp-APR group both before and after propensity score matching. The rates of urinary disturbance and perineal wound infection were significantly less in the tp-APR group after matching. Further, postoperative hospital stay was significantly shorter in the tp-APR group both before and after matching. However, pathological outcomes did not differ between the groups before and after matching. There has been no local recurrence in the tp-APR group with a median follow-up period of 18 months. Standardized tp-APR for low rectal cancer is feasible and seems superior to conventional laparoscopic APR in terms of short-term outcomes. Further larger-scale studies with a longer follow-up period are required to evaluate oncological outcomes.

Although transanal total mesorectal excision (ta-TME) is adopted for rectal cancer surgery by an increasing number of surgeons, it is still technically challenging. We have employed a lateral-first approach for ta-TME to overcome technical difficulties. However, its outcomes and advantage over conventional laparoscopic TME remain unclear. Thirty-five consecutive patients who underwent ta-TME using a lateral-first approach (the ta-TME group) and 53 consecutive patients who underwent conventional laparoscopic TME (the lap-TME group) for low rectal cancer were included. Propensity score matching (PSM) was used to create balanced cohorts of ta-TME (n = 28) and lap-TME (n = 28). Their clinical outcomes were compared after PSM. The operative time and intraoperative blood loss were significantly lower in the ta-TME group than in the lap-TME group (P = 0.042 and P

Background Recently to improve depth perception, the performance of three-dimensional (3D) laparoscopic surgeries has increased. However, the effects of laparoscopic training using 3D are still unclear. This study aimed to clarify the effects of using a 3D monitor among novices in the early phase of training. Methods Participants were 40 novices who had never performed laparoscopic surgery (20 medical students and 20 junior residents). Three laparoscopic phantom tasks (task 1: touching markers on a flat disk with a rod; task 2: straight rod transfer through a single loop; and task 3: curved rod transfer through two loops) in the training box were performed ten times, respectively. Performances were recorded by an optical position tracker. The participants were randomly divided into two groups: one group performed each task five times initially under a 2D system (2D start group), and the other group performed each task five times under a 3D system (3D start group). Both groups then performed the same task five times. After the trial, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and the learning curves for both groups. Results Scores for all tasks performed under the 3D system were significantly better than scores for tasks using the 2D system. Scores for each task in the 2D start group improved after switching to the 3D system. However, scores for each task in the 3D start group were worse after switching to the 2D system, especially scores related to technical errors. Conclusions The stereoscopic vision improved laparoscopic surgical techniques of novices from the early phase of training. However, the performance of novices trained only by 3D worsened by changing to the 2D environment.

Laparoscopic complete mesocoloic excision (CME) with central vascular ligation for splenic flexure cancer is technically challenging because of its anatomical complexity. Although embryological and anatomical consideration should be helpful to perform CME in colorectal cancer surgery, such studies on the splenic flexure are lacking. The splenic flexure is located embryologically between the terminal portion of the midgut and the beginning of the hindgut, and is supplied by the superior mesenteric and inferior mesenteric arteries. The mesentery of the transverse and descending colon originally is a continuous sheet, although they rotate and partially fuse to each other during development. Our surgical strategy was excision of the transverse and descending mesocolon with ligation of the left colic artery and left branch of the middle colic artery, and extraction of the specimen in an intact package wrapped by the embryological planes. We performed laparoscopic surgery according to our surgical strategy in 17 patients with splenic flexure colon cancer. There were no conversions to open surgery or serious intraoperative complications. Two patients had pathological stage (pStage) I, 5 pStage II, 9 pStage III, and 1 pStage IV disease. No patient had recurrence except for 1 with pStage IV cancer, with a median follow-up of 16 months. Our laparoscopic CME technique is feasible for treatment of splenic flexure cancer. Knowledge of anatomy based on embryology is essential to perform this surgery.

Background During the past decade, minimally invasive esophagectomy (MIE) for esophageal cancer has been adopted worldwide with expectations of lower invasiveness. However, the rate of postoperative pneumonia, which is an independent risk factor for oncological prognosis in esophageal cancer, remains high. The aim of this retrospective follow-up study is to clarify whether there is a strong correlation between recurrent laryngeal nerve (RLN) palsy and postoperative pneumonia in MIE. Methods This retrospective follow-up study included 209 patients with esophageal cancer who underwent thoracoscopic esophagectomy in the prone position (TEP) at Kobe University between 2011 and 2018. Inclusion criteria included age 18-85 years; cT1-3, cN0-3 disease; upper mediastinal lymphadenectomy; and ability to undergo simultaneous esophagectomy and reconstruction of the gastric conduit or pedicled jejunum. Univariate and multivariate logistic regression were conducted to identify independent risk factors for pneumonia. Results Among 209 TEPs, pneumonia of Clavien-Dindo classification grade > II occurred in 44 patients (21%). In the pneumonia positive and negative groups, there were significant differences in age (67.9 ± 7.5 vs. 64.9 ± 8.6 years), 3-field lymph node dissection [27 (61%) vs. 67 (41%)], transfusion [20 (45%) vs. 41 (25%)], left RLN palsy [19 (43%) vs. 18 (11%)], and any RLN palsy [20 (45%) vs. 18 (11%)]. In multivariate analysis, any RLN palsy was associated with a higher incidence of pneumonia [odds ratio (OR), 6.210; 95% confidence interval (CI), 2.728-14.480; P < 0.0001]. In addition, age was associated with a higher incidence of pneumonia (OR, 1.049; 95% CI, 1.001-1.103; P = 0.046). Changes in the rate of any RLN palsy over time were quite similar to changes in the incidence of pneumonia. Conclusion There is a strong correlation between RLN palsy and pneumonia in MIE for esophageal cancer. Prevention of RLN palsy may reduce the incidence of pneumonia, leading to better oncological prognosis.

In esophageal squamous cell carcinoma, the number of dissected lymph nodes (LNs), including those along the recurrent laryngeal nerves (RLNs), influences prognosis and nodal staging accuracy. However, dissection of LNs along the RLN increases the risk of complications, especially RLN palsy. Therefore, complete dissection of these LNs with prevention of RLN palsy is recommended. We present herein a new method for lymphadenectomy along the right RLN, named the Pincers maneuver, during thoracoscopic esophagectomy in the prone position (TEP). The fundamental concept in this new method is to first exfoliate the two-dimensional membrane (lateral pedicle), which includes the right RLN, LNs along the right RLN, and the primary esophageal artery, from the right side of the trachea toward the neck. Using a Pincers strategy, closing in from the inner and outer sides of the two-dimensional membrane (lateral pedicle), lymphadenectomy along the right RLN toward the right inferior thyroid artery should be easy. This technique was evaluated in 30 consecutive cases of TEP for squamous cell cancer. There were 15 patients who underwent the new method (Pincers maneuver; Pm) and 15 patients who underwent the conventional method (Cm). There were no significant differences between the two groups in the duration of the thoracic procedure and dissection along the right RLN. No intraoperative and postoperative morbidity related to the right RLN was observed in either group. The Pm group had a higher number of dissected LNs along the right RLN than the Cm group (6.3 vs 3.1, p = 0.044). The Pincers maneuver for lymphadenectomy along the right RLN during TEP is technically safe and feasible. It increases the number of dissected LNs along the right RLN.

Laparoscopic lateral pelvic lymph node dissection (LLND) has been reported to be feasible; however, studies comparing the outcomes of laparoscopic LLND with that of open LLND following preoperative chemoradiotherapy (CRT) are limited. Between November 2005 and October 2017, 38 patients with locally advanced rectal cancer underwent total mesorectal excision and LLND following preoperative CRT at Kobe University Hospital. The data of the patients who underwent open LLND (OP group, n = 19) and laparoscopic LLND (LAP group, n = 19) were retrospectively collected and compared. The operative time was significantly longer in the LAP group compared with that in the OP group. However, the volume of blood loss was significantly higher, and transfusion was more frequently performed in the OP group than in the LAP group. The number of LLNs harvested in the LAP group was significantly higher than that in the OP group. The prevalence of perineal wound infection and bowel obstruction was significantly higher in the OP group than in the LAP group. However, no significant differences were observed between the groups in terms of 5-year overall survival, relapse-free survival, and local recurrence-free survival. Laparoscopic LLND is feasible and safe for patients with rectal cancer who were treated with preoperative CRT. Compared with open LLND, laparoscopic LLND might have several advantages such as higher yields of dissected LLNs and lower incidences of perineal wound infection and bowel obstruction.

Recently, several new imaging technologies, such as three-dimensional (3D)/high-definition (HD) stereovision and high-resolution two-dimensional (2D)/4K monitors, have been introduced in laparoscopic surgery. However, it is still unclear whether these technologies actually improve surgical performance. Participants were 11 expert laparoscopic surgeons. We designed three laparoscopic suturing tasks (task 1: simple suturing, task 2: knotting thread in a small box, and task 3: suturing in a narrow space) in training boxes. Performances were recorded by an optical position tracker. All participants first performed each task five times consecutively using a conventional 2D/HD monitor. Then they were randomly divided into two groups: six participants performed the tasks using 3D/HD before using 2D/4K; the other five participants performed the tasks using a 2D/4K monitor before the 3D/HD monitor. After the trials, we evaluated the performance scores (operative time, path length of forceps, and technical errors) and compared performance scores across all monitors. Surgical performances of participants were ranked in decreasing order: 3D/HD, 2D/4K, and 2D/HD using the total scores for each task. In task 1 (simple suturing), some surgical performances using 3D/HD were significantly better than those using 2D/4K (P = 0.017, P = 0.033, P = 0.492 for operative time, path length, and technical errors, respectively). On the other hand, with operation in narrow spaces such as in tasks 2 and 3, performances using 2D/4K were not inferior to 3D/HD performances. The high-resolution images from the 2D/4K monitor may enhance depth perception in narrow spaces and may complement stereoscopic vision almost as well as using 3D/HD. Compared to a 2D/HD monitor, a 3D/HD monitor improved the laparoscopic surgical technique of expert surgeons more than a 2D/4K monitor. However, the advantage of 2D/4K high-resolution images may be comparable to a 3D/HD monitor especially in narrow spaces.

While thoracoscopic esophagectomy is a widely performed surgical procedure, only few studies regarding the influence of body position on changes in circulation and breathing, after the surgery, have been reported. This study aimed at evaluating the effect of body position, during surgery, on the postoperative breathing functions of the chest. A total of 266 patients who underwent right-sided transthoracic esophagectomy for esophageal cancer from 2004 to 2012 were included in this study. Fifty-four of them underwent open thoracotomies in the left lateral decubitus position (Group O), 108 underwent thoracoscopic esophagectomy in the left lateral decubitus position (Group L) and 104 patients were treated by thoracoscopic esophagectomy in the prone position (Group P). Two patients in Group P, who presented with intra-operative bleeding and underwent thoracotomy, were subsequently excluded from the pulmonary function analysis. Two patients in Group P had to be changed from the prone position to the lateral decubitus position and underwent thoracotomy in order to control intra-operative bleeding. Despite the significantly longer chest operation period in Group P, total blood loss was significantly lower in this group when compared to Groups O and L. Furthermore, patients in Group P presented with significantly lower water balance during the perioperative period and markedly higher SpO2/FiO2 ratio after the surgery. The incidence of respiratory complications was significantly higher in Group O when compared to the other two groups; however, no significant differences were observed between the Groups L and P. The findings of this study demonstrate that thoracoscopic esophagectomy in the prone position improves postoperative oxygenation and is therefore a potentially superior surgical approach.

In esophageal cancer, lymph nodes along the recurrent laryngeal nerves (RLNs) are thought to be highly involved. Complete dissection of these lymph nodes is recommended but there is limited working space in the left upper mediastinum and advanced dissection skills are required. We present herein a new method for lymphadenectomy along the left RLN, called the Bascule method during prone esophagectomy. The fundamental concept of this new method is to draw the proximal portion of the divided esophagus and tissue that includes the left RLN and lymph nodes through a gap between the vertebral body and the right scapula. Using this technique, a two-dimensional membrane, similar to the “esophageal mesenteriolum” (lateral pedicle), will be easily recognizable. Identification and reliable cutting of the tracheoesophageal artery and distinguishing the left RLN from the lymph nodes should be easy. This technique was evaluated in 39 consecutive cases of prone esophagectomy for squamous cell cancer. There were 18 patients who underwent the new method (Bascule method; Bm) and 21 patients who underwent the conventional method (Cm). The duration of the thoracic procedure and dissection along the left RLN was significantly shorter in Bm group than in Cm group (258 ± 30 vs. 291 ± 39 min; p = 0.007 and 66 ± 9 vs. 75 ± 14 min; p = 0.036, respectively). Estimated blood loss in Bm group was 20 ± 11 g compared to 38 ± 32 g in Cm group (p = 0.028). No intraoperative morbidity related to the left RLN was observed in either group. The hoarseness rate in Bm group was 28 %, which was lower than that in the Cm group (48 %). The Bascule method for lymphadenectomy along the left RLN during prone esophagectomy is technically safe and feasible and reduces operative time and blood loss.

Totally laparoscopic distal gastrectomy (TLDG) with intracorporeal anastomosis has been introduced to achieve safer anastomosis with good vision, and a small wound. However, little is known about the surgical outcomes of newly introduced TLDG compared with established procedures of laparoscopy-assisted gastrectomy (LADG) with extracorporeal anastomosis. This retrospective study included 114 patients who underwent laparoscopic distal gastrectomy (LDG) between January 2010 and September 2012. The patients were classified into two groups according to the approach of reconstruction (LADG group: n = 74; TLDG group: n = 40). The parameters analyzed included patients, operation details, and operative outcomes. No complication was observed in the TLDG group. Surgical outcomes of the TLDG group, such as mean operation time, estimated blood loss, and rate of conversion to laparotomy were not inferior to the LADG group. Furthermore, postoperative hospital stay of the TLDG group was significantly shorter than the LADG group (p