Recurrent laryngeal nerve lymph node dissection with subcomplete sealing using advanced bipolar energy device in minimally invasive esophagectomy

IntroductionRecurrent laryngeal nerve (RLN) palsy is a complication that must be avoided during esophagectomy. While RLN injury is thought to be caused by thermal spread from electric devices, electric devices are useful to avoid bleeding. When dissecting lymph nodes around RLNs, to seal small vessels, we use subcomplete technique with advanced bipolar. We describe our surgical technique, termed the subcomplete sealing technique, in RLN lymph node dissection.Materials and Surgical TechniqueThe first step is to perform blunt dissection with forceps on both sides of the esophageal branch near the right RLN. A distance of at least 2 mm from the RLN was preferred. Sealing with advanced bipolar often causes tissue shrinkage, pulling the RLN near the device. To prevent this, sealing should be stopped before reaching completion. Although the sealing was not complete, it was sufficient to seal the small vessels. After subcomplete sealing, the sealed tissues were dissected using laparoscopic scissors. The lymph nodes around left RLN are dissected in the same manner.DiscussionA total of 76 patients received esophagectomy with the subcomplete technique. Grade IIIa RLN palsy occurred in three cases (3.95%). Over Grade IIIb RLN palsies did not occur. This subcomplete sealing technique can assist surgeons in performing RLN lymph node dissection without bleeding and increasing the rate of RLN palsy.