Hirji Sameer A, Balderson Stafford S, D'Amico Thomas A
Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Surgery, Duke University Medical Center, Durham, NC, USA.
J Vis Surg. 2016 Jan 5;2:1. doi: 10.3978/j.issn.2221-2965.2015.12.15. eCollection 2016.
The completion of thoracoscopic lobectomy can be more difficult in the setting of clinically positive lymph nodes, which may be found in the setting of a proximal tumor causing bronchial obstruction or a larger tumor which may create an inflammatory state, both of which cause benign significant enlargement of hilar lymph nodes. Knowledge of the typical locations of these enlarged nodes facilitates the conduct of the operation. For all video-assisted thoracoscopic surgery (VATS) lobectomies, it is prudent to remove all visible lymph nodes prior to arterial and bronchial dissection. Moreover, in cases of significant hilar adenopathy, this strategy becomes more important and effective. For left upper lobectomy, the removal of level 11 lymph node anteriorly improves visualization of both bronchi, the interlobar pulmonary artery, the arterial aspect of the fissure, and the lingular artery. Subsequent dissection of the level 10 lymph node superior to the upper lobe bronchus exposes the main pulmonary artery and the truncal branches. For right upper lobectomy, dissection of the level 11 lymph node posteriorly not only exposes the upper lobe bronchus, but also the adjacent posterior ascending pulmonary artery. Dissection of the level 10 lymph node at the superior hilum facilitates exposure of the right pulmonary artery.
在临床淋巴结阳性的情况下，完成胸腔镜肺叶切除术可能会更加困难，这种情况可能出现在近端肿瘤导致支气管阻塞或较大肿瘤引发炎症状态时，这两种情况都会导致肺门淋巴结出现良性显著肿大。了解这些肿大淋巴结的典型位置有助于手术的进行。对于所有电视辅助胸腔镜手术（VATS）肺叶切除术，在进行动脉和支气管解剖之前，谨慎地切除所有可见淋巴结是明智的。此外，在肺门淋巴结肿大明显的情况下，这种策略变得更加重要且有效。对于左上肺叶切除术，向前切除第11组淋巴结可改善对两个支气管、叶间肺动脉、裂的动脉面以及舌叶动脉的可视化。随后解剖上叶支气管上方的第10组淋巴结可暴露主肺动脉和主干分支。对于右上肺叶切除术，向后解剖第11组淋巴结不仅可暴露上叶支气管，还可暴露相邻的后升肺动脉。解剖肺门上缘的第10组淋巴结有助于暴露右肺动脉。
