How is left upper lobe mediastinal lymphadenectomy performed?

Updated: Feb 16, 2021
  • Author: R James Koness, MD, FACS; Chief Editor: Erik D Schraga, MD  more...
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Answer

For a left upper lobectomy, the surgeon stands to the front of the patient after performing a thoracotomy into the pleural space through the fourth or fifth intercostal space. The mediastinal pleura is opened anterior to the hilum, where the phrenic nerve is identified and preserved and the superior pulmonary vein is isolated, ligated, and divided.

The lung is retracted anteriorly, and the descending aorta and esophagus are retracted posteriorly. The lymph node tissue is dissected away from the inferior surface of the right mainstem bronchus (station 10), and the subcarinal lymph nodes (stations 7) are dissected free.

Next, the upper mediastinal pleura is incised to the apex of the thorax. The hemiazygos vein is identified, ligated, and divided, and the ascending aorta is exposed. By working posteriorly, para-aortic as well as subaortic lymph nodes (stations 6 and 5) can be dissected out. Inferior paraesophageal and pulmonary ligament lymph nodes (stations 8 and 9) can be removed at this point.

Next, the left common carotid and left subclavian arteries are exposed at the apex of the thorax, and caudal dissection of fatty tissue containing the lymph nodes is carried out. The right paratracheal, pretracheal, and tracheobronchial nodes (stations 2, 3, and 4) are removed en bloc between the lateral and anterior border of the trachea, the ascending aorta, and the posterior aspect of the SVC, and from the brachiocephalic artery to the right pulmonary artery.

The thoracic duct is in the deepest area between the left common carotid artery and the left subclavian artery. It is not usually identified; thus, all lymphatic channels and fine blood vessels should be ligated before division. Furthermore, in left thoracotomies, the ligamentum arteriosum (ligament of Botallo) must be ligated and divided and the aorta mobilized to dissect lymph node station 4.


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