ANATOMIC LANDMARKS FOR SAFE MEDIASTINAL ENDOVIDEOSURGICAL NAVIGATION

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Aim. Adequate lymphadenectomy is one of the main factors for a favorable long-term prognosis of surgical treatment of thoracic esophageal cancer. Material and Methods. Superior mediastinal lymph node dissection causes some difficulties. The paratracheal lymph nodes removal increases the risk of injury to the recurrent laryngeal nerves. Using the thoracoscopic extirpation of esophagus requires clear visualization of anatomic landmarks which allows safe and accurate orientating in close proximity to major vascular and neural structures, trachea and bronchi. Results and Discussion. The most important anatomic landmarks for thoracoscopic access to the esophagus from the right pleural cavity are azygos vein and arch of the azygos vein. They are used for subsequent locatingthe bifurcation of the trachea and near lying lymph nodes. Ligation of the azygos vein at the beginning of the operation provides adequate access to the bifurcation of the trachea, the main groups of lymph nodes and the aortic arch. Incision of the pleura in the groove between the azygos vein and the aorta is an important stage of esophageal dissection which permits performing a ligation of the thoracic duct. Clipping of the thoracic duct near the thoracic diaphragm helps to avoid the lymphorrhea in postoperative period. Transaction of the esophagus and the vagus nerves is most preferably performed under the bifurcation of the trachea, after the vagus nerves give off bronchial branches. This prevents impairing lung function. Transection of the esophagus at this level simplifies identification of lymph nodes lying near the recurrent nerves without damaging them. The right recurrent laryngeal nerve is rarely injured during the esophageal mobilization because of its location in the region of the cervical pleura on the lower surface of the right subclavian artery, and because the nerve is well visualized under the pleura. Injury to the left recurrent laryngeal nerve which loops under the aortic arch often occurs in the groove at the junction of the trachea and esophagus. Conclusions. We believe that dissection of the esophagus along its posterior wall, between it and the spine is the least injuring.