Transdiaphragmatic approach to the posterior mediastinum and thoracic esophagus
R. C. Thirlby, S. J. Kraemer and L. D. Hill
Department of Surgery, Virginia Mason Medical Center, Seattle, Wash.
OBJECTIVE: Complex operations involving the lower esophagus and posterior
mediastinum are frequently compromised by poor exposure, thereby requiring
combined thoracic and abdominal incisions. We describe our technique and
report our experience with a transdiaphragmatic approach to the posterior
mediastinum that improves exposure and eliminates the need for
thoracotomies. PATIENTS: The lower thoracic esophagus and posterior
mediastinum were exposed through a semicircular incision in the central
tendon of the diaphragm. The indications for operation in 14 patients were
benign conditions of the lower esophagus (reflux esophagitis, lye
stricture, scleroderma, and achalasia) (n = 8), malignant neoplasm of the
lower esophagus (n = 3), and revagotomy (n = 3). RESULTS: All indicated
procedures, resections, and esophagogastric, esophagojejunal, or
esophagocolonic anastomoses were completed through abdominal and/or
cervical incisions. There were no thoracotomies performed. CONCLUSIONS: We
believe this transdiaphragmatic approach greatly improves exposure to the
lower and middle esophagus and posterior mediastinum compared with
transhiatal approaches; preserves the integrity of the gastroesophageal
junction; allows easy access to the vagus nerves without risking esophageal
injury in patients who had undergone surgery previously; shortens operative
time; and lessens pulmonary morbidity and decreases patients' pain and
recovery time when compared with thoracotomy.
