Article Abstract

VATS lymph node dissection and staging: the Southampton experience

Authors: Khalid Amer, Ali Zamir Khan, Rajinder Parshad, Andrew Jones


Background: We set out to describe the Southampton experience with video-assisted thoracoscopic surgery (VATS) mediastinal nodal dissection. We aim to discuss our refined technique and the rationale behind it, as well as complications, caveats and trouble shooting. We describe our experience about how to avoid injury to the recurrent laryngeal nerves (RLNs).
Methods: This is an observational descriptive review of the operation notes and video recordings of patients undergoing VATS mediastinal systematic nodal dissection (SND) performed during major pulmonary resections for non-small cell lung cancer (NSCLC). VATS-SND was routinely performed at the time of anatomical resection. Our SND conformed to the American College of Surgery Oncology Group (ACOSOG) Z0030 trial definition of SND. In addition, we routinely explore stations 3a, 3p, 4L and 2L. The majority of cases were performed using monopolar diathermy, but in the last 2 years this was replaced by a bipolar energy device. Knowledge about the nodal anatomy and that of the RLN was obtained by dissecting freshly embalmed human cadavers at the All India Institute of Medical Sciences.
Results: Five video clips summarizing our current state of experience are presented. These include right nodal harvesting, left nodal harvesting, across midline harvesting of specific nodes, how to avoid damage to the RLN, complications and troubleshooting. Between 2007–2017, we operated on 600 patients (240 left side, 40%). Bleeding in excess of 500 mL which was directly related to SND occurred 3 times. Immediate conversion to thoracotomy was required in one case, and 2 cases required postoperative VATS re-exploration. There were three port-access site metastases, but none of the patients had nodal micrometastases. Three phrenic nerve palsies are reported, one right and two left-sided. There was no RLN palsy on the right side and 3 on the left side (1.3%). Two RLN palsies were due to thermal injury and one due to inadvertent transection of the descending vagal trunk. There was no RLN palsy attributable to energy spray after changing practice from monopolar to bipolar diathermy. The ligamentum arteriosum had to be transected in four patients without complications.
Conclusions: Cumulative experience in a large throughput centre has improved the safety record of VATS comprehensive mediastinal nodal dissection. VATS allows the surgeon to access all nodal stations consistently, safely and with minimal complications. A better understanding of the RLN anatomy and the use of a bipolar energy device have contributed to the significant drop in phrenic and RLN palsies in our experience.