Thoracoscopic Esophageal Mobilization During Minimally Invasive Esophagectomy: a Head-to-head Comparison of Prone Versus Decubitus Positions

Background: Minimally invasive esophagectomy (MIE) is being performed at an increasing number of institutions. The thoracoscopic portion is generally performed in the left lateral decubitus position. Recently there has been increasing interest in esophageal mobilization in the prone position and the potential benefits of this technique with regard to operative time, surgeon ergonomics, and operative exposure. We sought to objectively compare thoracoscopic mobilization of the esophagus in the left lateral decubitus position versus the prone position and identify potential differences between the two techniques.

Methods: A retrospective review of a prospectively maintained esophagectomy database identified 44 patients undergoing MIE during a 20-month period (June 2005-February 2007). Of these, 32 patients underwent thoracoscopic esophageal mobilization with cervical esophagogastric anastomosis. Eleven cases were performed in the left lateral decubitus position and 21 performed in the prone position.

Results: The patients were comparable in age, tumor stage, and fraction undergoing neoadjuvant therapy. There was no statistically significant difference between decubitus position and prone position with regard to number of lymph nodes procured (14.6 versus 15.5, p = 0.69), complications (6/11 versus 10/21, p = 1.0), length of stay (9 versus 10 days, p = 1.0), or intraoperative blood loss (85 versus 65 cc, p = 0.14). Thoracoscopic operative times were significantly shorter in the prone group than the decubitus group (86 versus 123 min, p = 0.0001).

Conclusions: Prone thoracoscopic esophageal mobilization appears to be equivalent to decubitus thoracoscopic esophageal mobilization with respect to blood loss, number of lymph nodes dissected, and complications, but with a significant reduction in thoracoscopic surgical time.