Lymphadenectomy with continuous vagus nerve stimulation for recurrent laryngeal nerve monitoring in thoracoscopic esophagectomy

Abstract

Background: Lymphadenectomy by videothoracoscopic (VATS) approach for esophageal cancer is technically challenging. Extended lymphadenectomy may increase the chance of recurrent laryngeal nerve (RLN) injury. Continuous Intraoperative RLN monitoring (CIONM) may help reduce the incidence of nerve injury. We present a video illustrating the use of a system of continuous intraoperative vagus nerve stimulation to monitor RLN function during VATS esophagectomy.

Methods: The patient is placed in the supine position first. The left vagus nerve is exposed between the carotid artery and internal jugular vein via a left cervical approach. A stimulation probe is anchored to the nerve. Continuous vagus nerve stimulation is applied and the functional integrity of the left RLN is monitored by a sensor that is integral with the endotracheal tube. The patient is then placed in the left lateral position for VATS esophagectomy. One lung anaesthesia is achieved by a right bronchial blocker. A 5cm minithoracotomy and 4 other port sites are created. In right RLN nodal dissection, we utilize intermittent stimulation of the right RLN for nerve mapping and testing its integrity, but for the left RLN, CIONM was used since the chance of damaging the left RLN is much higher. Stimulation frequency was set at once per second while left RLN lymphadenectomy is performed. After the VATS phase, the patient is placed again in the supine position for laparoscopic gastric mobilization and the gastric conduit is delivered to the neck for cervical esophagogastrostomy. Nerve monitoring is terminated after completion of the anastomosis.

Results: The patient recovers from his surgery without complication.

Discussion: CIONM with vagus nerve stimulation is a useful adjunct to RLN lymphadenectomy for esophageal cancer.