Endoscopic mediastinal lymph node dissection for stage I lung carcinoma

In this video, we will focus on mediastinal lymph node dissection as defined by the American College of Surgeons Oncology Group, i.e.: for right-sided tumors: removal of all lymphatic tissue bounded by the right upper bronchus, the right subclavian artery, the superior vena cava and the trachea (stations 2R and 4R); for left-sided tumors: removal of all lymphatic tissue bounded by the phrenic nerve, the vagus nerve and the top of the aortic arch (stations 5 and 6); and for both sides, removal of lymph nodes from stations 7, 8, 9, 10 and 11. A perfect vision is necessary during mediastinal lymph node dissection. An oblique viewing 30 degree scope or a deflectable thoracoscope is almost essential to avoid the drawbacks linked to tangential vision, as it frequently occurs with a low inserted scope. During open or video-assisted lymphadenectomy, it is usual to control small vessels by a combination of clipping and transection. This is time-consuming and it can be replaced by either bipolar cautery or ultrasonic shears or a vessel-sealing device, which both allow coagulating and transecting with a single tool. This technique is presented in the book : D. Gossot Atlas of endoscopic major pulmonary resections (2010) Springer-Verlag France www.springer.com/978-2-287-99776-1

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Endoscopic mediastinal lymph node dissection for stage I lung carcinoma

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Abstract

In this video, we will focus on mediastinal lymph node dissection as defined by the American College of Surgeons Oncology Group, i.e.: for right-sided tumors: removal of all lymphatic tissue bounded by the right upper bronchus, the right subclavian artery, the superior vena cava and the trachea (stations 2R and 4R); for left-sided tumors: removal of all lymphatic tissue bounded by the phrenic nerve, the vagus nerve and the top of the aortic arch (stations 5 and 6); and for both sides, removal of lymph nodes from stations 7, 8, 9, 10 and 11.
A perfect vision is necessary during mediastinal lymph node dissection. An oblique viewing 30 degree scope or a deflectable thoracoscope is almost essential to avoid the drawbacks linked to tangential vision, as it frequently occurs with a low inserted scope.
During open or video-assisted lymphadenectomy, it is usual to control small vessels by a combination of clipping and transection. This is time-consuming and it can be replaced by either bipolar cautery or ultrasonic shears or a vessel-sealing device, which both allow coagulating and transecting with a single tool.

This technique is presented in the book :
D. Gossot Atlas of endoscopic major pulmonary resections
(2010) Springer-Verlag France
www.springer.com/978-2-287-99776-1

Keywords

Endoscopic mediastinal lymph node dissection, stage I lung carcinoma

Media type

Surgical video

Duration

09'15''

Publication

2010-03

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E-publication

WeBSurg.com, Mar 2010;10(03).
URL: http://www.websurg.com/doi-vd01en2922.htm

Endoscopic mediastinal lymph node dissection for stage I lung carcinoma

1. Right side stations 9 and 8 00'18''

Dissection of the lymph nodes in the pulmonary ligament (station 9) is usually straightforward. It is started from the diaphragmatic attachment of the pulmonary ligament and continued upwards with the dissection of the paraesophageal nodes (station 8). These nodes are close to fragile organs: the esophagus and the inferior pulmonary vein. Therefore, cautious dissection and use of bipolar diathermy are recommended.

2. Right side station 7 00'52''

The access to station 7 from the right side is much easier than from the left side as the vision on the subcarinal area is direct and as there is no need to retract the bronchi and the surrounding organs. The mediastinal pleura is incised upwards, in continuity with the dissection of stations 9 and 8, and up to the azygos arch. The posterior surface of the bronchus intermedius and right main bronchus is clearly visible. Node clearance is performed from the periphery to the carina while paying attention to the esophagus, which can be in close contact to some of the nodes. Electrocautery and suction devices must be used with caution. Once the lymph node dissection has been completed, the 2 main-stem bronchi are fully exposed as demonstrated in the following images.

3. Right side stations 4R and 2R 03'00''

Even after completion of a right upper lobectomy, the paratracheal region can be obscured by the lung, which must be retracted downwards. The endoscope is positioned in such a way that a bird’s eye view on all the area located above the azygos arch is obtained, since a tangential vision can lead to a difficult understanding of the anatomy. The mediastinal pleura is incised horizontally on either side of the azygos arch so that the latter can be lifted up if necessary. Division of the azygos vein is seldom needed in patients operated upon for a clinical stage I tumor, in whom nodes are usually not enlarged and not invaded. Incision of the mediastinal pleura is then continued so that a square pleural flap is designed. Its limits are, inferiorly: the azygos arch; superiorly: the lowest visible part of the subclavian artery; anteriorly: the posterior aspect of the superior vena cava; posteriorly: the posterior aspect of the trachea. The pleural flap is removed and the fatty tissues are dissected and removed ‘en bloc’ with the nodes. Dissection and division of the mediastinal tissue is best achieved by bipolar sealing. Care should be taken to not tear off the small venous branches arising from the vena cava. Dissection can be conducted either with an ultrasonic scissor as shown here, or with a Ligasure device as in the following images. All paratracheal nodes located at the level of the middle third of the lateral aspect of the trachea (station 2R), and those located near the angle between the trachea and main bronchus (station 4R) are removed ‘en bloc’. Dissection of 4R nodes may require upwards lifting of the azygos vein, either with an instrument or by taping it.

4. Left side stations 9 and 8 04'39''

Dissection is performed in the same manner as on the right side.

5. Left side station 7 04'57''

As for open surgery, the difficulties faced during the dissection of station 7 from the left side are variable. It can be difficult when the nodes are adherent and located in a deep groove between the esophagus and the 2 main bronchi. Since exposure of the subcarinal region can be difficult, it is advisable to perform this step before the pulmonary resection. Indeed, the vision can be partly obscured by the stump of the left inferior pulmonary vein (in case of lower lobectomy). In addition, this prevents the risk of tearing a vascular or a bronchial stump during lung retraction. Once stations 8 and 9 have been dissected, the incision of the posterior mediastinal pleura is continued up to the aortic arch. The vagus nerve is located and the esophagus retracted posteriorly with a blunt tip instrument, thus exposing the subcarinal lymph nodes and/or the right main bronchus. The lymph nodes are dissected with caution to avoid any troublesome oozing and the carina is progressively cleared. Excessive traction on lymph nodes should be avoided to prevent injury of a bronchial artery whose control can be tedious, as shown here.

6. Left side stations 5 and 6 07'02''

The left upper lobe is retracted downwards. The endoscope is then positioned in such a way that a bird’s eye view on the aortopulmonary window is obtained. The phrenic nerve and the vagus nerve are identified. The mediastinal pleura facing the aortopulmonary window is incised, taking care to preserve the nerves, which can be difficult to visualize in some overweight patients. Pleural flaps are gently moved away and the take off of the recurrent laryngeal nerve is identified. This is achieved by prudent opening of the mediastinal fat with a smooth tip dissecting forceps. All lymph nodes located between the vagus and phrenic nerve (station 6) and all those located adjacent and posteriorly to the vagus nerve (station 5) are excised.