Anatomical Variations in Critical Structures in Esophageal Surgery: Implications for Personalized Surgery

Esophageal cancer remains a global challenge, with poor overall survival despite advances in multimodal therapy. Surgical resection continues to be the main curative treatment, yet esophagectomy is among the most technically challenging oncological procedures due to the esophagus's location within the densely packed mediastinal corridor. Critical vascular, neural, and lymphatic structures surround the esophagus, and their frequent anatomical variations pose significant risks during mobilization, lymphadenectomy, and reconstruction. This review synthesizes current evidence on the anatomical variability in the vessels, nerves, lymphatics, and fascial compartments relevant to esophageal surgery. Particular emphasis is placed on aberrant arterial and venous patterns, recurrent and non-recurrent laryngeal nerve pathways, thoracic duct variants and atypical courses, and the fascial planes that are used to define surgical boundaries. By shifting the surgical paradigm from standardized anatomical assumptions to patient-specific structural mapping, we highlight how understanding these variations is driving the field of personalized surgical medicine. By integrating these anatomical insights with surgical approaches-including right and left transthoracic, transhiatal, and transcervical techniques-we highlight the implications of variations for intraoperative safety and postoperative outcomes. A thorough understanding of these relationships is essential for surgical planning, minimizing morbidity, and achieving oncological outcomes. Ultimately, a thorough understanding of these relationships is essential for patient-tailored surgical planning.