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Background <p>Lymphadenectomy along the left recurrent laryngeal nerve (RLN) is essential for curative esophagectomy but carries a high risk of RLN palsy, which impairs postoperative quality of life. Despite advances in robot-assisted minimally invasive esophagectomy (RAMIE), safe and radical dissection around the left RLN remains technically demanding. To achieve both oncological completeness and nerve preservation, we developed a novel Visceral sheath targeted approach (VISTA) based on precise anatomical understanding of the visceral and alar fasciae.</p> Methods <p>This retrospective observational study included 20 consecutive patients who underwent RAMIE with upper mediastinal lymphadenectomy using the VISTA approach for thoracic esophageal cancer between March 2024 and May 2025 at the Wakayama Medical University Hospital. RLN palsy was evaluated via bronchoscopy on postoperative day 1.</p> Results <p>No postoperative RLN palsy (Clavien–Dindo ≥ I) was observed. The median number of dissected lymph nodes along the left RLN was four. Anastomotic leakage was observed in two patients (10%), and no other severe complications classified as Clavien–Dindo grade ≥ IIIa were observed.</p> Conclusion <p>The VISTA approach has enabled anatomically guided, safe, and radical left RLN lymphadenectomy by stabilizing the nerve through the visceral sheath and expanding the operative field without traction. This technique may reduce RLN palsy while maintaining oncological precision, thereby offering a promising and reproducible procedure for upper mediastinal dissection in RAMIE.</p> Graphical Abstract <p></p>

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VIsceral sheath targeted approach for left recurrent laryngeal nerve lymphadenectomy during robot-assisted minimally invasive esophagectomy (VISTA approach)

  • 期刊论文

  • 发表日期：

    2026年3月5日

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  • Keiji Hayata,
  • Junya Kitadani,
  • Taro Goda,
  • Shinta Tominaga,
  • Naoki Fukuda,
  • Tomoki Nakai,
  • Shotaro Nagano,
  • Manabu Kawai

摘要

Background

Lymphadenectomy along the left recurrent laryngeal nerve (RLN) is essential for curative esophagectomy but carries a high risk of RLN palsy, which impairs postoperative quality of life. Despite advances in robot-assisted minimally invasive esophagectomy (RAMIE), safe and radical dissection around the left RLN remains technically demanding. To achieve both oncological completeness and nerve preservation, we developed a novel Visceral sheath targeted approach (VISTA) based on precise anatomical understanding of the visceral and alar fasciae.

Methods

This retrospective observational study included 20 consecutive patients who underwent RAMIE with upper mediastinal lymphadenectomy using the VISTA approach for thoracic esophageal cancer between March 2024 and May 2025 at the Wakayama Medical University Hospital. RLN palsy was evaluated via bronchoscopy on postoperative day 1.

Results

No postoperative RLN palsy (Clavien–Dindo ≥ I) was observed. The median number of dissected lymph nodes along the left RLN was four. Anastomotic leakage was observed in two patients (10%), and no other severe complications classified as Clavien–Dindo grade ≥ IIIa were observed.

Conclusion

The VISTA approach has enabled anatomically guided, safe, and radical left RLN lymphadenectomy by stabilizing the nerve through the visceral sheath and expanding the operative field without traction. This technique may reduce RLN palsy while maintaining oncological precision, thereby offering a promising and reproducible procedure for upper mediastinal dissection in RAMIE.

Graphical Abstract