A transdiaphragmatic retroperitoneal approach for lower esophageal and gastroesophageal junction carcinomas

Radical surgery and a regional lymphadenectomy still appear to be the treatment of choice for lower esophageal and gastroesophageal carcinomas. However, in some instances, difficulties can be encountered both in assessing the resectability of tumors extending toward retroperitoneal structures and in performing a lymphadenectomy of the preaortic area extending between the hiatus and celiac axis. For these reasons, we developed a specific transdiaphragmatic retroperitoneal approach. After thoraco-phreno-laparotomy, and exploration of both the thorax and the abdomen to rule out any metastatized disease, an extraperitoneal, posterior phrenotomy is performed from the aortic hiatus and extending anteriorly for 5 cm. This creates an access to the retroperitoneal space and, by incising the arcuate ligament, a wide exposure of the aorta can be obtained at this level. In this way a more complete visualization of the transdiaphragmatic preaortic area and an easier and safer dissection of the preaortic lymphoid tissue is possible.