What is the role of video-assisted thoracoscopic surgery (VATS) mediastinal lymphadenectomy in lung cancer staging and treatment?

Updated: Dec 10, 2019
  • Author: R James Koness, MD, FACS; Chief Editor: Erik D Schraga, MD  more...
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Lobectomy by means of video-assisted thoracoscopic surgery (VATS), introduced in the early 1990s, has become a popular and accepted alternative to open thoracotomy techniques. [20, 21, 22]  Reported benefits include faster patient recovery with less pain, fewer respiratory complications, and shorter hospital stay without compromising the oncologic complete resection.

VATS has been used by a number of thoracic surgeons with expertise in mediastinal staging. Although thoracoscopy allows access to most of the nodal stations accessible to mediastinoscopy, it also allows access to nodal stations not accessible, such as subaortic, para-aortic, paraesophageal, and inferior pulmonary ligament nodes (stations 5, 6, 8, and 9).

Although useful in right-side neoplasms, VATS plays an even more valuable role in left-side cancers. Aortopulmonary window (station 5) and para-aortic (station 6) lymph nodes are inaccessible via standard cervical mediastinoscopy. VATS has replaced anterior mediastinotomy (the Chamberlain procedure) as the procedure of choice, allowing superior visualization, requiring less operating time, and providing more information about the extent of local disease. [23]

In 2002, Hurtgen et al published their initial experience with video-assisted mediastinoscopic lymphadenectomy (VAMLA). [24]  They used a two-bladed spreading cervical laryngoscope developed by Linder and Dahan in cooperation with the Wolf Company (Richard Wolf GmbH, Knittlingen, Germany; see the image below).

Video-mediastinoscope (Wolf Company, Knittlingen, Video-mediastinoscope (Wolf Company, Knittlingen, Germany), with the 2 blades opened for demonstration.

This instrument markedly increases surgical options, allowing bimanual dissection of lymph node tissue and limiting mediastinal structures that are much better exposed than in standard mediastinoscopy. In 46 VAMLA procedures, the mean number of nodes removed was 20.7, with one recurrent nerve palsy on the left side. [24]

One year later, Leschber and Linder reported on 25 procedures in which the mean number of resected lymph nodes as determined by the surgeon was 8.6. [25]  More important, 18 patients subsequently underwent thoracotomy for resection and standard lymphadenectomy. No false-negative lymph nodes were discovered, and the authors concluded that VAMLA could be used together with VATS to achieve a complete mediastinal lymph node dissection. European and Asian groups subsequently reported results of this combined approach.

Witte et al prospectively collected their VATS resections for cancer and compared patients who underwent VATS alone (n = 14) with those who underwent VATS plus VAMLA (n = 18). [26]  Both the mean number of dissected mediastinal lymph nodes stations (6.4 vs 3.6) and the mediastinal sample weight (11.2 vs 5.5 g) were significantly higher in the VATS plus VAMLA group. The improved radicality was realized without increased total operating time, morbidity, or drainage time. VAMLA was performed before or after VATS in a combined procedure or sometimes staged within 1 week prior to avoid mediastinal fibrosis.

Yoo et al published their results with 108 consecutive VAMLA lung cancer patients, 103 of whom also had a lung resection (101 were performed with VATS). [27]  During combined or staged operations, no residual lymph nodes were found in stations 2R, 4R, and 7 in right-side lung cancer or in stations 4L and 7 in left-side lung cancer. A mean of 16 mediastinal nodes and a mean of 3.5 stations were removed, with no known false-negative lymph nodes noted at resection.

The mean operating time for VAMLA in this study was 39.8 minutes, and five complications were observed, all of them recurrent laryngeal nerve palsies. [27] To avoid this complication, Yoo et al recommended visual identification of the left recurrent nerve, systematic sampling instead of en-bloc resection of stations 2L and 4L, and the use of clips for hemostasis instead of electrocautery.

Zhang et al retrospectively studied the surgical outcomes of 497 non-small cell lung cancer (NSCLC) patients who underwent mediastinal lymph node dissection VATS (n = 242) or thoracotomy (n = 255). [28] The range of dissection included groups 2R, 4R, 7, 8, 9 in right-side cancer procedures and groups 4L, 5, 6, 7, 8, 9 in left-side procedures. VATS was associated with quicker recovery, fewer postoperative complications, and shorter hospital stays, with comparable surgical outcomes. Thoracotomy, however, had an advantage with regard to dissection of group 7L nodes.

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