Guido Guerrero William, Gonzalez-Rivas Diego, Hernandez Arenas Luis Angel, Jiang Gening, Yang Yang, Li Wentao, Zhou Yiming, Huang Wei
Department of Thoracic Surgery, Shanghai Pulmonary Hospital, Tongji University School of Medicine, Shanghai 200433, China.
Department of Thoracic Surgery, Coruña University Hospital and Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña, Spain.
J Vis Surg. 2016 Jan 31;2:23. doi: 10.3978/j.issn.2221-2965.2016.01.05. eCollection 2016.
Surgical treatment of lung cancer has evolved to a minimally invasive approach and currently is recognized as an acceptable treatment for resectable non-small cell lung cancer (NSCLC). As the volume and complexity of cases has increased technical difficulties had arisen. Hilar and sublobar lymph nodes can represent a challenge for video-assisted thoracoscopic surgery (VATS) surgeons in order to complete a safe dissection of vascular and bronchial structures without complications or conversion. It is not unusual the patients with smoking history or benign infections in the past present with enlarged calcified nodes that are fused to the hilum, fissure and specially the bronchus which can lead to an accident during the procedure if the surgeon has no experience handling this issue. As the amount of surgeons carrying out VATS lobectomies grows it is very important for them to know what to do in this specific case so the completion of the procedure can be achieved safely.
The coordination between the surgeon and the assistant is very important in order to carry out the procedure without discomfort positions and good visualization, the use of energy devices in expert hands can help considerably during the dissection of lymph nodes in the hilum and fissure reducing the bleeding, which provides a clean operative field. It is a necessary maneuver during the dissection to find the correct adventitial plane between the lymph node and the structure before passing it.
The videos in this article show the different maneuvers a VATS surgeon can implement when facing enlarged fussed lymph nodes in the hilum, fissure or mediastinum. Improving exposure, opening the fissure, using energy and carrying out the dissection through the correct plane are keys to complete the procedure successfully.
With growing experience in uniportal VATS and advances in surgical technology, enlarged or fussed lymph nodes are no longer a contraindication to complete a VATS lobectomy, experience VATS surgeons have a repertory of options in order to perform a safe and effective dissection.
肺癌的外科治疗已发展为微创方法，目前被认为是可切除非小细胞肺癌（NSCLC）的一种可接受的治疗方式。随着病例数量和复杂性的增加，出现了技术难题。肺门和亚叶淋巴结对于电视辅助胸腔镜手术（VATS）外科医生来说可能是一项挑战，以便在不发生并发症或中转开胸的情况下安全地解剖血管和支气管结构。有吸烟史或既往有良性感染的患者出现钙化的肿大淋巴结并与肺门、叶间裂特别是支气管融合并不罕见，如果外科医生没有处理此问题的经验，在手术过程中可能会导致意外。随着进行VATS肺叶切除术的外科医生数量增加，了解在这种特定情况下该怎么做对他们来说非常重要，这样才能安全地完成手术。
外科医生和助手之间的协作对于在无不适体位且视野良好的情况下进行手术非常重要，在专家手中使用能量设备在解剖肺门和叶间裂的淋巴结时可大大减少出血，从而提供一个清晰的手术视野。在解剖过程中，在穿过淋巴结和结构之前找到它们之间正确的外膜平面是必要的操作。
本文中的视频展示了VATS外科医生在面对肺门、叶间裂或纵隔中肿大融合的淋巴结时可以实施的不同操作。改善暴露、打开叶间裂、使用能量并通过正确的平面进行解剖是成功完成手术的关键。
随着单孔VATS经验的增加和手术技术的进步，肿大或融合的淋巴结不再是完成VATS肺叶切除术的禁忌证，经验丰富的VATS外科医生有一系列选择来进行安全有效的解剖。
