A Totally Laparoscopic Transhiatal Approach for Esophageal Cancer During Mediastinoscopic Esophagectomy

Background: Mediastinoscopic esophagectomy is a minimally invasive approach that avoids thoracotomy and single-lung ventilation. We previously performed this procedure using hand-assisted laparoscopic surgery (HALS) and recently established a totally laparoscopic transhiatal approach. This retrospective, non-randomized study reported laparoscopic technique and compared the feasibility and surgical outcomes of these approaches. Methods: We retrospectively reviewed 262 patients who underwent radical mediastinoscopic esophagectomy using left cervical and transhiatal approaches at the Kyoto Prefectural University of Medicine between January 2020 and June 2026. HALS was performed in 202 patients and laparoscopy in 60 patients. Surgical procedures and perioperative outcomes were compared between the groups. Results: Blood loss and total operative time did not differ significantly between the groups, although the transhiatal procedure tended to require a longer operative time with laparoscopy (p = 0.09). The approach used for middle mediastinal lymphadenectomy was similar between the two groups (43% vs. 35%, p = 0.28), and the overall number of dissected lymph nodes, excluding the upper mediastinal and cervical nodes, was comparable. However, significantly more abdominal lymph nodes were dissected with laparoscopy than with HALS (17.9 vs. 15.7, p = 0.04). Laparoscopic gastric mobilization and lymph node dissection were safely performed, with no significant differences in the rate of postoperative complications or curability. Conclusions: The totally laparoscopic transhiatal technique is a feasible and safe approach for mediastinoscopic esophagectomy, with surgical outcomes comparable to those of HALS and not inferior abdominal lymph node dissection. It may be particularly advantageous for cases requiring meticulous abdominal lymphadenectomy.