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A 31-year-old woman was referred for investigation of mediastinal lymphadenopathy. A large right-sided paratracheal mass of lymph nodes was identified. Possible approaches included the mediastinoscopy via a cervical incision, right video-assisted thoracic surgery (VATS), or even a subxiphoid approach. Of course, open approaches might also be considered by some surgeons.
A very straightforward approach is a two-port operation via incisions slightly smaller than 1 cm, through which conventional VATS instruments can be passed. These incisions also allow for the removal of good-sized whole lymph nodes.
In this type of case, it is important to stay posterior to the phrenic nerve, to only grasp the lymph node at its edge or very gently so as to avoid crushing the tissues, and to pay attention to hemostasis.
The authors are generous with preoperative local and regional anesthetic, and increasingly they perform a serratus regional anesthetic block prior to any incision being made. The authors also place copious local anesthetic before incisions and just prior to skin closure.
The patient left the hospital the day after the operation with no pain on simple analgesics, and she was able to start her chemotherapy very soon after.
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3 Comments
Well done. Very near job
Well done. Very neat job
Thank you very much for the good quality video. Nevertheless, i am feeling obliged to kindly ask why use a thoracoscopic technique for such a lymph node mass in the above mentioned location. Though small incisions were used, a risk of intercostal nerve injury exists, a chest tube was inserted and one lung ventilation was used. The same quality and quantity of lymph node dissection-biopsy can be acquired via a cervical mediastinoscopy without chest tube, intercostal incision, local anesthesia or one lung ventilation. In an era of EBUS and continuously rising minimal invasive diagnostic techniques, videomediastinoscopy is more than often forgotten, although it is extremely minimal invasive, painless in most cases and highly specific in the hands of experienced thoracic surgeons. From my point of view, microportal techniques are extremely interesting and clearly an advance in thoracic surgery but in the above case a non intercostal access would be more preferable.