Surgical techniques

Video-Mediastinoscopy Thoracoscopy (VATS)

Gunda Leschber

Department of Thoracic Surgery

ELK Berlin Chest Hospital, Berlin, Germany

Teaching Hospital of Charit Universittsmedizin Berlin

No disclosures

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Alternative staging methods for the mediastinum

PET-CT
(+): non-invasive
(-): lack of sensitivity in BAC, Adeno-Ca or inflammatory diseases
EBUS-FNA/EUS-FNA
(+): less invasive
(-): observer dependend (experience), small tissue samples
Mediastinoscopy
(+): large tissue samples
(-): invasive
VATS
(+): large tissue samples, evaluation of intrathoracic tumor extent
(-): invasive
Schrager JB, Ann Thorcic Surg 2010; 89:S2084-9
G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Indication for Mediastinoscopy

Enlarged lymph nodes on CT scan (N2/3)
PET-positive lymph nodes

Suspicion of mediastinal invasion

Question: which kind of mediastinoscopy?

Conventional
Video
VAMLA

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Mediastinoscopy - history
1959 Carlens: Mediastinoscopy
1987 Ginsberg: extended mediastinoscopy

1994 Sortini (I), Lerut (B): Video-mediastinoscopy

2002 Hrtgen: VAMLA (video-assisted mediastinal lymphadenectomy)

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Conventional versus Video-Mediastinoscopy (n = 366)

Complications
Recurrent

Bleeding

laryngeal

(mediastinal enlargment

nerve palsy

on postop. chest X-ray)

234

5 (2.1%)

132

366

Video-

Others *

Total

2 (0.9%)

3 (1.3%)

10 (4.3%)

4 (3.0%)

3 (2.3%)

0 (0.0%)

7 (5.3%)

9 (2.5%)

5 (1.4%)

3 (0.8%)

17 (4.6%)

Mediastinoscopy
Conventional
mediastinoscopy
All

* pneumonia (1), laceration of pleura (1), laceration of main bronchus (1)

No perioperative death or hemorrhage
Leschber G et al. Eur J Cardiothorac Surg 2008; 33:289
G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Conventional versus Video-Mediastinoscopy

Negativ predictive value
Video-Mediastinoscopy
Conventional Mediastinoscopy
Accuracy
Video-Mediastinoscopy
Conventional Mediastinoscopy

0,83
0,81
87,9%
83,8%

Conclusion: Advantage of Video-Mediastinoscopy

Standardisation of the technique

Leschber G et al. Eur J Cardiothorac Surg 2008; 33:289

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Video-Mediastinoscopy
G. Leschber

State-of-the-art staging: Surgical techniques

VAMLA
3. European Lung Cancer Conference

19.April 2012

VAMLA by Hrtgen
Video-assisted mediastinal lymphadenectomy
Dissection of all mediastinal structures
trachea,
main bronchi,
pulmonary artery,
vena azygos,
superior vena cava,
esophagus

Complete lymphadenectomy
en bloc resection of station 7, 4 R+L, 3, (station 8)
Hrtgen M et al. Eur J Cardiothorac Surg 2002;21:348-51

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

VAMLA - Indication
Exact mediastinal staging
Prior to VATS lobectomy
(two-step-procedure: no frozen section of lymph nodes in Germany)
Advantage:
Complete resection of stat. 7 is easy by VAMLA
En-bloc resection of stat. 4 R and 7 by VAMLA saves time during VATSlobectomy

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

VAMLA - Results
n = 226

staging: 144

Operative time:
Complication:

diagnostic: 82

54 min
4.0% (beginning 5.3%, later 2.6%)

False-negative rate: 0.9%,

Sensitivity:
93.8%

VAMLA replaces conventional mediastinoscopy because of better

pretherapeutic staging

Witte B et al. Ann Thorac Surg 2006;82: 1821

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Thoracoscopy (VATS)
Tissue confirmation
Biopsy of tumor (or resection)
Biopsy of lymph nodes (hilar, mediastinal)

T-status (chest wall/mediastinal infiltration)

N-status
M-status (pleural involvement)
Resectability
Intervention

Howington JA. Semin Thorac Cardiovasc Surg 2007; 19:212-16

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Thoracoscopy (VATS)
Routine VATS as first step of the planned resection for lung cancer
N = 1306 (1991-2007)

4.4% unsuspected causes of inoperability

(pleural carcinosis, mediastinal infiltration, infiltration of artery in the
fissure)
34.4% Thoracoscopic resections (lobectomy, pneumonectomy, wedge)
61.2% Conventional resections (lobectomy, pneumonectomy, wedge)
Result: 38.4% spared thoracotomies
Vergani C et al. J Thorac Cardiovasc Surg 2009; 138:1206-12
G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Thoracoscopy (VATS)
Intervention:
Resection
Pleurodesis
Pericardial window

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012

Conclusion
(Video-)Mediastinoscopy remains Goldstandard for staging of
the mediastinum
Standardisation of lymphadenectomy by Video-Mediastinoscopy
VAMLA is a further devellopment of Video-Mediastinoscopy
VAMLA as a precondition for VATS-lobectomy

Thoracoscopy for TNM-Status

Thoracoscopy for staging AND intervention

G. Leschber

State-of-the-art staging: Surgical techniques

3. European Lung Cancer Conference

19.April 2012