Trujillo-Reyes Juan Carlos, Martínez-Téllez Elisabeth
Department of Thoracic Surgery, Hospital Universitari de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
Mediastinum. 2019 Jun 6;3:21. doi: 10.21037/med.2019.05.02. eCollection 2019.
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.
手术技术仍然是诊断和分期肺及胸膜肿瘤的金标准。非侵入性技术已变得更加准确，但实际上它们不足以用于规划和评估肺及胸膜肿瘤的预后。在某些情况下，我们需要探查胸膜腔和纵隔淋巴结状态，以确认或排除肿瘤播散。通过单一经颈切口进行的电视辅助纵隔镜淋巴结清扫术（VAMLA）和胸腔镜检查相结合，使外科医生能够扩大探查范围，并改善肺和胸膜癌的分期。VAMLA能够对隆突下间隙、右侧及气管前区域进行完整的淋巴结清扫。我们认为左侧取样更安全，以避免左侧喉返神经损伤。一旦切除该纵隔组织，即可识别并切开右侧纵隔胸膜。打开纵隔胸膜后，将一根5毫米30°的胸腔镜通过电视纵隔镜插入胸膜腔。如果存在壁层或脏层胸膜、胸水或肺结节，它可以获取样本。对于左侧胸腔镜检查，进入左胸膜腔的路径与扩大颈部纵隔镜检查一样，位于主动脉弓前方。VAMLA和胸腔镜检查相结合，有助于通过经颈入路，从单一切口并在同一手术环境中探查纵隔和胸膜腔。
