TRANSDIAPHRAGMATIC APPROACH TO THE POSTERIOR MEDIASTINUM AND THORACICESOPHAGUS

Objective: Complex operations involving the lower esophagus and poster ior mediastinum are frequently compromised by poor exposure, thereby r equiring combined thoracic and abdominal incisions. We describe our te chnique and report our experience with a transdiaphragmatic approach t o the posterior mediastinum that improves exposure and eliminates the need for thoracotomies. Patients: The lower thoracic esophagus and pos terior 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 esophag itis, lye stricture, scleroderma, and achalasia) (n=8), malignant neop lasm 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. Conclusi ons: We believe this transdiaphragmatic approach greatly improves expo sure to the lower and middle esophagus and posterior mediastinum compa red with transhiatal approaches; preserves the integrity of the gastro esophageal junction: allows easy access to the vagus nerves without ri sking esophageal injury in patients who had undergone surgery previous ly; shortens operative time; and lessens pulmonary morbidity and decre ases patients' pain and recovery time when compared with thoracotomy.