Transdiaphragmatic approach to the posterior mediastinum and thoracic esophagus

Complex operations involving the lower esophagus and posterior mediastinum are frequently compromised by poor exposure, thereby requiring combined thoracic and abdominal incisions. We describe our technique and report our experience with a transdiaphragmatic approach to the posterior mediastinum that improves exposure and eliminates the need for thoracotomies.

The lower thoracic esophagus and posterior 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 esophagitis, lye stricture, scleroderma, and achalasia) (n = 8), malignant neoplasm of the lower esophagus (n = 3), and revagotomy (n = 3).

All indicated procedures, resections, and esophagogastric, esophagojejunal, or esophagocolonic anastomoses were completed through abdominal and/or cervical incisions. There were no thoracotomies performed.

We believe this transdiaphragmatic approach greatly improves exposure to the lower and middle esophagus and posterior mediastinum compared with transhiatal approaches; preserves the integrity of the gastroesophageal junction; allows easy access to the vagus nerves without risking esophageal injury in patients who had undergone surgery previously; shortens operative time; and lessens pulmonary morbidity and decreases patients' pain and recovery time when compared with thoracotomy.