Mediastinoscopic Esophagectomy

Mediastinoscopic esophagectomy (ME) has been developed and refined as an alternative to open transthoracic esophagectomy (TTE), and then thoracoscopic esophagectomy (TE), for esophageal squamous cell carcinoma (ESCC). Conventional ME, initially developed as an extension of transhiatal esophagectomy (THE), was mainly applied to early-stage tumors or high-risk patients because of its limited ability to achieve mediastinal lymphadenectomy. In recent years, however, the introduction of single-port mediastinoscopy and robot-assisted surgery has enabled safe and reliable dissection in the deep mediastinum, resulting in lymphadenectomy comparable to TTE. These novel approaches, now recognized as transmediastinal radical esophagectomy (TME) or minimally invasive transcervical esophagectomy (MICE), have broadened the indications of ME to include advanced ESCC. Several perioperative strategies have contributed to improving safety and outcomes. Preoperative three-dimensional computed tomography (3D-CT) facilitates precise anatomical evaluation and prediction of surgical difficulty, while continuous intraoperative nerve monitoring (CIONM) helps to reduce recurrent laryngeal nerve (RLN) palsy, one of the major complications of the cervical single-port approach. A recent meta-analysis based on comparative studies has shown that ME is associated with shorter operative time, reduced blood loss, and fewer pulmonary complications compared with TE, although the incidence of RLN palsy remains higher. Survival outcomes appear equivalent, and emerging evidence suggests that robot-assisted TME may even provide a superior long-term survival compared with open TTE. In conclusion, ME represents a valuable minimally invasive option for the treatment of ESCC. Ongoing efforts to standardize surgical techniques, expand robot-assisted surgery application, and optimize perioperative management will be crucial for the safe dissemination.