Left-Sided Mediastinal Lymph Node Dissection—Video 22

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CHAPTER 22 Left-Sided Mediastinal Lymph Node Dissection—Video 22

Introduction

Mediastinal lymph node dissection is a critical part of any lung cancer operation. Lymph node dissection should be performed for all types of cancer resections (e.g., wedge, segmentectomy, lobectomy, pneumonectomy) to ensure proper tumor staging and for possible therapeutic benefit. Nodal dissection for left-sided resections should include station 5 (subaortic, between the aorta and left main pulmonary artery), station 6 (para-aortic, left side of the ascending aorta, and aortic arch), station 7 (subcarinal), station 8 (para-esophageal), and station 9L (inferior pulmonary vein). Video-assisted thoracic surgery (VATS) provides excellent visualization of the aortopulmonary window lymph nodes and has replaced anterior mediastinotomy (i.e., Chamberlain procedure) for biopsying nodes in this area at many institutions.

Approach to Video-Assisted Left-Sided Mediastinal Lymph Node Dissection

Order of Operative Steps

The lymph node dissection for right- and left-sided lung cancers can be performed after the parenchymal resection or can be performed before the resection, because node dissection can define the anatomy and make the lobectomy easier and because node dissection may identify stage III patients who would then undergo neoadjuvant treatment and lobectomy at another time. Exceptions include nodes in station 9, which are removed when the inferior pulmonary ligament is divided, and lymph nodes in station 10, which are usually dissected and removed just before division of the bronchus. Station 10 lymph nodes are not considered to be mediastinal nodes in the American lymph node mapping system, but they are mentioned here because unlike other N1 nodes, a standard lobectomy without a dedicated lymph node dissection may miss these nodes.

Key Points

♦ Carry out lymph node dissection through the standard VATS port sites using a 5- or 10-mm, 30-degree thoracoscope (Figure 22-1).

♦ With small ringed forceps, grasp the lymph nodes, which are friable and tend to disintegrate if only parts of them are grabbed. Alternatively, use a long Allis clamp to grasp the lymph nodes during the dissection.

♦ Dissect with standard electrocautery or an ultrasonic dissector. A partially covered Teflon-coated electrocautery can be used to avoid injury to surrounding structures. In some areas, adjacent structures may be at risk for injury during lymph node removal:

Station 7, the esophagus and mainstem bronchus: The vagus nerve should be left with the esophagus and can be used as a posterior landmark when dissecting in the level 7 area.

Station 9: To avoid esophageal injury during division of the inferior pulmonary ligament, keep the dissection close to the lung parenchyma. The inferior pulmonary vein is also at risk for injury during this dissection.

Stations 5 and 6: The left recurrent laryngeal nerve, left phrenic nerve, left main pulmonary artery, and aorta should be avoided.

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