**7. Conclusion**

tube is removed through the nose by anesthesiologist (**Figure 3B**). The wide operative field of left upper mediastinum is possible using this stripping technique. Lymph node dissection is performed after stripping the residual esophagus [28, 29] (**Figure 4A**). Moreover, working space is created by compressing the right main bronchus or retracting the trachea using a retractor. Lymph node and fat tissue are ablated from the left edge of the trachea, after which lymph node along the left RLN is dissected (**Figure 4B**). An electrical device is used to separate the node from the nerve, and endoscopic scissors and forceps are used during sharp dissection along the nerve. One hundred patients with esophageal carcinomas underwent VATS-E (27 in left lateral position and 73 in prone position). This original technique of lymphadenectomy along the left RLN has been performed in 54 patients in the prone position VATS-E. The rate of transient recurrent laryngeal nerve palsy is 17.2%, but permanent palsy is only 1.2% [29].

**Figure 4.** (A) Lymph node dissection along the lt. RLN. (B) After LN dissection along the lt. RLN.

**Lt.RLN**

**Stomach tube**

**esophagus**

A B

**esophagus**

**Figure 3.** (A) Cutting both the esophagus and stomach tube. (B) Stripping by pulling the stomach tube.

A B

82 Esophageal Abnormalities

**trachea**

**Lt.RLN**

**LN**

Oshikiri et al. developed the "Bascule method" where the proximal portion of the divided esophagus and tissue that includes the left RLN and lymph nodes are drawn through a gap between the vertebral body and the right scapula [30]. The membranous portion between the esophagus and the trachea like the esophageal mesenteriolum is ablated by traction of the tissue including the left RLN and lymph nodes along the left RLN by the proximal esophagus. The lymph node along the left RLN is distinguished from the left RLN and the tracheoesophageal artery on the posterior side of the left RLN can be detected and easily cut by this traction

In eastern countries ESCC is common and lymph node metastasis along the RLN is frequently seen. Many surgeons in Japan, China and India perform thoracoscopic lymph node dissection along the RLN. The prone position allows for visualization of a dry and wide surgical space without the need for special assistants, but there is difficulty in lymph node dissection along the left RLN. To obtain a good and wide operating field for lymph node dissection along the left RLN, only retraction or rotation of the trachea toward the right is insufficient. With our technique, the residual esophagus can easily be pulled up to the neck after sufficient ablation. In this technique, it is not necessary to retract the esophagus with more holes or to fix the esophagus. Esophageal stripping in lymph node dissection is easier and more effective than other methods.

Lymph node dissection along the left RLN after esophageal stripping is possible in the prone position during VATS-E.
