(1)
IMM, Curie-Montsouris Thorax Institute, Paris, France
Electronic Supplementary Material
The online version of this chapter (doi:10.1007/978-3-319-55901-8_2) contains supplementary material, which is available to authorized users.
2.1 Definition
The major pulmonary resections described in this atlas are mostly done for lung cancer. Surgical treatment of lung carcinoma with curative intent requires complete resection, that is, microscopically proven free resection margins and systematic node dissection. A systematic lymph node dissection means:
The extent of lymphadenectomy is still a controversial issue. Many different types of lymph node dissections are described in the literature, ranging from mere sampling to extended lymphadenectomy. In this chapter, we focus on lymph node clearance as defined by the American College of Surgeons Oncology Group Z0030 trial, that is:
Excision of hilar, interlobar, and/or intersegmental lymph nodes
Excision of mediastinal fat and enclosed lymph nodes, which are dissected and identified
For right-sided tumors: removal of all lymphatic tissue bounded by the right upper bronchus, the right subclavian artery, the superior vena cava, and the trachea (stations 2R and 4R)
For left-sided tumors: removal of all lymphatic tissue bounded by the phrenic nerve, the vagus nerve, and the top of the aortic arch (stations 5 and 6)
For both sides: removal of lymph nodes from stations 7, 8, 9, 10, and 11
2.2 Specific Issues Related to the Thoracoscopic Approach
The difficulties faced during mediastinal lymph node dissection vary. They are related to the amount of fatty tissue, the number and nature of the lymph nodes, and the difficulty in reaching and exposing some stations, for example, station 7 from the left-sided approach.
Perfect vision is necessary. An oblique (30°) viewing scope or a deflectable thoracoscope helps in avoiding the limitations of tangential vision, which frequently occurs with a low-inserted scope. Dedicated instruments are also useful (◘ Fig. 2.1). Reading of old textbooks dealing with lymphadenectomy shows that the hand is widely used for retraction of organs, such as the lung or the main bronchi, in order to expose the subcarinal region and/or to ensure sufficient working space. Manual assistance cannot be used during endoscopic dissection and must be replaced by the use of atraumatic instruments.
Fig. 2.1
Some helpful tools for lymph node dissection: a 3-mm grasping forceps for retraction, b and c three-leg retractor for space creation during dissection of station 7 from the left side (closed and open positions), d atraumatic lymph node grasping forceps, and e articulated electrothermal bipolar forceps
In order to limit the number of ports, we use either 3-mm retracting devices or throw-off retractors for retracting the lung (◘ Video 2.1). Even when operating with caution, avoiding fragmenting lymph nodes is difficult. The use of atraumatic fenestrated grasping forceps minimizes this risk. We have developed our own lymph node grasping forceps, whose jaws fit the shape of the nodes and reduce the risk of fragmenting them (◘ Video 2.2). In the event of a hemorrhage from a broken node, hemostasis is performed with bipolar cautery. During open or video-assisted lymphadenectomy, it is usual to control small vessels by a combination of clipping and transection. This is time consuming during endoscopic dissection and can be replaced by conventional bipolar shears (◘ Video 2.3), ultrasonic shears, or a vessel-sealing device (VSD), allowing both coagulation and transection with a single tool (◘ Fig. 2.1e). Previously, we used ultrasonic scissors, but we switched to a VSD because the cavitation effect created by ultrasonic devices made dissection less accurate. In addition, the active blade and/or its tip, which is not always under vision control during lymph node dissection, can provoke adverse effects.
In summary, the following equipment is needed to achieve a satisfactory endoscopic lymphadenectomy: a high-definition imaging system, an oblique viewing or deflectable scope, blunt-tip retractors, versatile energy devices, preferably a VSD, and dedicated instruments and retractors.
2.3 Technique
2.3.1 Stations 11, 12, and 13
Dissection and excision of interlobar nodes (◘ Fig. 2.2) and intersegmental nodes (◘ Fig. 2.3) are frequently neglected during thoracoscopic major pulmonary resections. As a result, there is less upstaging from cN0 to pN1 after thoracoscopy than after thoracotomy. However, interlobar and intersegmental lymph node clearance is not difficult but rather a matter of patience and strictness, provided that adequate instruments and energy devices are used.
Fig. 2.2
Examples of interlobar lymph nodes (arrow)
Fig. 2.3
Examples of intersegmental lymph nodes (arrows)
For sublobar resections, it is still unclear if all intersegmental lymph nodes must be resected. Some authors have suggested checking a representative intersegmental or “sump” node and converting to a lobectomy if the latter is positive (◘ Fig. 2.4). However, deciding which one is the sump node—which besides can be negative on a positron emission tomography (PET) scan—is not obvious, and this could be a suitable topic for research aimed at determining a sentinel node.
Fig. 2.4
Example of a small NSCLC a for which an S7 + 8 segmentectomy was planned. A frozen section of a small intersegmental lymph node revealed that it was invaded b. An inferior lobectomy was finally performed
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