VATS lobectomy lymph node management.

Abstract

Despite 20 years of development and published reports of thousands of cases (1), major pulmonary resections by video-assisted thoracic surgery (VATS) techniques have only recently experienced the uptake which was observed previously in other fields of minimally invasive surgery. One of the commonly stated reasons was the inability to perform an adequate complete mediastinal lymph node dissection, thus rendering the technique oncologically inadequate. On one occasion, I witnessed a prominent thoracic surgeon state this as “fact” during a major international lung cancer conference. Even before definitive evidence to the contrary became available, I felt this was a preposterous stance on several levels. Firstly, population-based studies have shown that the adequacy of lymph node sampling, let alone complete mediastinal lymph node dissection, is extremely variable, and generally variably performed in open lobectomy cases (2,3). Secondly, this stance assumed that a surgeon who was capable of carefully dissecting out the unforgiving pulmonary artery, finding and dividing all of the correct broncho-vascular structures for the diseased lobe, and completing a difficult fissure, was somehow incapable of removing well defined anatomic areas of lymph node-bearing fat. Thirdly, albeit more recently, it has been shown in the American College of Surgeons Oncology Group (ACOSOG) Z0030 study, that if a single node at each lymph node station is negative on frozen section (or previous mediastinoscopy), then a complete node dissection is not required for an oncologically optimal lung cancer procedure (4). Lymph node management at VATS lobectomy is therefore no different than it should be at lobectomy by thoracotomy. The first part of this perspective will therefore deal with the definitions of lymph node management and the evidence-based indications for sampling or complete mediastinal lymph node dissection regardless of surgical access. The remainder will deal with the practicalities of the VATS approach.