Anterior Subcarinal Node Dissection on the Left Side Using Video Thoracoscopy: An Easier Technique
2015; Elsevier BV; Volume: 99; Issue: 4 Linguagem: Inglês
10.1016/j.athoracsur.2014.12.078
ISSN1552-6259
AutoresJean‐Marc Baste, Laura Haddad, J. Melki, Christophe Peillon,
Tópico(s)Pleural and Pulmonary Diseases
ResumoLobectomy for lung carcinoma is usually associated with complete node dissection, but it is often difficult to perform using video thoracoscopy, especially on the left side. In this case, our team uses an anterior technique for subcarinal lymphadenectomy. After left lobectomy, we lift the bronchial stump by its anterior face to open and dissect the subcarinal space. Exposure is difficult using the more usual technique of posterior subcarinal lymphadenectomy, and the different techniques (often requiring retractors) remain complex because some vessels might be injured. We recommend using anterior lymphadenectomy, which should facilitate video thoracoscopy for lymphadenectomy on the left side. Lobectomy for lung carcinoma is usually associated with complete node dissection, but it is often difficult to perform using video thoracoscopy, especially on the left side. In this case, our team uses an anterior technique for subcarinal lymphadenectomy. After left lobectomy, we lift the bronchial stump by its anterior face to open and dissect the subcarinal space. Exposure is difficult using the more usual technique of posterior subcarinal lymphadenectomy, and the different techniques (often requiring retractors) remain complex because some vessels might be injured. We recommend using anterior lymphadenectomy, which should facilitate video thoracoscopy for lymphadenectomy on the left side. The Videos can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2014.12.078] on http://www.annalsthoracicsurgery.org.Dr Peillon discloses a financial relationship with Covidien; and Dr Baste with Covidien and Ethicon.There is still debate about complete node dissection and sampling in patients with non–small-cell lung cancer requiring pulmonary resection, even after the recent publication by Darling and colleagues [1Darling G.E. Allen M.S. Decker P.A. et al.Number of lymph nodes harvested from a mediastinal lymphadenectomy: results of the randomized, prospective American College of Surgeons Oncology Group Z0030 trial.Chest. 2011; 139: 1124-1129Crossref PubMed Scopus (108) Google Scholar]. European Society of Thoracic Surgeons guidelines (2006) advocate complete dissection, including the subcarinal area, even in the early stages of cancer [2Lardinois D. De Leyn P. Van Schil P. et al.ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer.Eur J Cardiothorac Surg. 2006; 30: 787-792Crossref PubMed Scopus (480) Google Scholar].Lung resection by video thoracoscopy is now well accepted and results in a lower rate of morbidity and the same long-term results as achieved with open operations [3Yan T.D. Black D. Bannon P.G. McCaughan B.C. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.J Clin Oncol. 2009; 27: 2553-2562Crossref PubMed Scopus (572) Google Scholar]. However, some surgeons argue that node dissection, especially on the left side, is not appropriate for subcarinal dissection [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar]. To facilitate subcarinal node resection, especially on the left side, some authors recommend using dedicated instruments, such as the L-shaped retractor, for easier access to this region [5Ramos R. Girard P. Masuet C. Validire P. Gossot D. Mediastinal lymph node dissection in early-stage non-small cell lung cancer: totally thoracoscopic vs thoracotomy.Eur J Cardiothorac Surg. 2012; 41: 1342-1348Crossref PubMed Scopus (42) Google Scholar, 6Sato Y. Tezuka Y. Kanai Y. et al.Novel retractor for lymph node dissection by video-assisted thoracic surgery.Ann Thorac Surg. 2008; 86: 1036-1037Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar].Our team uses an anterior technique for subcarinal node dissection using video thoracoscopy after left lobectomy [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar]. This enables complete subcarinal node resection on the left side without resorting to the use of surgical retractors.This report demonstrates the advantages of our technique, which could help surgeons who doubt the accuracy and relevance of subcarinal dissection on the left side and still advise an open procedure for this reason.TechniqueWe use the standardized anterior approach for video thoracoscopy as described by Hansen and associates [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar]. For left upper or lower lobectomy, the vessels, fissures, and bronchi are divided sequentially. The bronchus is transected with a mechanical endostapler (Tri-Staple, Covidien, Minneapolis, MN), loaded with a purple Tri-stapler, whereas the vessels and parenchyma require transection by a tan Tri-Stapler. We then perform a complete lymph node dissection using a LigaSure device (Covidien). For subcarinal lymphadenectomy, we use an anterior technique. We pull and lift the bronchial stump by catching hold of it on its anterior cartilaginous face very carefully using an atraumatic clamp. We can also lift the main bronchus without grabbing the bronchus, as shown in Fig 1, which opens the subcarinal space and makes it easy to dissect and resect the subcarinal node (Fig 2). To optimize exposure, we can slide the surgical aspirator under the bronchial carina and gently lift it (Fig 1). We follow the different landmarks, keeping the esophagus and aorta behind the right main bronchus (Videos 1 and 2).Fig 2Subcarinal dissection using video thoracoscopy and anterior technique. (A) Anterior view of subcarinal area. (B) Bronchial stump is pulled and lifted to open subcarinal space. Bronchus can sometimes be grabbed carefully. We have done more than 100 left lobectomies with no bronchial complications.View Large Image Figure ViewerDownload (PPT)CommentSubcarinal lymphadenectomy is usually performed by a posterior technique, necessitating forward retraction of the remaining lung (currently with additional endoscopic retractors [6Sato Y. Tezuka Y. Kanai Y. et al.Novel retractor for lymph node dissection by video-assisted thoracic surgery.Ann Thorac Surg. 2008; 86: 1036-1037Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]). The posterior technique is usually difficult to achieve even in expert hands, which is why Gopaldas and coworkers [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar] reported that lymphadenectomy using video thoracoscopy was not optimal when compared with thoracotomy. Moreover, lymphadenectomy in the subcarinal area is risky, especially on the left side, because the subcarinal node is deeply embedded and difficult to expose. This dissection is performed behind the inferior pulmonary vein, which is located on the inner face of the left main bronchus, and could damage the bronchial microvasculature, often causing bronchial necrosis and bronchopleural fistula [8Satoh Y. Okumura S. Nakagawa K. et al.Postoperative ischemic change in bronchial stumps after primary lung cancer resection.Eur J Cardiothorac Surg. 2006; 30: 172-176Crossref PubMed Scopus (42) Google Scholar]. Posterior dissection may also damage the pericardium or the aorta [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar].Our technique of subcarinal node dissection on the left side is atraumatic, easy, and quick.If necessary, grabbing the bronchus is done very carefully with an atraumatic forceps. We have no bronchial complications to declare on more than 100 left video-assisted thoracoscopic lobectomies. Furthermore, the anterior technique enables risk-free exposure and does not necessitate retraction of surrounding tissue by additional retractors [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar].In conclusion, we are convinced that our technique of an anterior approach for subcarinal lymphadenectomy on the left side could make lung operations using video thoracoscopy more attractive for surgeons. In our experience, video thoracoscopy facilitates subcarinal node dissection on the left side. The Videos can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2014.12.078] on http://www.annalsthoracicsurgery.org.Dr Peillon discloses a financial relationship with Covidien; and Dr Baste with Covidien and Ethicon.There is still debate about complete node dissection and sampling in patients with non–small-cell lung cancer requiring pulmonary resection, even after the recent publication by Darling and colleagues [1Darling G.E. Allen M.S. Decker P.A. et al.Number of lymph nodes harvested from a mediastinal lymphadenectomy: results of the randomized, prospective American College of Surgeons Oncology Group Z0030 trial.Chest. 2011; 139: 1124-1129Crossref PubMed Scopus (108) Google Scholar]. European Society of Thoracic Surgeons guidelines (2006) advocate complete dissection, including the subcarinal area, even in the early stages of cancer [2Lardinois D. De Leyn P. Van Schil P. et al.ESTS guidelines for intraoperative lymph node staging in non-small cell lung cancer.Eur J Cardiothorac Surg. 2006; 30: 787-792Crossref PubMed Scopus (480) Google Scholar]. The Videos can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2014.12.078] on http://www.annalsthoracicsurgery.org. The Videos can be viewed in the online version of this article [http://dx.doi.org/10.1016/j.athoracsur.2014.12.078] on http://www.annalsthoracicsurgery.org. Dr Peillon discloses a financial relationship with Covidien; and Dr Baste with Covidien and Ethicon. Dr Peillon discloses a financial relationship with Covidien; and Dr Baste with Covidien and Ethicon. Lung resection by video thoracoscopy is now well accepted and results in a lower rate of morbidity and the same long-term results as achieved with open operations [3Yan T.D. Black D. Bannon P.G. McCaughan B.C. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer.J Clin Oncol. 2009; 27: 2553-2562Crossref PubMed Scopus (572) Google Scholar]. However, some surgeons argue that node dissection, especially on the left side, is not appropriate for subcarinal dissection [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar]. To facilitate subcarinal node resection, especially on the left side, some authors recommend using dedicated instruments, such as the L-shaped retractor, for easier access to this region [5Ramos R. Girard P. Masuet C. Validire P. Gossot D. Mediastinal lymph node dissection in early-stage non-small cell lung cancer: totally thoracoscopic vs thoracotomy.Eur J Cardiothorac Surg. 2012; 41: 1342-1348Crossref PubMed Scopus (42) Google Scholar, 6Sato Y. Tezuka Y. Kanai Y. et al.Novel retractor for lymph node dissection by video-assisted thoracic surgery.Ann Thorac Surg. 2008; 86: 1036-1037Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]. Our team uses an anterior technique for subcarinal node dissection using video thoracoscopy after left lobectomy [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar]. This enables complete subcarinal node resection on the left side without resorting to the use of surgical retractors. This report demonstrates the advantages of our technique, which could help surgeons who doubt the accuracy and relevance of subcarinal dissection on the left side and still advise an open procedure for this reason. TechniqueWe use the standardized anterior approach for video thoracoscopy as described by Hansen and associates [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar]. For left upper or lower lobectomy, the vessels, fissures, and bronchi are divided sequentially. The bronchus is transected with a mechanical endostapler (Tri-Staple, Covidien, Minneapolis, MN), loaded with a purple Tri-stapler, whereas the vessels and parenchyma require transection by a tan Tri-Stapler. We then perform a complete lymph node dissection using a LigaSure device (Covidien). For subcarinal lymphadenectomy, we use an anterior technique. We pull and lift the bronchial stump by catching hold of it on its anterior cartilaginous face very carefully using an atraumatic clamp. We can also lift the main bronchus without grabbing the bronchus, as shown in Fig 1, which opens the subcarinal space and makes it easy to dissect and resect the subcarinal node (Fig 2). To optimize exposure, we can slide the surgical aspirator under the bronchial carina and gently lift it (Fig 1). We follow the different landmarks, keeping the esophagus and aorta behind the right main bronchus (Videos 1 and 2). We use the standardized anterior approach for video thoracoscopy as described by Hansen and associates [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar]. For left upper or lower lobectomy, the vessels, fissures, and bronchi are divided sequentially. The bronchus is transected with a mechanical endostapler (Tri-Staple, Covidien, Minneapolis, MN), loaded with a purple Tri-stapler, whereas the vessels and parenchyma require transection by a tan Tri-Stapler. We then perform a complete lymph node dissection using a LigaSure device (Covidien). For subcarinal lymphadenectomy, we use an anterior technique. We pull and lift the bronchial stump by catching hold of it on its anterior cartilaginous face very carefully using an atraumatic clamp. We can also lift the main bronchus without grabbing the bronchus, as shown in Fig 1, which opens the subcarinal space and makes it easy to dissect and resect the subcarinal node (Fig 2). To optimize exposure, we can slide the surgical aspirator under the bronchial carina and gently lift it (Fig 1). We follow the different landmarks, keeping the esophagus and aorta behind the right main bronchus (Videos 1 and 2). CommentSubcarinal lymphadenectomy is usually performed by a posterior technique, necessitating forward retraction of the remaining lung (currently with additional endoscopic retractors [6Sato Y. Tezuka Y. Kanai Y. et al.Novel retractor for lymph node dissection by video-assisted thoracic surgery.Ann Thorac Surg. 2008; 86: 1036-1037Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]). The posterior technique is usually difficult to achieve even in expert hands, which is why Gopaldas and coworkers [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar] reported that lymphadenectomy using video thoracoscopy was not optimal when compared with thoracotomy. Moreover, lymphadenectomy in the subcarinal area is risky, especially on the left side, because the subcarinal node is deeply embedded and difficult to expose. This dissection is performed behind the inferior pulmonary vein, which is located on the inner face of the left main bronchus, and could damage the bronchial microvasculature, often causing bronchial necrosis and bronchopleural fistula [8Satoh Y. Okumura S. Nakagawa K. et al.Postoperative ischemic change in bronchial stumps after primary lung cancer resection.Eur J Cardiothorac Surg. 2006; 30: 172-176Crossref PubMed Scopus (42) Google Scholar]. Posterior dissection may also damage the pericardium or the aorta [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar].Our technique of subcarinal node dissection on the left side is atraumatic, easy, and quick.If necessary, grabbing the bronchus is done very carefully with an atraumatic forceps. We have no bronchial complications to declare on more than 100 left video-assisted thoracoscopic lobectomies. Furthermore, the anterior technique enables risk-free exposure and does not necessitate retraction of surrounding tissue by additional retractors [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar].In conclusion, we are convinced that our technique of an anterior approach for subcarinal lymphadenectomy on the left side could make lung operations using video thoracoscopy more attractive for surgeons. In our experience, video thoracoscopy facilitates subcarinal node dissection on the left side. Subcarinal lymphadenectomy is usually performed by a posterior technique, necessitating forward retraction of the remaining lung (currently with additional endoscopic retractors [6Sato Y. Tezuka Y. Kanai Y. et al.Novel retractor for lymph node dissection by video-assisted thoracic surgery.Ann Thorac Surg. 2008; 86: 1036-1037Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar]). The posterior technique is usually difficult to achieve even in expert hands, which is why Gopaldas and coworkers [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar] reported that lymphadenectomy using video thoracoscopy was not optimal when compared with thoracotomy. Moreover, lymphadenectomy in the subcarinal area is risky, especially on the left side, because the subcarinal node is deeply embedded and difficult to expose. This dissection is performed behind the inferior pulmonary vein, which is located on the inner face of the left main bronchus, and could damage the bronchial microvasculature, often causing bronchial necrosis and bronchopleural fistula [8Satoh Y. Okumura S. Nakagawa K. et al.Postoperative ischemic change in bronchial stumps after primary lung cancer resection.Eur J Cardiothorac Surg. 2006; 30: 172-176Crossref PubMed Scopus (42) Google Scholar]. Posterior dissection may also damage the pericardium or the aorta [4Gopaldas R.R. Bakaeen F.G. Dao T.K. Walsh G.L. Swisher S.G. Chu D. Video-assisted thoracoscopic versus open thoracotomy lobectomy in a cohort of 13,619 patients.Ann Thorac Surg. 2010; 89: 1563-1570Abstract Full Text Full Text PDF PubMed Scopus (134) Google Scholar]. Our technique of subcarinal node dissection on the left side is atraumatic, easy, and quick. If necessary, grabbing the bronchus is done very carefully with an atraumatic forceps. We have no bronchial complications to declare on more than 100 left video-assisted thoracoscopic lobectomies. Furthermore, the anterior technique enables risk-free exposure and does not necessitate retraction of surrounding tissue by additional retractors [7Hansen H.J. Petersen R.H. Christensen M. Video-assisted thoracoscopic surgery (VATS) lobectomy using a standardized anterior approach.Surg Endosc. 2011; 25: 1263-1269Crossref PubMed Scopus (114) Google Scholar]. In conclusion, we are convinced that our technique of an anterior approach for subcarinal lymphadenectomy on the left side could make lung operations using video thoracoscopy more attractive for surgeons. In our experience, video thoracoscopy facilitates subcarinal node dissection on the left side. The authors are grateful to Nikki-Sabourin-Gibbs, Rouen University Hospital, for editing the manuscript. 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The main points of their paper are the following: (1) complete nodal dissection is recommended even in early staged non–small cell lung cancer (NSCLC), to guarantee the most accurate staging; and (2) to be accepted, VATS lung resection should allow the same nodal dissection as open thoracotomy. Full-Text PDF
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