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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_747_Библиотеки_им_академика_М_И_Перельмана
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294 Thoracic outlet syndromes
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The posterior superior serratus muscle is resected,
2b
sacrospinalis muscle medially. Cautery is used to expose the
first rib remnant (stump) and to open the periosteum. A
periosteal elevator, or joker, is used to remove the stump subperiosteally. The head and the neck of the rib usually have not
been removed in the initial operation. The rib shears are used
to divide the rib remnant, and the Urschel-Leksell reinforced
and Urschel pituitary rongeurs are used carefully to remove
the head and neck of the rib. The T1 nerve root is identified
grossly or with the nerve stimulator.
and the first rib stump is identified by retracting the
1
2
4
3
5
2b
Once the T1 nerve root is identified, neurolysis is
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2c
a knife, and special microscissors. A nerve stimulator may be
helpful if extensive scarring is present. Neurolysis is extended
to the C7 and C8 nerve roots and to the brachial plexus. All
the scar is removed as far forward as necessary so that the
nerve roots as well as the upper, middle, and lower trunks of
the brachial plexus lie free. Care is taken not to injure the long
thoracic nerve or any other brachial plexus branch. The axillary subclavian artery and vein are decompressed through the
same incision.
carried out using a right-angle clamp, magnification,
Operation 295
2c
The second rib is dissected free, and the cautery is
2d
ment of the rib is resected posteriorly, medial to the
sacrospinalis muscle, to perform the dorsal sympathectomy.
This exposure may also help identify the T1 nerve root.
used to open the periosteum linearly. A 2-cm seg-
2d
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After the head and neck of the second rib are
2e
vertebra, or it may have been separated and lie on the pleura.
The stellate ganglion lies in an almost transverse rather than
vertical position.
removed, the sympathetic chain is identified on the
2e
The lower third of the stellate ganglion is incised
2f
nicantes are clipped and divided. The T1, T2, and T3 ganglia are removed along with the sympathetic chain using
clips on all of the branches. Cautery is used to effect hemostasis and to char the area so that sprouting and regeneration of the sympathetic chain are discouraged. After
irrigation with antibiotic solution, methylprednisolone
(Depo-Medrol) and Sepra Film are left on the areas of
neurolysis. The wound is closed in layers with interrupted
No. 1 Nurolon in a figure-of-eight fashion (Tom Jones
stitch) in each of the muscle layers. Running and interrupted 2/0 Vicryl sutures are used in the subcutaneous tissue and skin clips in the skin. A large round Jackson-Pratt
drain is placed in the area of neurolysis through a separate
stab wound 2 cm below the inferior part of the incision.
Care is taken not to incorporate the drain while closing the
muscle layers over the top.
sharply (T1), and the gray and white rami commu-
2f
Further reading 297
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OUTCOME
No deaths occurred in a series of 3 914 primary and 1 221
reoperative thoracic outlet syndrome decompressive
procedures. The major complication observed was the leaving of a rib remnant by the initial surgeon from which fibrocartilage and new bone regenerated, producing a high
incidence of recurrence. More retractor help (two arm
holders) and increased light improved the technique and
facilitated the initial operation. These maneuvers minimized
the time of anesthesia, surgery, retractor use, and arm
holding.
FURTHER READING
Roos DB. Transaxillary approach for first rib resection to relieve thoracic
outlet compression syndrome. Annals of Surgery 1966; 163: 354–8.
Urschel HC, Cooper JD. Atlas of Thoracic Surgery. Churchill Livingstone,
New York 1995.
Urschel HC Jr, Razzuk MA. Neurovascular compression in the thoracic
outlet: changing management over 50 years.
1998; 228(4): 609–17.
Urschel HC Jr, Razzuk MA. The failed operation for thoracic outlet
syndrome: the difficulty of diagnosis and management. Annals of
Thoracic Surgery 1986; 42: 523–8.
Urschel HC Jr, Razzuk MA, Ryland JW, et al. Thoracic outlet syndrome
masquerading as coronary artery disease. Annals of Thoracic Surgery
1973; 16: 239–48.
Annals of Surgery
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28
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Mediastinal lymph node dissection
PAOLO MACCHIARINI MD, PHD
Professor of Surgery, University of Barcelona Medical School; Chairman, Department of General Thoracic Surgery, Hospital Clinic of Barcelona,
Spain
HISTORY
Although mediastinal lymph node dissection was first mentioned in the 1940s, its optimal extent remains controversial.
Trends have evolved from procedures with virtually no
lymph node sampling to more radical operations including
minimal or more extensive hilar and mediastinal lymph node
sampling, complete ipsilateral mediastinal dissection, and
extended lymph node dissection.
Proponents of the sampling of multiple lymph node stations argue that sampling results in improved staging and less
perioperative morbidity than lymph node dissection.
Conversely, proponents of mediastinal lymph node dissection claim that, without a complete removal of all ipsilateral
mediastinal lymph nodes, patients would be understaged,
and their cure rates worsened. The operative procedure of
extended nodal dissection includes the ipsilateral and contralateral mediastinal nodes and the supraclavicular lymph
nodes, but the magnitude of the operation and the fact that
non-small cell lung cancer (NSCLC) will recur in distant
locations has reduced its popularity except for patients
enrolled into clinical trials.
PRINCIPLES AND JUSTIFICATION
The normal patterns of intrathoracic lymphatic drainage are
as follows: On the right, the apical and posterior segments of
the upper lobe drain into the ipsilateral scalene nodes via the
hilar nodes, tracheobronchial angle nodes, and upper paratracheal lymph nodes. The anterior segment of the right
upper lobe drains either as previously described (50% of
cases) or into the right scalene nodes via the subcarinal and
pretracheal lymph nodes, or the anterior mediastinal lymph
nodes. Drainage to the left paratracheal nodes seldom occurs
and proceeds along the left innominate vein, left anterior
mediastinal nodes, and into the left scalene nodes. The middle lobe and superior segment of the lower lobe usually drain
to the ipsilateral scalene nodes via the two paths described
earlier. However, drainage from the middle lobe to the left
scalene nodes through the subcarinal and left paratracheal
nodes also may occur. Drainage from the basal segments of
the lower lobes reaches the subcarinal nodes via the hilar
nodes. Further drainage may reach the right scalene nodes by
way of the right paratracheal lymph nodes. On the left, the
apical and posterior segment of the left upper lobe drain primarily via the subcarinal lymph nodes and then either along
the left vagus nerve to the left scalene nodes or along the
recurrent laryngeal nerve to the mediastinal lymph nodes.
The anterior and lingular segments drain along the phrenic
nerve through the para-aortic nodes to the ipsilateral scalene
lymph nodes. Lymph from the basilar segments flows via the
subcarinal nodes to the pretracheal and contralateral paratracheal lymphatics to the right scalene nodes. Drainage along
the ipsilateral region to high mediastinal lymph nodes also
may occur. Drainage from the superior segment occurs via all
of these paths.
The patterns of intra- and extrapulmonary lymph node
metastasis in patients with NSCLC are as follows: Disease in
all right lung lobes commonly metastasizes to the lymph
nodes along the bronchus intermedius between the origins of
the upper and middle lobe bronchi, whereas tumors in both
left lobes commonly metastasizes to the lymph nodes located
between the origins of the lobar bronchi. Among right upper
lobe tumors, ipsilateral mediastinal lymph nodes represent
the most common metastatic site, whereas spread to the subcarinal, contralateral mediastinal, and scalene nodes is
uncommon. Conversely, left upper lobe tumors spread more
frequently to the contralateral mediastinal and scalene lymph
300 Mediastinal lymph node dissection
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nodes. Right lower lobe tumors spread frequently in the subcarinal and ipsilateral mediastinal regions and less rarely in
the contralateral mediastinal or scalene nodes. Left lower lobe
tumors spread mostly to the contralateral scalene and contralateral mediastinal nodes. Watanabe et al. showed, however, that right upper lobe tumors may spread to the
subcarinal lymph nodes, whereas right middle and right
lower lobe tumors commonly spread to the ipsilateral paratracheal lymph nodes. They also found that subcarinal metastases commonly arise from left upper lobe and left lower lobe
tumors.
This predictable sequence of metastases beginning in the
intrapulmonary lymph nodes and progressing to the mediastinal and finally to the scalene lymph nodes is not always
observed, however. The absence of intrapulmonary lymph
node metastases may be documented in almost one-third of
patients with resected NSCLC, and right upper lobe tumors
may commonly skip to the ipsilateral paratracheal lymph
nodes, left upper lobe tumors to the aortopulmonary window
lymph nodes, and lower lobe tumors to the subcarinal region.
The prognosis of NSCLC is directly related to the completeness of resection and the status of the regional lymph
nodes. The 50–80% cure rate of patients without lymph node
involvement (N0 disease) drops to 30–50% if the N1 (hilar)
lymph nodes are involved, and falls further to 10–30% if the
lymph nodes in the mediastinum (N2) are involved. N2 disease can be divided into ‘minimal’ disease, with involvement
of only one node by microscopic foci of tumor, or ‘advanced’,
bulky disease. Only 20% of all cases of N2 disease are technically resectable, and most of them are discovered only at thoracotomy. The challenge is to identify correctly patients with
N0, N1, or minimal N2 disease who are candidates for curative resection and to avoid inappropriate surgery in patients
with advanced N2 or N3 disease. Moreover, patients presumed to have N0 or nonhilar N1 disease at the time of resection have a frequent (10–15%) occurrence of occult
mediastinal lymph node metastases. The principles cited earlier make it evident that the status of the mediastinal lymph
nodes must be known before surgery and that, without this
assessment, a pulmonary resection must be considered as an
incomplete procedure.
PREOPERATIVE ASSESSMENT AND
PREPARATION
A growing body of evidence indicates that positron-emission
tomography (PET) with fluorine-18-fluorodeoxyglucose is
more accurate than computed tomography (CT) in the mediastinal staging of NSCLC, and that no significant improvement in accuracy is seen when the CT data are added to the
PET result. The recommendation has been that patients with
a positive result on PET study for mediastinal disease
undergo confirmatory surgical mediastinal exploration, so
that no patient is denied potentially curative resection. By
contrast, the high negative predictive value of a negative PET
result should provide the surgeon with the impetus to proceed directly to thoracotomy without invasive mediastinal
staging. Such a philosophy is certainly followed in North
America, where Medicare and many third-party insurers
reimburse the costs of PET.
This algorithm is not yet the case in Europe, where CT and
invasive mediastinal investigation still represent the reimbursed staging tools. Except in patients with hilar and mediastinal nodes measuring less than 1 cm in the short-axis
diameter on preoperative CT scan, mediastinoscopy should
be routinely performed preoperatively, especially for leftsided tumors for which the exposure of the left paratracheal
nodes is restrained anatomically. Mediastinoscopy should
not replace a lymph node dissection, however, but represents
the essential tool to obtain a histological and anatomical
description of the mediastinal lymph node status.
ANESTHESIA
The anesthetic management mirrors that for the other major
pulmonary resections. In our experience, however, the
avoidance of perioperative fluid overload reduces the postoperative risks of mechanical noncariogenic edema of the
residual lobes. Special care should be given to those patients
who have had neoadjuvant chemotherapy and/or radiation
therapy in whom mediastinal lymph node dissection is likely
to result in additional fluid imbalances in the residual lung
tissues.
OPERATIONS
Three approaches can be taken to the intraoperative assessment of the extrapulmonary lymph nodes:
1 Systematic sampling
2 Complete lymph node dissection
3 Extended lymph node dissection
Whichever technique is used, it is mandatory to uniformly
label the intrathoracic lymph nodes according to a regional
mediastinal lymph node classification (Table 28.1), such as
that adapted from Mountain et al., which is the one used in
my institution. To ensure accuracy and consistency, intraoperative labeling of the level of all harvested lymph nodes must
be correct and reproducible, and having the lymph node map
in the operative room is very helpful. Although mediastinal
lymph node sampling or dissection can be accomplished
either before or after the planned lung resection, the wiser
course is to determine the lymph node status first to see
whether this factor will alter the nature of the operative procedure. Metallic clips are used only to delineate the proximal
and distal margins of the dissection to guide postoperative
radiation planning; hemostasis is usually obtained with
absorbable ligatures.
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Table 28.1 Lymph node classification
a
N class Nodal stationbDesignation Anatomical landmarks
N2 1 Highest mediastinal nodes Nodes lying above a horizontal line at the upper rim of the brachiocephalic (left
innominate) vein where it ascends to the left, crossing in front of the trachea at its
midline.
N2 2 Upper paratracheal nodes Nodes lying above a horizontal line drawn tangential to the upper margin of the
aortic arch and below the inferior boundary of No. 1 nodes.
N2 3 Prevascular and Prevascular and retrotracheal nodes may be designated 3A and 3P; midline nodes are
retrotracheal considered to be ipsilateral.
N2 4 Lower paratracheal nodes The lower paratracheal nodes on the right of the midline of the trachea between a
horizontal line drawn tangential to the upper margin of the aortic arch and a line
extending across the right main bronchus at the upper margin of the upper lobe
bronchus, and contained within the mediastinal pleural envelope.
The lower paratracheal nodes on the left lie to the left of the midline of the
trachea between a horizontal line drawn tangential to the upper margin of the aortic
arch and a line extending across the left main bronchus at the level of the upper
margin of the left upper lobe bronchus, medial to the ligamentum arteriosum and
contained within the mediastinal pleural envelope.
N2 5 Subaortic Subaortic nodes are lateral to the ligamentum arteriosum or the aorta or left
(aortopulmonary window) pulmonary artery and proximal to the first branch of the left pulmonary artery, and
lie within the mediastinal pleural envelope.
N2 6 Para-aortic nodes Nodes lying anterior and lateral to the ascending aorta and the aortic arch or the
(ascending aorta or phrenic) innominate artery, beneath a line tangential to the upper margin of the aortic arch.
N2 7 Subcarinal nodes Nodes lying caudal to the carina of the trachea but not associated with the lower
lobe bronchi or arteries within the lung.
N2 8 Paraesophageal nodes Nodes lying adjacent to the wall of the esophagus and to the right or left of the
(below carina) midline, excluding subcarinal nodes.
N2 9 Pulmonary ligament nodes Nodes lying within the pulmonary ligament, including those in the posterior wall and
lower part of the inferior pulmonary vein.
N1 10 Hilar nodes The proximal lobar nodes distal to the mediastinal pleural reflection and the nodes
adjacent to the bronchus intermedius on the right.
N1 11 Interlobar nodes Nodes lying between the lobar bronchi.
N1 12 Lobar nodes bronchi Nodes adjacent to the distal lobar bronchi.
N1 13 Segmental nodes Nodes adjacent to the segmental bronchi.
N1 14 Subsegmental nodes Nodes around the subsegmental bronchi.
a
All N2 nodes lie within the mediastinal pleural envelope on the ipsilateral side. All N1 nodes lie distal to the mediastinal pleural reflection and within the visceral
pleura.
b
The American College of Surgical Oncologists suggests designating the lower paratracheal nodes as No. 4s (superior) and No. 4i (inferior) subsets for study
purposes; the No. 4s nodes may be defined by a horizontal line extending across the trachea and drawn tangential to the cephalic border of the of the azygos vein;
the No. 4i nodes may be defined by the lower boundary of No. 4s and the lower boundary of No. 4, as described earlier.
Adapted with permission from Mountain and Dresler.
302 Mediastinal lymph node dissection
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Systematic sampling
Systematic sampling refers to visual and tactile examina-
1
tion of each of the mediastinal lymph node levels
followed by biopsy of selected lymph nodes, whether or not
they have been exposed by opening the mediastinal pleura.
On the right side (the regional nodal station locations), sampling should include one or two lymph nodes from stations 2,
4, 7, and 10. Levels 2 and 4 may not be resampled at thoracotomy if a mediastinoscopy had shown negative lymph nodes.
The numbers in this figure and Figure 2 correspond with
those explained in detail in Table 28.1.
3p
12
12
1R
2R
4R
11
4L
7
11
8
9
Inferior pulmonary ligament
1L
2L
Innominate
vein
Aorta
Pulmonary
artery
10
11
12
11
12
9
12
Vagus
nerve
3a
6
Phrenic
nerve
Aortic
arch
Pulmonary
trunk
5
2
Complete mediastinal lymph node dissection
Complete mediastinal lymph node dissection refers to the
removal of all the mediastinal nodes found at the common
nodal sites within the ipsilateral hemithorax. This procedure,
which I prefer, is usually best performed through an ipsilat-
1
For left-sided tumors (the regional nodal stations in the
2
left hemithorax), sampling consists of removing one or
two lymph nodes from stations 5, 6, 7, and 10. This approach
may be inaccurate, especially when the in situ lymph nodes
assessment (level and number) is made through an intact
pleura, because it relies on the personal experience of the
operating surgeon as to which and how many nodes are
sampled.
eral posterolateral thoracotomy or a muscle-sparing incision
in the fifth intercostal space. Patients with contralateral
lymph nodes involvement (N3 disease) are usually
approached through a median vertical sternotomy, and this
approach represents my preference for all N3 left-sided
tumors.
COMPLETE LYMPH NODE DISSECTION FOR A RIGHT
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THORACOTOMY
SUPERIOR MEDIASTINAL DISSECTION
Operations 303
Dissection of the superior mediastinum (view is as by a
3
right posterolateral thoracotomy) removes all tissue
lying in an area bounded inferiorly by the takeoff of the right
upper lobe, superiorly by the innominate artery, ventrally by
the superior vena cava (SVC), and dorsally by the trachea.
The mediastinal pleura is elevated and opened with a cautery
midway between the trachea and SVC. The dissection is continued to the cephalic border of the azygos vein caudally and
the innominate artery cephalad. Ligation of the azygos vein is
unnecessary. Several small vessels may be present near the
innominate artery that need to be ligated. The right recurrent
nerve should be identified. The fat pad containing the lymph
nodes is bluntly dissected away from the anterolateral borders
of the trachea and posterior aspects of the SVC, grasped in
situ, and then elevated from the medially located posterior
pericardium and aortic arch. Before transection, ligatures or
clips are applied at the most cephalad aspect of the fat pad.
The specimen is removed and labeled as 2R (above aortic
arch) or 4R (below aortic arch). When present, lymph nodes
in front of the SVC and in the retrotracheal area are removed
and labeled as 3A and 3P, respectively (Figure 2). A warm
gauze pad can be placed in the dissection root to enhance
hemostasis.
Right
recurrent
laryngeal
nerve
Trachea
Vagus
nerve
Esophagus
Innominate
artery
Azygos
vein
Superior
vena cava
Phrenic
nerve
Right
lung
Level 4
nodes
Right main
bronchus
3
Right main
bronchus
Azygos
vein
Vagus
nerve
Level 7
nodes
Esophagus
4
Level 9
nodes
Phrenic
nerve
Level 10
nodes
Inferior
pulmonary
ligament
HILAR DISSECTION
The azygos vein is slightly elevated with a vein retractor,
4
and the nodes located between the right upper lobe takeoff and the origin of the right main stem anteriorly beyond
the reflection of the pleura (in the pleural cavity) are grasped
away and removed and labeled as 10R (N1 lymph nodes).
Care should be taken to avoid injury of the phrenic nerve and
pulmonary artery. This figure depicts the hilar (level 10) and
subcarinal nodal (level 7) right mediastinal lymphadenectomy. The view is as by a right posterolateral thoracotomy.
The numbers correspond with those explained in detail in
Table 28.1.
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