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Eur J Cardiothorac Surg 2002;21:348-351
© 2002 Elsevier Science NL

How-to-do-it

Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results

^a Department of Thoracic Surgery, Centre for Pneumology and Thoracic Surgery, Schillerhoehe Hospital, Solitudestrasse 18, D-70839 Gerlingen, Germany
^b Institute of Pathology, Robert-Bosch-Hospital, Auerbachstrasse 110, D-70341 Stuttgart, Germany

Received 21 November 2000; received in revised form 21 September 2001; accepted 20 November 2001.

* Corresponding author. Tel.: +49-7156-203-2258; fax: +49-7156-203-2003
e-mail: martin{at}huertgen-huertgen.de

	Abstract

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Exact pretherapeutic lymph node staging of lung cancer is of special importance for selecting patients for neoadjuvant therapy or for video-assisted thoracoscopic resection. Staging is usually performed by computerized tomography scan and mediastinoscopy. However, these methods do not reach the accuracy of open nodal dissection. Therefore, we developed a technique of radical video-assisted mediastinoscopic lymphadenectomy (VAMLA). In a prospective study, all VAMLA procedures were documented. Lymph nodes were counted and compared to open lymphadenectomy. In 40/46 patients, radical paratracheal and subcarinal dissection was achieved by VAMLA. An average number of 20.7 (5–60, SD 11.1) nodes was gained. This is comparable to our data from open lymphadenectomy.

Key Words: Mediastinoscopy • Staging of lung cancer • Video-assisted surgery • Lung neoplasm • Lymphadenectomy

	1. Introduction

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Pretherapeutic staging of mediastinal lymph nodes in lung cancer patients is frequently performed using computerized tomography (CT) scan. The low sensitivity and specificity of CT for nodal staging is well known [1]. Positron emission tomography (PET) scanning is superior to CT scanning but is not sufficiently reliable [2] and is not yet available on a broad basis.

The sensitivity of mediastinoscopy largely depends on the amount of lymph node tissue resected and the number of lymph node stations investigated which vary considerably [3]. In 25% of our own collective of N2 stages [4] only single mediastinal lymph nodes are involved. In such cases, mediastinoscopic lymph node biopsy may often lead to false-negative results.

For this reason, we tried to increase the sensitivity of mediastinoscopy to the level of open systematic lymphadenectomy by further technical and surgical development.

Since mediastinoscopy was introduced by Carlens in 1959 [5], it has hardly been modified. Meanwhile, various companies offer conventional mediastinoscopes with integrated optics to be connected to a video system. These modifications have improved visibility and provide advantages for the training of surgeons but did not change the surgical procedure.

Occasionally, the employment of a spreading laryngoscope for mediastinoscopy was reported on, preferably by otolaryngologists [6]. In 1992, on the basis of this device, Linder und Dahan in cooperation with the Wolf Company (Richard Wolf GmbH, Postfach 1164, D-75434 Knittlingen, Germany) developed a video-assisted mediastinoscope for bimanual preparation. The bimanual preparation markedly increases surgical options. After gathering some experience, we have been able to further develop the mediastinoscopic lymph node biopsy to systematic video-assisted mediastinoscopic lymphadenectomy (VAMLA) since 1999.

	2. Materials and methods

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
2.1. Instrumentation
In contrast to a conventional mediastinoscope, the video-mediastinoscope consists of a two bladed speculum. After introducing and positioning the device in the pretracheal space, both blades at the tip can be opened widely (Fig. 1a ) thus creating an operative field for bimanual surgery. The slightly longer ventral spatula of the mediastinoscope houses an optics rinsing tube and a smoke aspirator as well as an optics connected to a video system (Fig. 1a).

View larger version (52K): [in this window] [in a new window]   Fig. 1. (a) Video-mediastinoscope, total view with the speculum widely opened and elements of the upper blade (insert) (1: eyepiece, 2: adjustment wheel for transversal opening, 3: adjustment wheel for spreading of half tubes, 4: suction and irrigation connector, 5: light connector, 6: upper blade, 7: lower blade, 8: optics, 9: suction channel and irrigation channel). (b) Box plot of total number of resected nodes by thoracotomy and VAMLA (horizontal lines show the 10th, 25th, 50th (median), 75th and 90th percentiles, values above the 90th and below the 10th percentile are plotted as points).

During bimanual preparation, the position of the mediastinoscope is maintained by a holding device that is fixed to the operation table.

2.2. Surgical technique
The preparation of the pretracheal space and the introduction of the closed video-mediastinoscope are the same as those employed for standard mediastinoscopy. By conventional preparation with the aspirator tube, first the bifurcation, both main bronchi and the left recurrent nerve are clearly identified.

On the left side, several lymph nodes become visible tracheobronchially next to the recurrent nerve. In the cranial direction between aorta and trachea, there are hardly any lymph nodes to be found. The optical enlargement in video-mediastinoscopy and the bimanual preparation facilitate the removal of several complete left-sided lymph nodes in spite of the adjacent nerve (Fig. 2a, b ).

View larger version (82K): [in this window] [in a new window]   Fig. 2. Mediastinoscopic views of the operation field (1: suction probe, 2: left recurrent nerve, 3: lymph node, 4: grasper, 5: trachea, 6: left main bronchus, 7: right main bronchus, 8: esophagus, 9: right vagus nerve, 10: vena cava, 11: mediastinal pleura, 12: confluence of azygos vein and vena cava). (a) Left-sided tracheobronchial node adjacent to recurrent nerve. (b) Left paratracheal region with recurrent nerve after complete resection of lymph nodes. (c) Subcarinal region with anterior wall of the esophagus after dissection. (d) Right paratracheal region after dissection.

The right paratracheal and tracheobronchial compartments are mostly resected en bloc. Directly caudal to the brachiocephalic trunk the lymph nodes are grasped and pushed caudally to the left. Thus, the small cranial vascular and lymphatic attachments can be clearly dissected. Subsequently, the lymph nodes are drawn en bloc to the left and are dissected in a blunt fashion from the mediastinal pleura and the vena cava (Fig. 2d). Frequently, a clip has to be applied to a small venous branch originating from the vena cava. Now, at the right dorsal side of the trachea, the esophagus with the vagus nerve and after further caudal dissection, the junction of the azygos vein with the vena cava are exposed (Fig. 2d). As soon as the azygos vein is exposed, the lymph nodes are pulled into left-cranial direction and are dissected from the distal margin of the tracheobronchial angle.

	3. Results

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
In a prospective study, all VAMLA procedures have been documented. From June 1999 until February 2001, 46 patients (39 men) with a mean age of 61 years (38–75, SD 8.5) received VAMLA predominantly for non-small cell lung carcinoma (NSCLC) except one SCLC, one mixed type, one lymphoma and one metastasis of a colon carcinoma.

In 40 patients the subcarinal and paratracheal compartments were both radically dissected, proven by subsequent thoracotomy. The other six cases underwent an anatomic dissection as well, however, single nodes were left behind due to calcification or to a particularly fatty mediastinum. A radical paratracheal and subcarinal dissection was frequently achieved within 30–60 min.

The mean total number of lymph nodes resected using video-assisted mediastinoscopy was 20.7 (SD 11.1, minimum 5, maximum 60). Fig. 1b compares the number of nodes resected from the right paratracheal and subcarinal compartments by VAMLA and by open lymphadenectomy via right-sided thoracotomy [4]. From these two compartments, VAMLA harvested significantly (P<0.0001) more nodes than open lymphadenectomy.

As complication, we observed a left-sided recurrent nerve palsy in one patient after resection of 11 enlarged tracheobronchial lymph nodes on the left side with extended exposure of the nerve. Increased difficulty with hilar dissection because of scarring was remarked in about a quarter of all subsequent thoracotomies for resection of bronchial tumor.

	4. Discussion

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 
Our study proves the technical feasibility of a radical paratracheal and subcarinal mediastinoscopic lymphadenectomy. The para- and subaortic region is also accessible with the video-mediastinoscope in the technique described by Ginsberg et al. [7] with own experience in 13 patients.

So far, we have not obtained any false-negative histological findings after VAMLA. For conventional mediastinoscopy, up to one half of false-negative findings with regard to the following thoracotomy are reported. In clinical stage I, without enlarged lymph nodes, sensitivity of conventional mediastinoscopy drops to only 27.3% [8].

Recurrent nerve palsy is reported on after conventional mediastinoscopy in 0.15–6% [9]. The small number of cases does not allow a statement on the incidence of recurrent nerve palsy after VAMLA. One palsy in our collective resulted from an extensive dissection of the left tracheobronchial and subaortic compartment. The incidence of left-sided palsy of the recurrent nerve after open subaortic lymphadenectomy is supposed to be about 5% [10].

VAMLA is particularly suited to identify minor N2 disease in patients eligible for neoadjuvant therapy. In high-risk patients or prior to video-assisted thoracoscopic lobectomy lymph node metastases can be excluded with high sensitivity and make the thoracoscopic procedure easier.

Thus, VAMLA is markedly superior to conventional mediastinoscopy and in our opinion constitutes an important contribution to the staging of bronchial carcinomas.

	Footnotes

 
Presented at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, London, UK, November 1–4, 2000.

	References

Top Abstract 1. Introduction 2. Materials and methods 3. Results 4. Discussion References

 

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Godehard Friedel Heikki Toomes Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Hürtgen, M. Articles by Fritz, P. Search for Related Content PubMed PubMed Citation Articles by Hürtgen, M. Articles by Fritz, P. Related Collections Mediastinum