Eur J Cardiothorac Surg 2007;32:766-769. doi:10.1016/j.ejcts.2007.07.034
Copyright © 2007, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
The right upper lobe pulmonary resection performed through the transcervical approach
Marcin Zieli
skia,*,
Juliusz Pankowskib,
ukasz Hauera,
Jaros
aw Ku
daa,
Tomasz Nabiaekc
a Department of Thoracic Surgery Pulmonary Hospital, Zakopane, Poland
b Department of Pathology Pulmonary Hospital, Zakopane, Poland
c Department of Anesthesiology and Intensive Care Pulmonary Hospital, Zakopane, Poland
Received 31 May 2007;
accepted 16 July 2007.
* Corresponding author. Address: ul. Gadkie 1, 34-500 Zakopane, Poland. Tel.: +48 18 2015045; fax: +48 18 2014632. (Email: marcinz{at}mp.pl).
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Abstract
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Objective: Preliminary report: presentation of the new technique of transcervical right upper lobectomy with transcervical extended mediastinal lymphadenectomy (TEMLA) for NSCLC. Methods: Two patients underwent the operation that was performed through the collar incision, with elevation of the sternal manubrium with the mechanical sternal retractor. TEMLA and bilateral mediastinal lymph node excision (stations 1, 2R, 4R, 2L, 4L, 3A, 3P, 7 and 8) and bilateral supraclavicular lymph node excision were performed (frozen section analysis: all nodes negative). The mediastinal pleura was opened and the following structures were dissected in the open fashion with standard surgical instruments and divided with the use of endostaplers: the azygos vein, the upper trunk of the right pulmonary artery, the branch of the superior pulmonary vein to the upper lobe, the upper lobe bronchus, the segment 2 artery, the posterior part of the oblique fissure and the horizontal fissure. The operation was performed with the use of one videothoracoscopic (VTS) port for insertion of 5 mm, 30 degree VTS camera for intraoperative control and for single thoracic drain for the postoperative period. Results: The operative times were 250 and 270 min, respectively; intraoperative blood loss was 110 and 100 ml, respectively. There were no intraoperative complications. The postoperative course was remarkably smooth. The final pathologic report: large cell carcinoma pT2N0M0 and squamous cell carcinoma pT2N0M0, no metastatic changes of 51 and 41 mediastinal and intrapulmonary (stations 10, 11 and 12) and supraclavicular nodes, respectively. Conclusions: This preliminary report indicates possible advantages of the transcervical right upper lobe pulmonary resection including: (1) extremely radical, minimal invasive procedure with no need for utility thoracotomy; (2) dissection performed with standard surgical instruments in the open fashion.
Key Words: Lung cancer • Lobectomy • Mediastinal staging
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1. Introduction
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Videothoracoscopically assisted (VATS) lobectomy has become an accepted technique for early-stage non-small cell lung cancer (NSCLC); however, this procedure is technically demanding and the completeness of lymphadenectomy is a matter of debate [1–3]. Additionally, performance of utility thoracotomy of several centimeters in length is necessary. This relatively lengthy incision adds considerable invasiveness to the procedure, although retraction of the ribs is generally avoided. Due to considerable experience with a transcervical approach gained with more than 300 transcervical extended mediastinal lymphadenectomies (TEMLAs), we realized that the performance of the right upper pulmonary lobectomy was possible through this approach. In this report we present our initial experience with two patients with NSCLC operated on using this technique [4,5].
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2. Material and methods
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Two patients underwent right upper lobectomy through the transcervical approach with use of videothoracoscope (VTS) introduced through the single VTS port, subsequently used for insertion of chest tube. Both patients had peripheral tumors of the upper lobe. In both cases the diagnosis of NSCLC was established with use of transthoracic fine needle biopsy. Bronchoscopy, CT and PET/CT and EBUS/TBNA were negative in both patients. The informed consent was obtained from both patients and the study was approved by the institutional ethics committee on human research. The operative procedure was performed under general anesthesia with use of left intrabronchial intubation for selective lung ventilation. Both patients underwent transcervical extended mediastinal lymphadenectomy with excision of stations 1, 2R, 4R, 3A, 3P, 2L, 4L, 7 and 8 and supraclavicular nodes bilaterally with intraoperative frozen section analysis of the nodes. The technique of TEMLA is described in detail elsewhere. In brief, the operation is performed through 5–9 cm collar incision in the neck. The sternal manubrium is elevated with the hook connected to the special frame for widening the access to the mediastinum. Before the operation the patients were informed that in case of a positive result of TEMLA (metastatic nodes found) the procedure would be cancelled at this moment with no attempt to perform any pulmonary resection. After obtaining negative results from the examination of all nodes, ventilation of the right lung was disconnected and left lung ventilation was started. The right mediastinal pleura was opened and the right chest cavity and the right lung were examined for possible metastatic spread, firm pleural adhesions and the lack of well-developed interlobar fissures. In both patients no contraindications for proceeding with resection were found. The azygos vein was dissected and divided with use of the vascular endostapler (Fig. 1
). Single VTS port was inserted in the V intercostal space in the right anterior axillary line for introduction of the 5 mm 30 degree VTS camera and single 28 Ch chest tube after completion of the resection. All further dissections were performed in the open fashion through the transcervical incision under control of VTS camera. The upper trunk of the right pulmonary artery was dissected and divided (Fig. 2
). The superior vena cava was retracted medially and the upper part of the superior pulmonary vein was dissected with sparing of the branches to the middle lobe (Fig. 3
). The branches of the upper lobe were divided with the vascular endostapler. The hilar (station 10), interlobar and intralobar (stations 11 and 12) were dissected and removed. The ascending branch of the pulmonary artery (segment 2 branch) was dissected, closed with vascular clips (two clips used proximally) and divided (Fig. 4
). The upper lobe bronchus was dissected and divided with endostapler (Fig. 5
). The upper lobe was connected with the rest of the lung only by fissures. The division of the fissures was started from the posterior part of the oblique fissure, between segments 2 and 6. After division of this part of the fissure with endostapler, the upper lobe could be delivered to the level of the transcervical incision and division of the horizontal fissure could be easily completed outside the chest. The hemostasis was checked and the single 28 Ch chest tube was inserted through the incision for the VTS port. The transcervical incision was closed in the standard fashion without any other drain.
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3. Results
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Patients’ characteristics are presented in Table 1
. The numbers of removed mediastinal, intrapulmonary and supraclavicular nodes were 51 and 41, respectively. The numbers of removed nodes and nodal stations are shown in Table 2
. All nodes in both patients were negative for metastatic changes on frozen section analysis. There were no intraoperative or postoperative complications. The times of the whole operations, including TEMLA, bilateral supraclavicular lymph nodal dissection and frozen section analysis of all nodes were 250 and 270 min, respectively. Blood losses were 110 and 100 ml, respectively. Duration of pleural drainage was 3 and 4 days, respectively. Final histology was macrocellular carcinoma pT2N0M0 in the first patient and squamous cell carcinoma pT2N0M0 in the second patient.
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4. Discussion
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The presented technique has several advantages and several limitations. The advantages include performance of the operation with open fashion and normal surgical instruments, which is the most familiar approach for majority of thoracic surgeons. Previous thyroidectomy for nodular goiter was not an obstacle for use of transcervical approach in one of our patients. There is no need for utility thoracotomy and only a single VTS port for 5 mm 30 degree VTS camera is necessary. Avoidance of several VTS ports and utility thoracotomy probably decrease the risk of postoperative pain. The most important advantage of the transcervical approach is an extremely complete mediastinal, intrapulmonary and if desired, supraclavicular lymphadenectomy with removal of 51 and 41 nodes, respectively. It is also possible to be quite flexible with the strategy of operation which can be cancelled if the mediastinal nodes are positive for metastasis. In such cases, the procedure can be limited to TEMLA. Disadvantages of the procedure include time of the operation (250 and 270 min) and the need for intraoperative frozen section analysis of multiple nodes. Because the experience with the presented technique is limited only to two patients it is difficult to predict which pulmonary resections can be performed through this approach. In the authors’ opinion, performance of the other pulmonary resections will be more convenient with combining the transcervical and VTS approaches.
Concluding, the transcervical approach combined with single-port VTS is feasible for safe and radical performance of the right upper lobe pulmonary resection for NSCLC.
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Acknowledgments
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The authors acknowledge the contribution of the artist, Mr Bogdan Dziadzio, the author of figures.
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Footnotes
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\#9734; Presented at the 15th European Conference on General Thoracic Surgery, Leuven, Belgium, June 3–6, 2007.
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References
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Abstract
1. Introduction
