Ann Thorac Surg 2008;86:1036-1037. doi:10.1016/j.athoracsur.2008.04.002
© 2008 The Society of Thoracic Surgeons
How To Do It
Novel Retractor for Lymph Node Dissection by Video-Assisted Thoracic Surgery
Yukio Sato, MD, PhD*,
Yasuhiro Tezuka, MD,
Yoshihiko Kanai, MD,
Shinichi Otani, MD,
Shinichi Yamamoto, MD,
Kenji Tetsuka, MD,
Yasunori Sohara, MD, PhD
Division of Thoracic Surgery, Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
Accepted for publication April 1, 2008.
* Address correspondence to Dr Sato, Division of Thoracic Surgery, Department of Surgery, Jichi Medical University, 3311-1 Yakushiji, Shimotsuke, Tochigi, 329-0498, Japan (Email: tcvysato{at}jichi.ac.jp).
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Abstract
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In nonrandomized studies, the video-assisted thoracic surgical (VATS) lobectomy seems to be a safe and effective procedure for treatment of lung cancer. However, there are some difficulties in VATS complete mediastinal lymph node dissection. The presence of the lymph node deep in the mediastinal space necessitates retraction of the surrounding organs. Therefore, we developed a retractor to create enough working space during the VATS procedure. To dissect lymph nodes, we use endoscopic bipolar forceps. These instruments are connected to a special electrosurgical generator to apply bipolar soft coagulation, which enables simultaneous dissection and sealing. Thus, "en bloc" lymph node dissection can be performed during the VATS procedure.
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Introduction
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In nonrandomized studies, the video-assisted thoracic surgical (VATS) lobectomy seems to be a safe and effective procedure for treatment of early-stage nonsmall cell lung cancer. Advantages of the VATS lobectomy as compared with the lobectomy with a thoracotomy include less postoperative pain, faster return to full activity, preserved pulmonary function, shorter duration of chest tube use and hospital stay, reduced inflammatory response, facility of adjuvant chemotherapy, and lower incidence of postoperative atrial fibrillation [1–3]. Surgeons can recognize small vessels deep in the thoracic cavity by enlarged high-resolution images with the advance of the thoracoscopic system.
Despite these advantages, some thoracic surgeons do not accept VATS lobectomy and continue to perform the lobectomy with a thoracotomy. One major obstacle to acceptance of the thoracoscopic approach is uncertainty as to whether the extent and quality of mediastinal lymph node dissection are equal to those of the thoracotomy. Complete mediastinal lymph node dissection, confirmed by enumerating the lymph node removed, is reportedly as feasible with the VATS procedure as it is with a conventional surgical procedure [4, 5]. However, "number of lymph nodes" harvested might not be a proper indicator for quality of mediastinal lymph node dissection, as fragmented lymph nodes that could occur during the VATS procedure that would falsely elevate the number of lymph nodes. Actually there are some difficulties in complete mediastinal lymph node dissection to perform so-called "en bloc" lymph node dissection with the VATS procedure. The presence of the lymph node deep in the mediastinal space necessitates retraction of surrounding organs, such as the large vessels and the main bronchus to ensure sufficient working space and visibility for en bloc lymph node dissection. The hands and device as a spatula can be used to retract surrounding organs during the conventional procedure, but not during the VATS procedure.
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Technique
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To ensure en bloc lymph node dissection with the VATS procedure, we developed an "L"-shaped retractor (see Fig 1) (Midori-jaSugiura, Tokyo, Japan) for lymph node dissection by the VATS procedure. This retractor consists of a 3-cm wide tip, a narrow (8-mm in diameter) intermediate pole, and a hand grip. The tip can be inserted through a small thoracotomy for use during the VATS procedure. Once the tip is inserted into the thoracic cavity, it can be rotated to retract large vessels or the main bronchus to allow en bloc dissection of lymph nodes deep in the mediastinal space. The retractor is held by the assistant, and the intermediate pole is placed at the edge of small thoracotomy to avoid the interference with other forceps of the operator. The angle part of retractor was made oblique to minimize interference. We use two 1-cm incisions for trocar introduction and an access incision of 5 cm placed in the fourth or fifth intercostal space for specimen retrieval. Our retractor was introduced through access incision. A completed lymph node dissection in the right upper mediastinum after a VATS right upper lobectomy is shown in Figure 2. The superior vena cava was retracted by our device, creating enough working space in front of trachea for en bloc lymph node dissection. This device can also be applied to retract the main bronchus for the subcarinal lymph node dissection. By retraction of the main bronchus, the subcarinal space was mobilized toward the operative pleural cavity, creating enough working space for en bloc lymph node dissection.
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Fig 1. The retractor consists of a 3-cm wide tip, narrow (8-mm in diameter) intermediate pole, and a hand grip. The tip can be inserted through a small thoracotomy for use in video-assisted thoracic surgery. Once the tip is inserted into the thoracic cavity, it can be rotated to retract large vessels or the main bronchus to allow en bloc dissection of lymph nodes deep in the mediastinal space.
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Fig 2. Intraoperative photograph of a completed lymph node dissection in the right upper mediastinum. The superior vena cava is retracted by our device, creating enough working space in front of trachea for en bloc lymph node dissection. The surfaces of the trachea, ascending aorta, brachiocephalic artery, and subclavian artery are revealed. (PA = pulmonary artery; Subclavian a. = subclavian artery; SVC = superior vena cava; vagal n. = vagal nerve.)
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To dissect lymph nodes from surrounding organs, we used the endoscopic bipolar Metzenbaum scissors (AdTec Bipolar; Aesculap, Tuttlingen, Germany) and BiClamp forceps (ERBE, Germany), which were designed to be used through an endoscopic port. These instruments were connected to a VIO electrosurgical generator (VIO 300D; ERBE, Tuttlingen, Germany) to apply Bipolar Soft Coag mode and BiClamp vessel sealing. These modes offer low voltage (< 200 Vp) penetration based on the effect level and time of activation for faster tissue coagulation, and also prevent adherence of coagulated tissue to the scissors and forceps due to overcoagulation. Dissection and sealing of small vessels around the lymph nodes can be done simultaneously and effectively with these tools.
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Comment
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Thus, with the use of our retractor and the bipolar coagulation system, en bloc lymph node dissection can be performed during the VATS procedure. Therefore, we consider the extent and quality of mediastinal dissection with VATS to be equal to those with thoracotomy, and we expect VATS lobectomy with lymph node dissection to become the standard operative strategy for early stage nonsmall cell lung cancer.
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Acknowledgments
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No financial support was received for this study. The retractor was purchased by the budget for surgical instruments of our hospital. The authors had full control of the study design, methods used, outcome measurements, analysis of data, and production of the written report.
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References
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- Daniels LJ, Balderson SS, Onaitis MW, D'Amico TA. Thoracoscopic lobectomy: a safe and effective strategy for patients with stage I lung cancer Ann Thorac Surg 2002;74:860-864.[Abstract/Free Full Text]
- McKenna Jr RJ, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases Ann Thorac Surg 2006;81:421-426.[Abstract/Free Full Text]
- Petersen RP, Pham D, Burfeind WR, et al. Thoracoscopic lobectomy facilitates the delivery of chemotherapy after resection for lung cancer Ann Thorac Surg 2007;83:1245-1250.[Abstract/Free Full Text]
- Watanabe A, Koyanagi T, Ohsawa H, et al. Systematic node dissection by VATS is not inferior to that through an open thoracotomy: a comparative clinicopathologic retrospective study Surgery 2005;138:510-517.[Medline]
- Shigemura N, Akashi A, Funaki S, et al. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study J Thorac Cardiovas Surg 2006;132:507-512.[Abstract/Free Full Text]
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Abstract
Introduction
