Techniques My Way
Thoracoscopic Mediastinal Lymph Node Dissection for Lung Cancer

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Technique

Planning the port sites is an important part of nodal dissection, and if the ports are set too low, the dissection will be a struggle. The anterior utility port should not be lower than the 5th space. The use of CO2 is completely unnecessary. A hyperinflated emphysematous lung could be deflated by deliberately digging holes in the target lobe or segment by the use of diathermy. Our method of dissection has evolved into using a malleable diathermy spatula that is insulated albeit for the tip,

Results

We practice systematic MLND at Southampton General Hospital.4 By definition, this means at least 3-field nodal dissection and at least 2 nodes from each field (98.9% had ≥6 and 72.9% had ≥10 nodes harvested). We always include subcarinal lymph nodes. The Southampton “motto” is to dissect every visible node; “if you see a node, it should be in a pot!” (Table 2).

Compared with the clinical positron emission tomography (PET)/computed tomography staging, systematic MLND upstaged 16 patients (16.6%)

Conclusions

Thoracoscopic systematic MLND is technically feasible and safe and does not add to the morbidity or mortality of the originally planned operation. Systematic MLND should be performed routinely even when nodal involvement is unlikely, because 10% of patients in clinical stage N0-1 will have N2 disease. We found PET to be blinded to adenocarcinoma nodal metastases in 16.6% of cases; therefore, a negative PET should not be an excuse against mediastinal nodal dissection. Multidisciplinary

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