MMCTS
(October 9, 2006). doi:10.1510/mmcts.2005.001693
Copyright © 2006 European Association for Cardio-thoracic Surgery
Procedure
Transcervical extended mediastinal lymphadenectomy
Marcin Zieli skia,d,*,
Jaros aw Ku daa,
Tomasz Nabiaekb,
 ukasz Hauera,
Juliusz Pankowskic and
Bogdan Dziadziod
a Department of Thoracic Surgery, Pulmonary Hospital in Zakopane, ul. Gadkie 1, 34-500 Zakopane, Poland
b Department of Anesthesiology and Intensive Care, Pulmonary Hospital in Zakopane, ul. Gadkie 1, 34-500 Zakopane, Poland
c Department of Pathology, Pulmonary Hospital in Zakopane, ul. Gadkie 1, 34-500 Zakopane, Poland
d ul.Ubocz 22, 34-500 Zakopane, Poland
* Corresponding author: * Tel.: +48 18 2015045. E-mail: marcinz{at}mp.pl
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Summary
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Transcervical extended mediastinal lymphadenectomy (TEMLA) is a new procedure for bilateral excision of all nodal stations of the mediastinum, except for the pulmonary ligament nodes (station 9) and the most distal left lower paratracheal nodes (station 4L). The procedure is performed through a transverse 5–8 cm incision in the neck with elevation of the sternum with a traction device facilitating the access to the mediastinum. Most of the procedure is performed with an open technique, while the removal of the subcarinal (station 7) and periesophageal nodes (station 8) is performed with the mediastinoscopy assisted technique and excision of the paraaortic nodes (station 6), the aorta-pulmonary window nodes (station 5) and, sometimes, the prevascular nodes (station 3A) is performed with the aid of a videothoracoscope introduced to the mediastinum through the neck incision, without violating the pleura.
Key Words: Lung cancer • Mediastinum • Neoplasm staging • Lymph node excision
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Introduction
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Cervical mediastinoscopy introduced by Carlens remains the gold standard surgical technique of the mediastinal nodal staging in lung cancer patients [1]. Visual inspection of the right and left paratracheal spaces and the subcarinal space, and taking biopsies from the nodes of station 2R, 4R, 2L, 4L and 7 is possible during mediastinoscopy, while the other mediastinal stations are not accessible with this procedure [2,3]. Hürtgen et al. modified the technique of mediastinoscopy and described VAMLA (video-assisted mediastinoscopic lymphadenectomy), which enabled dissection and removal through the mediastinoscope of the same mediastinal lymph nodes stations (and additionally periesophageal nodes – station 8) as is possible during standard mediastinoscopy [4]. In 2004, the first author of this chapter (MZ) developed the technique of transcervical extended mediastinal lymphadenectomy (TEMLA), which is a combination of mediastinoscopy and the bilateral extended mediastinal lymphadenectomy [5]. TEMLA is currently used for staging of all potentially operable non-small cell lung cancers. TEMLA has proved to be a very accurate staging technique, while its therapeutic potential is to be determined in the future [6,7,8]. Since the original presentation the technique of TEMLA underwent some modifications and refinements – the up-to-date version is presented below.
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Surgical technique
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The transcervical incision is made (Video 1) and the platysma and the anterior jugular veins are divided (Video 2).
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Video 1 The 5–6 cm collar incision is made in the neck.
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Video 2 The platysma is divided and the anterior jugular veins are divided and suture-ligated.
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The subplatysmal flaps are developed, with the upper flap reaching the level of the thyroid cartilage and the lower flap then extends below the margin of the sternal notch (Video 3). The strap muscles are separated in the midline and dissected from the thyroid gland (Video 4).
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Video 3 Dissection of the strap muscles from the inner surface of the sternum.
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Video 4 Division of the raphe between the strap muscles.
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The middle and lower thyroid veins are secured with clips and divided. The further dissection is started on the right side first. The fascial layers covering the right carotid artery are divided until the clean wall of the artery is reached (Videos 5 and 6).
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Video 5 Dissection of the right carotid artery. The fascial layers covering the right carotid artery are divided until the clean wall of the artery is reached. It is extremely important to keep the line of cutting strictly over the anterior surface of the artery, to protect the laryngeal recurrent nerve from injury.
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Video 6 Dissection of the right carotid artery – continued.
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In some patients the accessory vessel, a. thyroid ima artery, is present, which must be carefully searched for, dissected, ligated or secured with clips and divided (Videos 7 and 8).
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Video 7 Dissection, double-clipping and division of the accessory vessel, the a. thyroidea ima.
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Video 8 Right carotid artery after division of the a. thyroidea ima.
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The right laryngeal recurrent nerve is visualized with blind dissection with a peanut sponge (Videos 9 and 10). Our technique for visualization of the laryngeal recurrent nerves is described in detail elsewhere [9].
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Video 9 The right laryngeal recurrent nerve is visualized with blind dissection with a peanut sponge. The deepest fascial layer covering the nerve is preserved, so the nerve is visualized, but not dissected circumferentially, therefore the risk of injury to the nerve is minimalized.
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Video 10 Dissection of the left laryngeal recurrent nerve. To expose the nerve, the vascularized fascial layers covering over the nerve are clipped and divided.
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With the use of the sternal retractor inserted under the manubrium, the sternum is elevated (Video 11). The right vagus nerve is identified and dissected (Video 12) and the right paratracheal space is entered (Video 13).
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Video 11 At this stage of the procedure a retractor is placed under the manubrium of the sternum and connected to the frame with a traction system, mounted on the operating table. The sternum is elevated, allowing much better exposure of the mediastinum.
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Video 12 The right vagus nerve, running between the right carotid artery and the right internal jugular vein is dissected.
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Video 13 The right paratracheal space is opened with proceeding of the dissection along the right vagus nerve.
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The highest mediastinal nodes (station 1) are dissected and removed (Videos 14 and 15). Resection of the upper poles of the thymus facilitates access to the mediastinum (Videos 16 and 17). The thick fascial layer between the left innominate vein and the left carotid artery is divided (Video 18). Both laryngeal recurrent nerves are clearly visible (Video 19). The dissection proceeds along the posterior wall of the superior vena cava (Video 20).
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Video 14 The highest mediastinal nodes (station 1) lying above the left innominate vein and medially to the right innominate vein are removed. The dissection of this nodal station starts from the right internal jugular vein, then proceeds along the right innominate vein towards the confluence of both innominate veins.
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Video 15 Dissection and removal of the highest mediastinal nodes (station 1) – continued.
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Video 16 To gain a better access to the mediastinum and to improve the completeness of removal of station 1 nodes, the upper poles of the thymus are divided below the thyroid and ...
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Video 17 ... at the upper margin of the left innominate vein. The whole mediastinal tissue lying above the whole length of the innominate vein, from the right to the left, is dissected and removed.
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Video 18 The thick fascial layer extending between the left innominate vein and the left carotid artery is divided. This maneuver facilitates the access to the aorta-pulmonary window.
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Video 19 View of the dissected right and left laryngeal recurrent nerves.
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Video 20 The posterior wall of the superior vena cava is dissected with the peanut sponge until the azygos vein is clearly visible.
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The upper and lower right paratracheal nodes are dissected and removed (Videos 21, 22 and 23). The retrotracheal nodes (station 3P) are occasionally found (Video 24). The prevascular nodes (station 3A) are removed (Video 25).
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Video 21 The paratracheal nodes (stations 2R and 4R) are bluntly dissected from the right side of the ascending aorta, the trachea, the superior vena cava and the right mediastinal pleura. The right paratracheal nodes (station 2R), lying above the upper margin of the aortic arch (marked by the origin of the innominate artery), are dissected and removed, with all vessels going to the nodes clipped and divided.
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Video 22 The lower paratracheal nodes (station 4R) are carefully dissected from the azygos vein and the right main bronchus.
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Video 23 Dissection of the right lower paratracheal nodes (station 4R) – continued.
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Video 24 The retrotracheal nodes (station 3P), located behind the trachea are dissected and removed.
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Video 25 The prevascular nodes (station 3A) lying in front of the confluence of the innominate veins, and the superior vena cava, and laterally to the ascending aorta, are dissected blunt using the peanut sponge and removed with care to avoid injury of the right mediastinal pleura.
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The next step is the dissection of the left paratracheal space: retracting the trachea to the right side and the left common carotid artery to the left and upwards, enables excellent visualization of the whole left paratracheal space to the level of 1/3 of the left main bronchus.
The dissection proceeds along the left laryngeal recurrent nerve below the level of the tracheal bifurcation. The nerve is dissected from the left wall of the trachea and the left main bronchus with a peanut sponge, while lateral connections of the nerve are preserved to maintain the blood supply to the nerve. In most patients the left upper paratracheal nodes (station 2L) are located medially and in front of the nerve, while the lower paratracheal nodes (station 4L) almost always lie behind the nerve. Carefully preserving the left laryngeal recurrent nerve, the lymph nodes 2L (Video 26) and 4L are dissected.
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Video 26 Dissection and removal of the left upper paratracheal nodes (station 2L), usually located medially and in front of the left laryngeal recurrent nerve.
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The most distal lower paratracheal nodes (station 4L) are located around the distal part of the left main bronchus. Generally, these nodes are not accessible during TEMLA, the same as during all invasive mediastinal staging procedures, except from the TBNA (transbronchial needle aspiration). For removing of the subcarinal and periesophageal nodes (stations 7 and 8), the mediastinoscope is used; we prefer the operative Wolf videomediastinoscope (Richard Wolf GmbH, Knittlingen, Germany), equipped with moving blades, which are very useful in retracting the pulmonary artery from the carina during dissection of node station 7, and the left atrium from the esophagus during dissection of node station 8, to a level 5–8 cm below the carina. The mediastinoscope is used for retracting of these structures and visualization only – the removing of lymph nodes is carried out using a standard dissector for open surgery, introduced through the right paratracheal space along the mediastinoscope (Videos 27 and 28).
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Video 27 Dissection of the subcarinal nodes. The bronchial artery is secured with the endoscopic clips and divided.
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Video 28 Dissection of the subcarinal nodes (station 7) with the use of an endoscopic dissector with cautery.
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Afterwards, the periesophageal nodes are dissected and removed (Video 29).
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Video 29 Removal of the periesophageal node (station 8).
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In some patients the mediastinoscope is also helpful in the removal of the lower paratracheal nodes (station 4L). In these patients removal of the lower paratracheal nodes (station 4L) is postponed until the subcarinal and the periesophageal nodes are removed (Videos 30 and 31).
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Video 30 View of the subcarinal region after removal of the subcarinal (station 7) and periesophageal (station 8 nodes).
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Video 31 Dissection and removal of the left lower paratracheal nodes (station 4L), usually located behind left laryngeal recurrent nerve, which must be carefully preserved from injury.
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The aorta-pulmonary widow is entered (Video 32). After retracting of the vein upwards using a long retractor, the plane is developed at the anterior surface of the aortic arch and the nodes-containing tissue from between the arch and the mediastinal pleura is dissected to the level of aorta-pulmonary window (Video 33).
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Video 32 To enter the paraaortic and aorta-pulmonary window nodes (stations 6 and 5) the left innominate vein is dissected from the aortic arch by blunt and sharp dissection and the left vagus nerve running between the left carotid artery the left internal jugular vein is visualized.
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Video 33 Dissection of the paraaortic nodes (station 6). Clipping and division of the small mediastinal vein.
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The paraaortic nodes (station 6) are located above the lower margin of the aortic arch and in front of the left vagus, left recurrent nerve and the Botallo ligament. The nodes station 5 are dissected with the use of a videothoracoscope introduced to the region of the aorta-pulmonary window through the operative incision, between the left innominate vein and the left common carotid artery. The inferior border of dissection is the left pulmonary artery and the left superior pulmonary vein (Video 34). During the dissection of the paraaortic space it is important to follow the left vagus nerve, being the important landmark and not to injure the accessory hemi-azygos vein, passing in some patients vertically to the left innominate vein.
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Video 34 The nodes station 5 are dissected with the use of a videothoracoscope introduced to the region of the aorta-pulmonary window through the operative incision, between the left innominate vein and the left common carotid artery. The inferior border of dissection is the left pulmonary artery and the left superior pulmonary vein. The left pulmonary artery, the left superior pulmonary vein, the left vagus and left phrenic nerve are visible after removal of the nodes.
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The hemostasis in all dissected areas is checked very carefully and in many cases the hemostatic sponge is inserted to the regions of bleeding. The wound is closed in the standard manner without leaving any drain. Generally, the mediastinal pleura is not violated during the procedure.
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Results
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One hundred and thirty-eight TEMLA procedures were performed by the time of submission of this chapter. One patient died from a hemorrhagic cerebral accident, which occurred on the 2nd postoperative day and two patients died from an exsanguinating respiratory hemorrhage on remote days after TEMLA procedures. In our opinion, all deaths were unrelated to the TEMLA procedure. The complications of TEMLA are shown in Table 1. The most prevalent complication was the palsy of the left laryngeal recurrent nerve, which was temporary in all but one patient. In one patient bilateral laryngeal recurrent nerve palsy occurred which necessitated tracheostomy. After 4 months the function of both nerves was restored and the tracheostomy tube could be removed safely. Preliminary results revealed high diagnostic accuracy of the TEMLA [5].
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Conclusions
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TEMLA is a new surgical operation enabling complete removal of most of the mediastinal lymph node stations with the aid of a videomediastinoscope and a videothoracoscope. Despite the extensiveness of this approach TEMLA is a safe procedure with a low morbidity. TEMLA has proved to be a very accurate staging technique, while its therapeutic potential is to be determined in the future.
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References
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- Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy in the superior mediastinum. Dis Chest 1959;36:343–352.[Medline]
- Mountain CF, Dresler CM. Regional lymph node classification for lung cancer staging. Chest 1997;111:1718–1723.[Abstract/Free Full Text]
- Hammoud ZT, Anderson RC, Meyers BF, Guthrie TJ, Roper CL, Cooper JD, Patterson GA. The current role of mediastinoscopy in the evaluation of thoracic disease. J Thorac Cardiovasc Surg 1999;118:894–899.[Abstract/Free Full Text]
- Hürtgen M, Friedel G, Toomes H, Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA) – technique and first results. Eur J Cardiothorac Surg 2002;21:348–351.[Abstract/Free Full Text]
- Kuzdzal J, Zielinski M, Papla B, Szlubowski A, Hauer L, Nabialek T, Sosnicki W, Pankowski J. Transcervical extended mediastinal lymphadenectomy – the new operative technique and early results in lung cancer staging. Eur J Cardiothorac Surg 2005;27:384–390.[Abstract/Free Full Text]
- Passlick B, Kubuschock B, Sienel W, Thetter O, Pantel K, Izbicki J. Mediastinal lymphadenectomy in non-small cell lung cancer: effectiveness in patients with or without nodal micrometastases – results of a preliminary study. Eur J Cardiothorac Surg 2002;21:520–526.[Abstract/Free Full Text]
- Wu Y, Huang ZF, Wang SY, Yang XN, Ou W. A randomized trial of systematic nodal dissection in resectable NSCLC. Lung Cancer 2002;36:1–6.[CrossRef][Medline]
- Hata E, Hayakawa K, Miyamoto H, Hayashida R. Rationale for extended lymphadenectomy for lung-cancer. Theor Surg 1990;5:19–25.
- Zielinski M, Kuzdzal J, Szlubowski A, Soja J. A safe and reliable technique for visualization of the laryngeal recurrent nerves in the neck. Am J Surg 2005;189:200–202.[CrossRef][Medline]
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Summary
Introduction