Surgical Technique Page 1 of 7 Video-assisted mediastinoscopic lymphadenectomy combined with transcervical thoracoscopy Juan Carlos Trujillo-Reyes, Elisabeth Martínez-Téllez Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain Correspondence to: Juan Carlos Trujillo-Reyes. Head of Thoracic Oncology Committee of the Spanish Society for Pneumology and Thoracic Surgery (SEPAR), Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Sant Antoni Mª Claret, 167, Barcelona 08029, Spain. Email: jtrujillo@santpau.cat. Abstract: Surgical techniques remain the gold standard to diagnose and staging lung and pleural tumours. Non-invasive techniques have become more accurate but actually they are not enough to plan and evaluating prognosis of lung and pleural tumours. In some cases, we need to explore the pleural cavity and the mediastinal lymph node status to confirm or rule out tumour dissemination. The combination of video- assisted mediastinoscopic lymphadenectomy (VAMLA) and thoracoscopy through a single transcervical incision allows the surgeon to widen the range of the exploration and to improve the staging for lung and pleural cancers. VAMLA allows to perform a complete lymphadenectomy of the subcarinal space, the right and pretracheal areas. We consider sampling more safety on the left side to avoid left recurrent nerve injuries. Once this mediastinal tissue is removed, the right mediastinal pleura can be identified and incised. Once mediastinal pleura is opened, a 5 mm 30º thoracoscope is inserted through the video- mediastinoscope into the pleural cavity. It allows to obtain samples of parietal or visceral pleural, pleural fluid or lung nodules if present. In case of left-sided thoracoscopy the access to the left pleural cavity is anterior to the aortic arch as for extended cervical mediastinoscopy. The combination of VAMLA and thoracoscopy is useful to explore the mediastinum and the pleural space from a single incision and in the same surgical setting through the transcervical approach. Keywords: Lung cancer; staging; mediastinal lymphadenectomy Received: 04 May 2019; Accepted: 20 May 2019; published: 06 June 2019. doi: 10.21037/med.2019.05.02 View this article at: http://dx.doi.org/10.21037/med.2019.05.02 Introduction It consists of complete lymphadenectomy (including fatty tissue and lymph nodes) of the subcarinal, the right The purpose of surgical staging of lung and pleural cancers paratracheal and the left paratracheal space- nodal stations is planning treatment and assessing prognosis. 7, 4R and 4L, respectively, according to the International Transcervical video-mediastino-thoracoscopy (VMT) (1,2) allows access to the mediastinum and one or both Association for the Study of Lung cancer lymph node map pleural cavities. It facilitates to identify the cell type and (4,9). In the left paratracheal space we need to be careful stage in lung cancer and other thoracic malignancies, such not to injury left recurrent nerve. Once right paratracheal as mesothelioma (3). lymphadenectomy is completed allows us to identify and Surgical explorations have the highest certainty (4) incise the right mediastinal pleural. Once it is opened, a before lung or pleural resection. 30º-5 mm thoracoscope is introduced through the video- Video-assisted mediastinoscopic lymphadenectomy mediastinoscope. With the 30º video-thoracoscope we (VAMLA) (5-8) is a completely endoscopic procedure can explore both pleural cavities and the lung surface. If performed with the two-valved video-mediastinoscope. we identify pleural or lung nodules, biopsies can be taken © Mediastinum. All rights reserved. Mediastinum 2019;3:21 | http://dx.doi.org/10.21037/med.2019.05.02 Page 2 of 7 Mediastinum, 2019 and no lymph node involvement in PET/CT scan but there are other criteria for mediastinal staging (15). (II) Patients with mesothelioma but the histological subtype (epithelioid, biphasic and sarcomatoid) is unknown or mediastinal staging is required. (III) Pleurodesis for symptomatic control of malignant pleural effusions. (IV) Pulmonary nodules detected during the exploration Basic instrument set. can be resected (13). A) Two-bladed spreadable video-mediastino scope by Linder–Dahan. B) Dissection–coagulation–suction cannula. C) Biopsy forceps with oval jaws, different size D D) 5mm 30º video-thoracoscope Operative techniques B E) Two Farabeufs spreaders F) Needle holder, forceps and scissors Figure 1 Patient’s position. Patient’s position and anaesthetic considerations F The patient is in supine position with a sandbag placed between the scapule. It allows to achieve the maximal neck E D hyperextension. The head is supported on a head ring. B One of the differences withC standard VAMLA is that a single-lung ventilation with a double- lumen tube is needed F to complete the exploration of pleural cavity (Figure 1). A E Instrumentation Figure 2 C We recommend to use the Linder-Dahan spreadable video- mediastinoscope (Richard Wolf, Knittlingen, Germany) instead of Lerut DCI video mediastinoscope (KARL A STORZ SE & Co. KG, Tuttlingen, Germany) because it allows to enlarge the operative field creating an optimal exposure of the mediastinum. Figure 2 Basic instrument set. (A) Two-bladed spreadable video- Regarding instrumentation, the same standard mediastinoscope by Linder-Dahan; (B) dissection-coagulation- mediastinoscopy instruments can be used (Figure 2). A suction cannula; (C) biopsy forceps with oval jaws, different size; 5 mm video-thoracoscope is used to explore the pleural (D) 5 mm 30º video-thoracoscope; (E) two Farabeufs spreaders; (F) cavity. A 30º viewing provides a panoramic view. needle holder, forceps and scissors. Biopsies of parietal pleural can be performed with the same forceps used during VAMLA. If pleural effusion is identified during thoracoscopy, we should take samples for to confirm or discard tumour dissemination. To access to cytological and biochemical analyses. the left pleural cavity, VAMLA is combined with extended mediastinoscopy, the route of which over the aortic arch is used to access the left mediastinal pleura (10-12). Surgical procedure With this procedure, the mediastinum and the pleural Incision cavities are explored from a single cervical incision and in the A cervical incision is performed over the sternal notch same surgical setting, widening the range of the explorations (Figure 3). The subcutaneous tissue and the platysma are and improving the staging of thoracic malignancies (13,14). incised, the paratracheal muscles are separated laterally and It is especially indicated in the next situations: the pretracheal fascia is incised. Then, a pretracheal space is (I) Patients with lung cancer associated with pleural created by digital dissections. This space is necessary to insert effusion with negative cytology by thoracocentesis the video-mediastinoscope into the mediastinum (Figure 4). © Mediastinum. All rights reserved. Mediastinum 2019;3:21 | http://dx.doi.org/10.21037/med.2019.05.02 Mediastinum, 2019 Page 3 of 7 Video 2. Right paratracheal lymphadenectomy ▲ Juan Carlos Trujillo-Reyes*, Elisabeth Martínez-Téllez Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain Figure 3 Cervical incision over the sternal notch. r the sternal notch Figure 6 Right paratracheal lymphadenectomy (17). Available online: http://www.asvide.com/article/view/32080 Video 3. Left paratracheal lymphadenectomy ▲ Juan Carlos Trujillo-Reyes*, Elisabeth Martínez-Téllez Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain Figure 4 Insertion of the video-mediastinoscope into the mediastinoscope into the mediastinum. Figure 7 Left paratracheal lymphadenectomy (18). Available online: http://www.asvide.com/article/view/32081 landmarks, along the main bronchi, the pulmonary artery and the oesophagus. Like you see in Figure 5, when the Video 1. Subcarinal lymphadenectomy subcarinal nodes are excised en bloc, the upper part of the para-oesophageal lymph nodes can be excised, too. ▲ Juan Carlos Trujillo-Reyes*, Right paratracheal lymphadenectomy Elisabeth Martínez-Téllez The right inferior paratracheal nodes are totally excised Department of Thoracic Surgery, Hospital down to the azygos vein and right main bronchus. Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain Once lymphadenectomy is completed the superior vena cava and the right mediastinal pleura are exposed (Figure 6). Left paratracheal lymphadenectomy Figure 5 Subcarinal lymphadenectomy (16). Available online: http://www.asvide.com/article/view/32079 First of all, the left recurrent laryngeal nerve is identified and then the left inferior paratracheal nodes are carefully dissected and removed individually. To explore subaortic VAMLA steps and para-aortic nodes in left lung cancers, extended cervical Subcarinal lymphadenectomy video-mediastinoscopy or parasternal mediastinotomy Subcarinal nodes are completely excised following the should be added (10) (Figure 7). © Mediastinum. All rights reserved. Mediastinum 2019;3:21 | http://dx.doi.org/10.21037/med.2019.05.02 Page 4 of 7 Mediastinum, 2019 Video 4. Right transcervical thoracoscopy ▲ Juan Carlos Trujillo-Reyes*, Elisabeth Martínez-Téllez Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain Figure 10 Right transcervical thoracoscopy (19). Available online: http://www.asvide.com/article/view/32082 Figure 8 The 5 mm 30º video-thoracoscope is introduced through he 5mm 30º video-thoracoscope is introduced the valves of the video-mediastinoscope. alves of the video-mediastinoscope Figure 7 Figure 11 Video mediastinoscope is inserted and advances in front Figure 7- Video mediastinoscope is inserted and advances in front or behind the left innominate or veinbehind the left innominate vein. Figure 9 Using two screens during the exploration. g two screens during the exploration of endoscopic staplers to perform wedge resections of the lung (13) (Figure 10). Transcervical thoracoscopy Left transcervical thoracoscopy (Figure 11) Right transcervical thoracoscopy To explore the left pleural cavity is necessary to create a The 5 mm 30º video-thoracoscope is introduced through the valves of the video-mediastinoscope (Figures 8,9). tunnel by digital blunt dissection. By the same cervical After removing the right inferior paratracheal lymph incision, this tunnel is created between the innominate nodes, the mediastinal pleura is grasped and incised. The artery and the left carotid artery moving above the aortic ipsilateral lung is collapsed and the video-thoracoscope arch and under the left innominate vein. is introduced to the pleural cavity. With a second screen Once the mediastinal pleura is identified we can perform connected to the video-thoracoscope, the entire pleural a pleurotomy under direct endoscopic view to examine the cavity is explored. The parietal or visceral pleura and lung left pleural cavity (20). nodules if present can be biopsied. The opening of the two- Assouad et al. described a new approach to the left valved video-mediastinoscope even allows the insertion pleural cavity passing through the retrosternal space. To © Mediastinum. All rights reserved. Mediastinum 2019;3:21 | http://dx.doi.org/10.21037/med.2019.05.02 Figure 8- An 8F chest drain placed through the opening mediastinal pleura SVC: superior vena cava; AV: azygos vein; RL: right lung Mediastinum, 2019 Page 5 of 7 proper transcervical lymphadenectomy of the subcarinal SVC and the right inferior paratracheal nodal stations and, thus, RL improving the accuracy of mediastinal staging compared to standard mediastinoscopy. With mesothelioma the combination of VAMLA and AV transcervical thoracoscopy may increase the evidence on prognostic information. On the one hand, VAMLA informs us of nodal involvement (25) and, on the other hand, transcervical thoracoscopy allows the biopsy of material from the pleural surface helping to determine the subtype (epithelioid, biphasic and sarcomatoid). All this information Figure 12 An 8 F chest drain placed through the opening is crucial in the decision-making of patients suitable for mediastinal pleura. SVC, superior vena cava; AV, azygos vein; RL, multimodality therapy (3). right lung. From a single transcervical incision, VAMLA and video-thoracoscopy can be combined. With the 30º video- thoracoscope, the parietal and visceral pleura are visualized, complete the thoracoscopy they used a flexible endoscope as well as the inferior and lateral lung and pleural surface. through the valves of the video mediastinoscope (21-23). In some cases, a flexible video-thoracoscope can be useful in This new approach was described to reduce the risk of order to visualise more of the chest cavity and improve the vascular lesions. yield of the procedure in terms of obtaining tissue samples Once the transcervical thoracoscopy is completed a small distant from the pleurotomy site (24). Through the valves chest drain could be placed through the opening mediastinal of the video-mediastinoscope, it also is possible to take pleura (Figure 12). The tube is connected to a suction system samples of pleural effusion introducing any suction system and if the air leak persists the tube could be externalized in the pleural cavity connected to a fluid container. through the cervical incision, and fixed to the skin. If malignancy is confirmed by frozen-section, a pleurodesis can be performed to avoid recurrence. Although Comments many agents can be used, magnesium sulphate (talc) is effective, easy to be applied and cheap (26). Transcervical VMT (1,2) was described by Deslauriers et al. The access to the left pleural cavity is not so direct as on in 1976. The absence of flexible endoscopes made that the the right side because the supra-aortic vessels and the aortic procedure had not been fully applied. Many years later, the arch have to be negotiated to reach the left mediastinal emergence of new endoscopes has allowed the revitalization pleura. The route of the extended cervical mediastinoscopy, of this technique (14,24). facilitates reaching the left mediastinal pleura to complete Although this technique can offer different utilities we the diagnostic and/or therapeutic procedures (3). want to emphasize its role in staging in lung cancer and Several relative or definitive contraindications of the mesothelioma. technique are described. Mediastinal adhesions secondary In lung cancer, a precise staging is crucial. In most to previous radiotherapy or surgery is the more common patients with lung cancer, mediastinal staging is key to but it exists other contraindications like: pleural infection, decide on the best therapeutic option. However, in those mediastinal pleural invasion, posterior location of lung with an accompanying pleural effusion and negative nodules, sever neck rigidity, large goitres, ascending aortic thoracocentesis, its malignant nature must be confirmed or aneurism or atheromatosis of the aorta (3,10,14,27). rule out, because if malignant nature is confirmed, tumour The most important difference with traditional resection is not indicated. thoracoscopy, is that you avoid a transthoracic approach. We have different surgical techniques for staging lung Avoidance of transthoracic ports probably decreases the risk cancers. At present, the improvement of endoscopic surgical of post-operative pain with no increase in surgical risk (28). techniques and their combination allow a more accurate Using a transcervical approach, we reduce the risk of wound staging with little surgical aggression to the patient (3). recurrence due to its contamination with tumour cells in VAMLA (5-8) gives us the possibility to perform a patients with malignant pleural mesothelioma (2,14). © Mediastinum. All rights reserved. Mediastinum 2019;3:21 | http://dx.doi.org/10.21037/med.2019.05.02 Page 6 of 7 Mediastinum, 2019 Table 1 Complications Conflicts of Interest: Both authors have completed the Injury of left recurrent nerve ICMJE uniform disclosure form (available at http:// Mediastinitis dx.doi.org/10.21037/med.2019.05.02). The series “Mediastinoscopic Surgery” was commissioned by the Wound infection editorial office without any funding or sponsorship. The Haemorrhage authors have no other conflicts of interest to declare. Prolonged air leak Ethical Statement: The authors are accountable for all Residual pneumothorax aspects of the work in ensuring that questions related Wound tumour recurrence to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in studies involving human participants were in Potential complications are described in Table 1 (2,7). accordance with the ethical standards of the institutional Like in traditional mediastinoscopy, we have to be careful and national research committees and with the Helsinki with the dissection of left paratracheal nodes to avoid the Declaration (as revised in 2013). Written informed consent transient or permanent left recurrent laryngeal nerve palsy. was obtained from the patient for publication of this Some series describe this complication after VAMLA in manuscript and any accompanying images. 3.2% of the patients (7). To reduce the risk of injury we recommend to visualize Open Access Statement: This is an Open Access article the nerve and avoidance of the electrocautery in close distributed in accordance with the Creative Commons proximity to the nerve. Small bleedings near to the nerve Attribution-NonCommercial-NoDerivs 4.0 International should be controlled by temporary compression or clipping. License (CC BY-NC-ND 4.0), which permits the non- In conclusion, the developed in VATS has allowed the commercial replication and distribution of the article with widespread application of video-assisted thoracoscopic the strict proviso that no changes or edits are made and the surgical techniques. Regarding lung cancer and original work is properly cited (including links to both the mesothelioma staging, it has allowed the combination of formal publication through the relevant DOI and the license). VAMLA and transcervical-thoracoscopy, improving the See: https://creativecommons.org/licenses/by-nc-nd/4.0/. accuracy in staging of lung cancer and mesothelioma. By one incision we can answer many questions about References diagnosis, staging and prognosis. For all these reasons, the combination of VAMLA and mediastino-thoracoscopy 1. Deslauriers J, Beaulieu M, Dufour C, et al. should be kept in mind for the described indications. Mediastinopleuroscopy: a new approach to the diagnosis of intrathoracic diseases. Ann Thorac Surg 1976;22:265-9. 2. Chamberlain MH, Fareed K, Nakas A, et al. Video- Acknowledgments assisted cervical thoracoscopy: a novel approach for We would like to express our gratitude to Aitana Belda diagnosis, staging and pleurodesis of malignant pleural Camós and Josep Belda for drawing figures and to the rest mesothelioma. Eur J Cardiothorac Surg 2008;34:200-3. of Thoracic Surgery Team, nurses and Anesthesiologists for 3. Dawson AG, Waller DA. 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Left paratracheal doi: 10.21037/med.2019.05.02 Cite this article as: Trujillo-Reyes JC, Martínez-Téllez E. Video-assisted mediastinoscopic lymphadenectomy combined with transcervical thoracoscopy. Mediastinum 2019;3:21. © Mediastinum. All rights reserved. Mediastinum 2019;3:21 | http://dx.doi.org/10.21037/med.2019.05.02