Original Article: Lung Surgery
A novel procedure of thoracoscopic 4L lymph node dissection: 4L posterior first technique
Abstract
Background: Left lower paratracheal (4L) lymph node dissection for left lung cancer is difficult because of the anatomic configurations of the aortic arch, pulmonary artery, and left recurrent nerve. This study aimed to describe a novel procedure of thoracoscopic 4L lymph node dissection and determine its surgical outcomes.
Methods: In this study, thoracoscopic lobectomy with lymphadenectomy was performed via four ports with confronting upside-down monitor setting. In our novel procedure, “4L posterior first technique,” we initially dissected the posterior side of 4L lymph nodes. The assistant surgeon retracted the lung with nodal packet, pulmonary artery, and vagus and left recurrent nerves; the retraction provided an excellent surgical view around the recurrent nerve. The bronchial arteries branching from the aorta were clipped and divided at the root. The dissection between the posterior side of nodal packet and the surrounding structures was completed before touching the hilar structures. The outcomes in the novel method group and the conventional method group were compared.
Results: From 2016 to 2018, 40 and 38 patients underwent thoracoscopic 4L lymphadenectomy using the novel method and conventional method, respectively. The total operation time was 200±41 min, and the total blood loss was 27±28 mL. The postoperative hospital stay was for 6±3 days. None of the patients died, and none of them was converted to thoracotomy. The matched comparison revealed that the operation time was shorter (194±33 vs. 218±41 min, P=0.01), and the amount of bleeding was relatively smaller (22±21 vs. 33±21 mL, P=0.06) in the novel method group. Transient recurrent nerve paralysis was noted in one patient from the conventional method group (3.7%) and in no one from the novel group (0%).
Conclusions: Our 4L posterior first technique is easier to perform and allows a more accurate dissection of thoracoscopic 4L lymph nodes.
Methods: In this study, thoracoscopic lobectomy with lymphadenectomy was performed via four ports with confronting upside-down monitor setting. In our novel procedure, “4L posterior first technique,” we initially dissected the posterior side of 4L lymph nodes. The assistant surgeon retracted the lung with nodal packet, pulmonary artery, and vagus and left recurrent nerves; the retraction provided an excellent surgical view around the recurrent nerve. The bronchial arteries branching from the aorta were clipped and divided at the root. The dissection between the posterior side of nodal packet and the surrounding structures was completed before touching the hilar structures. The outcomes in the novel method group and the conventional method group were compared.
Results: From 2016 to 2018, 40 and 38 patients underwent thoracoscopic 4L lymphadenectomy using the novel method and conventional method, respectively. The total operation time was 200±41 min, and the total blood loss was 27±28 mL. The postoperative hospital stay was for 6±3 days. None of the patients died, and none of them was converted to thoracotomy. The matched comparison revealed that the operation time was shorter (194±33 vs. 218±41 min, P=0.01), and the amount of bleeding was relatively smaller (22±21 vs. 33±21 mL, P=0.06) in the novel method group. Transient recurrent nerve paralysis was noted in one patient from the conventional method group (3.7%) and in no one from the novel group (0%).
Conclusions: Our 4L posterior first technique is easier to perform and allows a more accurate dissection of thoracoscopic 4L lymph nodes.
