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Lymphadenectomy for video-assisted pulmonary lobectomy
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摘要
The description of the lymphadenectomy for video-assisted pulmonary lobectomy covers all aspects of the surgical procedure used for the management of lung cancer.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: regional lymph nodes, technique, radical lymphadenectomy, lymph node sampling.
Consequently, this operating technique is well standardized for the management of this condition.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: regional lymph nodes, technique, radical lymphadenectomy, lymph node sampling.
Consequently, this operating technique is well standardized for the management of this condition.
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媒體類型
 刊物
2002-09
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普通的
最愛
 音訊
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數位出版
WeBSurg.com, Sept 2002;2(09).
URL: http://www.websurg.com/doi-ot02en207.htm
URL: http://www.websurg.com/doi-ot02en207.htm
Lymphadenectomy for video-assisted pulmonary lobectomy
1. Introduction
Video-assisted thoracic surgery (VATS) allows for considerable reduction of pain and shortens the hospital stay (Kaseda et al., 1997). VATS lobectomy is feasible, but must be performed according to the same oncological principles as conventional lobectomy (Naruke, 1999). This means a lymphadenectomy must complete the procedure. This chapter describes a thoracoscopic systematic lymph node dissection based on the lymph node classification (The Japan Lung Cancer Society, 2000; Naruke et al., 1999).
2. Indications
The role of VATS for lung cancer is still debated. A potentially curative standard operation for lung cancer requires complete resection of the tumor with systematic removal of all accessible intrathoracic lymph nodes along their lymphatic routes.Indications for VATS lobectomies are so far limited to stage 1 cancer (Asamura et al., 1996). The ideal case is a peripheral tumor whose diameter is less than 4 cm. It may be assumed that improvements in both surgical skill and instrumentation will make it possible to enlarge indications to more advanced cancer.
Contraindications to the VATS approach are:
- patient inability to tolerate split ventilation;
- tumor invasion of chest wall;
- tumor invasion of the lobar bronchus;
- tight pleural adhesions;
- inflammatory lymph nodes.
3. Regional lymph nodes
• Group 2
Station numbers 1 to 9 apply to Group 2 (mediastinal lymph nodes). Please click on the names of the lymph nodes to display their descriptions.• Group 1b
Station numbers 10 to 12 are applied to Group 1b (hilar lymph nodes). Please click on the names of the lymph nodes to display their descriptions.• Group 1a
Station numbers 13 to 14 are applied to Group 1a (intrapulmonary lymph nodes). Please click on the names of the lymph nodes to display their descriptions.• Group 3
1. Tumor2. Paratracheal lymph nodes
Group 3 comprises the contralateral lymph nodes:
- group 3a (contralateral mediastinal lymph nodes);
- group 3b (contralateral hilar lymph nodes);
- group 3y (supraclavicular lymph nodes).
4. Technique
Trocar entry sites depend on the lobectomy performed and thus are not detailed in this chapter. Lymph node dissection is performed using the same trocars as for the corresponding lobectomy.There are 2 modes of lymph node dissection:
1) radical lymphadenectomy, which aims at removing all lymph nodes in the corresponding area,
2) node sampling, which aims at checking 1 or 2 sentinel nodes.
5. Radical lymphadenectomy
• Dissection 1
1. Superior vena cava2. Phrenic nerve
Dissection of the mediastinal lymph nodes is carried out using electrocautery, scissors, or ultrasonic shears.
Dissection of the right superior mediastinum:
The taped arch of the azygos vein is pulled downwards or it can be divided with an endoscopic stapler (vascular cartridge). The mediastinal pleura is incised vertically from the upper aspect of the arch of the azygos vein right to the apex of the thorax. The mediastinal tissues are then exposed cephalad by using a retraction stay suture on each flap of the mediastinal pleura, as for a standard thoracotomy. Once the vagus nerve has been taped, the No. 1 lymph node should be grasped with a forceps. Once the surgeon has checked that no damage has been done to the recurrent nerve, the right brachiocephalic artery, the superior pulmonary vein, and the No. 1 and No. 3 lymph nodes are exposed. The No. 2 and No. 4 lymph nodes are then dissected. When exposing the superior vena cava hemostasis should be ensured by electrocautery, clip, or ultrasonic device.
• Dissection 2
1. Arch of the azygos vein2. Esophagus
Dissection of the subcarinal lymph node:
In the case of No. 7 carinal lymph node dissection or sampling, the patient's lung can be partly retracted by tilting the operating table forward.
For lower lobectomy, dissection of the lobe is preceded by carinal lymph node dissection.
• Dissection 3
1. Aorta2. Subclavian artery
3. Superior intercostal vein
4. Vagus nerve
Dissection of the left mediastinum:
Dissection of the left mediastinal nodes should mainly be done for the No. 6, No. 5, and the No. 4 lymph nodes.
For lower lobectomy, the paraesophageal lymph nodes (No. 8) and pulmonary ligament lymph nodes (No. 9) are dissected.
6. Lymph node sampling
• Principles
1. AortaLymph node sampling is an alternative for some T1 tumors.
Knowledge of the lymphatic route of each lobe is essential. Lymph node sampling should concern:
- No. 3 and No. 4 for a right upper lesion;
- No. 3 and No. 7 for a middle lobe lesion;
- No. 7 for a right lower lobe lesion.
The No. 3, No. 4, and No. 7 lymph nodes may be considered sentinel nodes.
Sampling for staging of tumors <3 cm in size should focus on the lymph nodes that are most likely to become metastatic first, ie the sentinel nodes. These are (regardless of the location of tumor) as follows:
- No. 12, No. 11, and/or No. 10 for N1 level where a dissection or sampling within these locations of lymph nodes becomes mandatory. For N2 level, No. 3, and/or No. 4 in a right upper lobe tumor, No. 3 and/or No. 7 in a right middle lobe tumor, No. 7 in a right lower lobe tumor, No. 5 and/or No. 6 in a left upper lobe tumor, and No. 7 in a left lower lobe tumor.
• Tumors
1. Superior vena cava2. Phrenic nerve
3. Laterotracheal lymph nodes
Right-sided tumors:
For a small-sized peripheral tumor (<3 cm) of the right upper lobe, subcarinal lymph node dissection may be neglected. If no lymph node involvement is seen in the upper mediastinum, complete mediastinal lymph node dissection may be omitted, given the very low incidence of 0.8% (2/249) residual node metastasis (Naruke et al., 1999).
For a middle lobe tumor, subcarinal, pretracheal, and/or tracheobronchial node sampling is necessary. However, if no metastatic lymph node is found, complete mediastinal lymph node dissection may be omitted.
For a right lower lobe tumor, if no sentinel node involvement is found, an upper mediastinal node dissection may not be required, since upper mediastinal node involvement is low (<3.4%, 5/147)(Naruke et al., 1999).
Left-sided tumors:
For a left upper lobe tumor, if no sentinel node involvement is found, No. 7 node dissection may not be necessary, as No. 7 node involvement is only 1.6% (3/186)(Naruke et al., 1999).
For a left lower lobe tumor, an upper mediastinal node dissection may not be necessary, since the upper mediastinal nodes are invaded in less than 4.0% (3/75) of cases (Naruke et al., 1999). However, a positive sentinel node indicates a complete lymphadenectomy.
Other types:
In a clinical N0M0 tumor <3 cm (and particularly those <2 cm), lymph node sampling is performed as above. In the absence of lymph node invasion at frozen section, the other lymph nodes are unlikely to be invaded. However, in the presence of lymph node invasion, complete lymphadenectomy should be performed.
7. Conclusion
VATS (video-assisted thoracoscopic surgery) is a new approach, but by no means a new surgery. A limited number of surgeons are capable of performing thoracoscopic lymphadenectomy, and this technical challenge inhibits the dissemination of the procedure. Surgeons must always be able to perform systematic lymph node dissection by VATS in the same manner as for a standard thoracotomy. Clinical T1N0M0 cases, especially those of tumor size <2 cm at its greatest diameter, require sentinel lymph node sampling. In the absence of lymph node invasion, there is hardly any chance of metastasis to other lymph nodes. In the future, identification of nodal status may become possible by radioisotopic technique. This could allow an accurate recognition of sentinel lymph nodes, thus avoiding needless lymphadenectomy.8. Reference
Asamura H, Nakayama H, Kondo H, Tsuchiya R, Shimosato Y, Naruke T. Lymph node involvement,recurrence, and prognosis in resected small, peripheral, non-small-cell lung carcinomas: are these
carcinomas candidates for video-assisted lobectomy? J Thorac Cardiovasc Surg 1996;111:1125-34.
Iwasaki M, Kaga K, Nishiumi N, Maitani F, Inoue H. Experience with the two-windows method for
mediastinal lymph node dissection in lung cancer. Ann Thorac Surg 1998;65:800-2.
Japan Lung Cancer Society (The). Classification of Lung Cancer, First English Edition. Tokyo: Kanehara &
Co.; 2000.
Kaseda S, Hangai N, Yamamoto S, Kitano M. Lobectomy with extended lymph node dissection by videoassisted
thoracic surgery for lung cancer. Surg Endosc 1997;11:703-6.
Naruke T, Tsuchiya R, Kondo H, Nakayama H, Asamura H. Lymph node sampling in lung cancer: how
should it be done? Eur J Cardiothorac Surg 1999;16 Suppl 1:S17-24.