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Laparoscopic creation of a retrosternal route for gastric conduit reconstruction

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Abstract

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.

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Funding

This research was not funded by any specific grants from agencies in the public, commercial, or not-for-profit sectors.

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Authors and Affiliations

  1. Division of Gastrointestinal Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Manabu Horikawa, Taro Oshikiri, Gosuke Takiguchi, Naoki Urakawa, Hiroshi Hasegawa, Masashi Yamamoto, Shingo Kanaji, Yoshiko Matsuda, Kimihiro Yamashita, Tetsu Nakamura & Yoshihiro Kakeji

  2. Division of Minimally Invasive Surgery, Department of Surgery, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Takeru Matsuda

  3. Division of Community Medicine and Medical Network, Department of Social Community Medicine and Health Science, Graduate School of Medicine, Kobe University, 7-5-2, Kusunoki-cho, Chuo-ku, Kobe, Hyogo, 650-0017, Japan

    Satoshi Suzuki

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  1. Manabu Horikawa
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  2. Taro Oshikiri
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  13. Yoshihiro Kakeji
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Contributions

MH, YO, and TN: Study conception and design. MH, TO, GT, NU, HH, and TN: Acquisition of data. MH, TO, MY, KY, and TM: Analysis and interpretation of data. MH, TO, SK, and YM: Video editing. MH, TO, and SS: Drafting of manuscript. MH, TO, and YK: Critical revision. All authors belong to Kobe University and read and approved the final manuscript.

Corresponding author

Correspondence to Taro Oshikiri.

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Disclosures

Drs. Manabu Horikawa, Taro Oshikiri, Gosuke Takiguchi, Naoki Urakawa, Hiroshi Hasegawa, Masashi Yamamoto, Shingo Kanaji, Yoshiko Matsuda, Kimihiro Yamashita, Takeru Matsuda, Tetsu Nakamura, Satoshi Suzuki, and Yoshihiro Kakeji have no conflicts of interest or financial ties to disclose.

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Horikawa, M., Oshikiri, T., Takiguchi, G. et al. Laparoscopic creation of a retrosternal route for gastric conduit reconstruction. Surg Endosc 36, 2680–2687 (2022). https://doi.org/10.1007/s00464-021-08745-y

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