Preoperative CT Three-dimensional Reconstruction Guides Single-incision Minimally Invasive Esophagectomy with Retrosternal Route Selection: A Prospective Cohort Study

Background The optimal reconstruction route following esophagectomy remains controversial, with limited objective criteria for route selection. This study investigated whether preoperative CT three-dimensional reconstruction can guide surgical route selection in single-incision minimally invasive esophagectomy (SIMIE) with retrosternal reconstruction. Methods We conducted a prospective analysis of 111 consecutive patients with esophageal cancer who underwent SIMIE with retrosternal route reconstruction between January 2024 and October 2025. Preoperative CT three-dimensional reconstruction measured both retrosternal reconstruction (RR) and posterior mediastinal reconstruction (PR) route lengths from esophagus at thyroid cartilage level to gastroduodenal artery. Primary outcomes included perioperative complications, particularly anastomotic leakage rates. Results Mean RR route length was 293.3±19.54 mm, significantly shorter than PR route length (315.4±19.13 mm, difference 22.1 mm, p<0.001). All patients completed SIMIE-RR successfully with mean operative time 209.5±25.7 minutes, blood loss 65.5±10.3 mL, and hospital stay 6.0±1.0 days. Anastomotic leakage occurred in 2 patients (1.8%), both having longer RR than PR routes on preoperative measurements. BMI demonstrated significant positive correlation with RR route length (r=0.6671, p<0.0001), while other patient characteristics showed no significant correlations. Total lymph node harvest achieved 34±10.2 nodes. Conclusions Preoperative CT three-dimensional reconstruction effectively guides optimal route selection in SIMIE esophagectomy through objective pathway measurements. When RR route length exceeds PR length, particularly in patients with higher BMI, posterior mediastinal reconstruction may be preferable to reduce anastomotic complications.