43●● The inferior pulmonary ligament is divided with electrocautery
to the root of the inferior pulmonary vein. Dissection is then
continued on the posterior surface of the pericardium. The
right main bronchus is identified, and lymph nodes and con-
nective tissue inferior to it are taken together with the esopha-
gus. Further dissection will lead to the infracarinal lymph node
package. The infracarinal dissection is followed toward the left
to expose the left main bronchus and the lymph nodes and
fatty tissues inferior to its edge (Fig. 7 ).
●● The mediastinal pleura is incised along the anterior aspect of
the length of the azygos vein from above downwards. Some
surgeons remove the whole length of the azygos vein and its
branches. The posterior limit of dissection can be defined using
the vein as a guide. When the point just above the hiatus is
reached, the dissection plane deepens onto the surface of the
aorta. Anteriorly within the areola tissue between the azygos
vein and the surface of the aorta is the thoracic duct. The tho-
racic duct is identified, isolated, and ligated (Fig. 8 ). When the
dissection reaches the esophagus anteriorly, the thoracic duct,
the areolar, and connective tissue on the aorta is removed en
bloc with the esophagus (see Note 4). This resection continues
from below upwards, until the previous dissection plane from
anteriorly on the left main bronchus is met. The limits of the
lymph node dissection extend inferiorly to the crura of the dia-
phragm, anterior on the pericardium, right main bronchus,
apically at the tracheal bifurcation, and posteriorly from the left
main bronchus along the length of the descending aorta.Fig. 7 Appearance after lower mediastinal dissection, the trachea (T), bronchi
(LMB, RMB), pericardium (P), and aorta (A) are clearly seen. The esophagus and
carinal lymph nodes are resected en bloc (E and C)
Surgery for Esophageal Adenocarcinoma