Right-Sided Mediastinal Lymph Node Dissection—Video 21

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CHAPTER 21 Right-Sided Mediastinal Lymph Node Dissection—Video 21

Ali Mahtabifard

Introduction

Right-sided and left-sided mediastinal lymph node dissections are discussed in separate chapters. No additional incisions are made for the mediastinal lymph node dissection; the procedure uses the existing incisions for the video-assisted lobectomy, which usually precedes the dissection.

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

Order of Operative Steps

The order of the steps of the lymph node dissection is as follows: level 9 and 8 nodes, level 7 nodes, level 10 nodes, and level 4 and 2 nodes.

Key Points

♦ Subcarinal lymph node dissection usually is easier on the right side.
♦ Transection of the azygous vein can simplify the level 2 and 4 node dissection.
♦ Use of electrocautery near nerves should be kept to a minimum. Nuisance bleeding from the lymph node dissection bed usually can be controlled with pressure or a Surgicel.

image Video-Assisted Right-Sided Mediastinal Lymph Node Dissection

Step 1. Level 9 and 8 Lymph Nodes

♦ Exposure: Hold the right lower lobe superiorly with a ring clamp through the utility incision.
♦ Aim the thoracoscope anteriorly, and point the 30-degree lens downward toward the inferior pulmonary ligament.
♦ Bring the suction catheter and the long-tipped electrocautery through the anteroinferior incision. Press the curve of the Yankauer suction catheter onto the diaphragm to hold it out of the way.
♦ If the diaphragm is high and in the way, as is seen frequently in obese patients, place a heavy stitch in the ligamentous portion of the diaphragm. Pull the stitch through the incision for the trocar. Suture it to the skin to retract the diaphragm.
♦ Hold the inferior pulmonary ligament toward the apex of the chest. Level 9 lymph nodes can be seen.
♦ Incise the inferior pulmonary ligament with the long-tipped electrocautery up to the level of the inferior pulmonary vein as shown in Figure 21-1. The tip of the suction catheter should be held close to the electrocautery tip to remove the smoke created.
♦ Remove the level 9 lymph nodes as the ligament is incised.
image

Figure 21-1 The inferior pulmonary ligament is on stretch and is cauterized through the anteroinferior incision.

Step 2. Level 7 Lymph Nodes

♦ Exposure: Hold the right lower lobe superiorly with a ring clamp through the utility incision.
♦ Aim the thoracoscope anteriorly, and point the 30-degree lens downward toward the inferior pulmonary ligament.
♦ With ring forceps, which are brought through the inferior and the utility incisions, retract the right lower lobe medially toward the heart.
♦ Point the thoracoscope posteriorly and the 30-degree lens toward the esophagus.
♦ Incise the posterior mediastinal pleura with scissors, which are brought through the anterior incision as shown in Figure 21-2. Carefully incise the pleura at its junction with the lung parenchyma. The natural tendency is to gravitate posteriorly toward the esophagus, but this should be avoided because it causes nuisance bleeding from the esophageal muscle.
♦ In the process of this dissection, remove the paraesophageal level 8 lymph nodes.
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