Laparoscopic Posterior Inferior Mediastinal Prone Position Lymphadenectomy for Recurrent Gynecologic Carcinoma

Abstract

Study Objective To demonstrate a prone position laparoscopic approach to posterior inferior mediastinal lymphadenectomy. Design This is an edited video including a step-by-step approach. Setting The patient was positioned in a prone position, similar to the thoracic step for esophagectomy. Selective ventilation was performed with a two-way endotracheal tube. Access was performed by the right side of the patient, with a 4-trocar placement. Patients or Participants The patient had been treated for a gynecologic poorly differentiated carcinoma with a sarcomatoid component, 4 years prior to this salvage procedure. She received a pelvic lymphadenectomy and total hysterectomy with pelvic adjuvant radiation therapy. Her nodal posterior mediastinal recurrence was detected during follow up, and partially responded to platin-based chemotherapy. After a multidisciplinary discussion, a surgical resection was offered for this residual specific site, positive at PET CT. Interventions A careful anatomical review was performed as the pleural space was entered and the right lung was collapsed with left selective ventilation. Azygos vein was preserved, and the dissection started with a mediastinal pleural dissection with regular bipolar and advanced bipolar, proximal to distal, from T10 to T12, between the thoracic aorta and the corpus vertebrae. Intercostal branches were preserved. All small vascular and lymphatic branches were sealed and/or clipped (with titanium clips or Hem-o-lok(R)). The specimen was inserted into a bag and retrieved by the incision of the 12mm trocar, at the 12 intercostal space, posterior axillary line. A thoracic drain was placed. Measurements and Main Results Surgical time was 96-minutes, total blood loss was 12cc. The thoracic drain was retrieved on POD 2, when the patient was discharged. Conclusion The laparoscopic prone surgical approach is safe, feasible, and standardized for the thoracic/upper digestive surgeon, and should be considered for posterior mediastinal approaches. Further studies, with more patients, is required before this information should be used in clinical settings. To demonstrate a prone position laparoscopic approach to posterior inferior mediastinal lymphadenectomy. This is an edited video including a step-by-step approach. The patient was positioned in a prone position, similar to the thoracic step for esophagectomy. Selective ventilation was performed with a two-way endotracheal tube. Access was performed by the right side of the patient, with a 4-trocar placement. The patient had been treated for a gynecologic poorly differentiated carcinoma with a sarcomatoid component, 4 years prior to this salvage procedure. She received a pelvic lymphadenectomy and total hysterectomy with pelvic adjuvant radiation therapy. Her nodal posterior mediastinal recurrence was detected during follow up, and partially responded to platin-based chemotherapy. After a multidisciplinary discussion, a surgical resection was offered for this residual specific site, positive at PET CT. A careful anatomical review was performed as the pleural space was entered and the right lung was collapsed with left selective ventilation. Azygos vein was preserved, and the dissection started with a mediastinal pleural dissection with regular bipolar and advanced bipolar, proximal to distal, from T10 to T12, between the thoracic aorta and the corpus vertebrae. Intercostal branches were preserved. All small vascular and lymphatic branches were sealed and/or clipped (with titanium clips or Hem-o-lok(R)). The specimen was inserted into a bag and retrieved by the incision of the 12mm trocar, at the 12 intercostal space, posterior axillary line. A thoracic drain was placed. Surgical time was 96-minutes, total blood loss was 12cc. The thoracic drain was retrieved on POD 2, when the patient was discharged. The laparoscopic prone surgical approach is safe, feasible, and standardized for the thoracic/upper digestive surgeon, and should be considered for posterior mediastinal approaches. Further studies, with more patients, is required before this information should be used in clinical settings.