Esophageal cancer is the seventh most common malignant tumor worldwide and the sixth leading cause of cancer-related deaths among patients with cancer [1,2]. It has a relatively high incidence in China, with nearly 90% of its pathological types being squamous cell carcinoma [3,4]. However, esophageal cancer has a relatively poor prognosis, with a 5-year survival rate of <40% [5]. Surgery is still considered the primary option for potentially curative treatment [6,7].

In recent years, with the advancement of minimally invasive techniques, laparoscopic esophagectomy has been widely used, which can shorten the postoperative rehabilitation time and reduce the probability of complications compared to traditional thoracotomy [8]. In comparison to transthoracic approaches, such as video-assisted thoracoscopic esophagectomy (VATE), which relies heavily on one-lung ventilation, the video-assisted mediastinoscopic transhiatal esophagectomy (IVMTE) procedure reaches the middle and upper esophagus via the cervical approach, eliminating the need for chest wall incisions and one-lung ventilation. This surgical method significantly reduces postoperative pain and the impact on cardiovascular function, ultimately accelerating patients’ recovery [9]. Consequently, this minimally invasive transmediastinal approach has become a viable alternative to the traditional transthoracic esophagectomy [10,11]. In 1947, Lewis et al. firstly proposed transhiatal esophagectomy [12]. In 1990, Buess first reported on esophagectomy via mediastinoscopy, which improved the safety of the surgical procedure by providing direct vision [13]. Nevertheless, achieving systematic lymph node dissection remains challenging because of limited operating space. Subsequently, mediastinoscopy has been performed for esophageal cancer resection, and carbon dioxide is used to enlarge the space by creating a pneumomediastinum [14]. Fujiwara et al. proposed IVMTE in 2015, making this surgical approach mature and progressively promoted after gradual evolution and improvement [15]. However, the tunneled surgical approach also brings difficulties to operation, and whether an anatomical structure can be clearly exposed and lymph nodes can be thoroughly dissected under mediastinoscopy has once been questioned [16,17]. 

IVMTE is less invasive than video-assisted thoracoscopic esophagectomy (VATE) because it avoids one-lung ventilation and chest trauma. This is a viable option for patients who cannot tolerate thoracotomy or thoracoscopic surgery. Indications for IVMTE include advanced age, severe pleural adhesions from a prior chest surgery, pleurisy, and past pulmonary tuberculosis. It is also recommended for patients with emphysema who have an FEV1 < 70% and vital capacity < 80% [18]. Additionally, it is suitable for patients with confirmed esophageal cancer who can be treated with R0 resection after preoperative evaluation. Some researchers suggest that IVMTE can be used for early esophageal cancer (T1–2 stage, tumor diameter < 2 cm, well-differentiated, and no lymph node metastasis), whereas others believe that it can be expanded to mid-stage esophageal cancer (no more than T3N1M0 stage) [19]. A study conducted by Daiko et al. found that surgical indications for patients with impaired lung function and a high Charlson Comorbidity Index (CCI ≥ 3) were viable as long as they could tolerate two-lung ventilation [20]. Additionally, for older patients, surgical indications for esophageal cancer should be evaluated based on the patient’s physical condition, life expectancy, tumor stage, and personal preferences [21]. When assessing the risk of postoperative complications, scoring systems, such as the estimation of physiological ability and surgical stress (E-PASS), the controlling nutritional status (CONUT), and the risk calculators provided by the Japanese National Clinical Database, should be used appropriately [22]. For patients with esophageal cancer and impaired organ function, non-thoracic esophagectomy, such as mediastinoscopy, is a better option for minimizing surgical trauma and replacing traditional transthoracic esophagectomy [23,24]. Additionally, it is crucial to preserve the bronchial artery, thoracic duct, and azygos vein arch.

Contraindications for IVMTE include (1) no definite pathological diagnosis made preoperatively; (2) severe organ dysfunction; (3) presence of distant metastasis; (4) no organ replacement in the digestive tract; and (5) when performing IVMTE, it is important to avoid factors that may hinder exposure and mobilization due to limited operating space. These factors include severe spinal deformity, stage T4 tumors, large primary tumors, significant lymphadenopathy, distant lymph node metastasis, and tissue swelling and adhesions resulting from preoperative adjuvant chemotherapy or radiotherapy. This has been mentioned in previous relevant literature [25,26]. Some investigators have suggested that IVMTE may be a viable option if CT examination determines that the tumor is resectable, regardless of whether prior treatment has been administered [27,28]. The indications and contraindications for IVMTE of esophageal cancer are summarized in Table 1.