Video-Mediastinoscopy Thoracoscopy (VATS)
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1 Surgical techniques Video-Mediastinoscopy Thoracoscopy (VATS) Gunda Leschber Department of Thoracic Surgery ELK Berlin Chest Hospital, Berlin, Germany Teaching Hospital of Charité Universitätsmedizin Berlin
2 No disclosures
3 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
4 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
5 Mediastinoscopy - history 1959 Carlens: Mediastinoscopy 1987 Ginsberg: extended mediastinoscopy 1994 Sortini (I), Lerut (B): Video-mediastinoscopy 2002 Hürtgen: VAMLA (video-assisted mediastinal lymphadenectomy)
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12 Conventional versus Video-Mediastinoscopy (n = 366) Complications n Recurrent laryngeal nerve palsy Bleeding (mediastinal enlargment on postop. chest X-ray) Others * Total Video- Mediastinoscopy Conventional mediastinoscopy (2.1%) 2 (0.9%) 3 (1.3%) 10 (4.3%) (3.0%) 3 (2.3%) 0 (0.0%) 7 (5.3%) All (2.5%) 5 (1.4%) 3 (0.8%) 17 (4.6%) * 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
13 Conventional versus Video-Mediastinoscopy Negativ predictive value Video-Mediastinoscopy 0,83 Conventional Mediastinoscopy 0,81 Accuracy Video-Mediastinoscopy 87,9% Conventional Mediastinoscopy 83,8% Conclusion: Advantage of Video-Mediastinoscopy Standardisation of the technique Leschber G et al. Eur J Cardiothorac Surg 2008; 33:289
14 Video-Mediastinoscopy VAMLA
15 VAMLA by Hürtgen 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) Hürtgen M et al. Eur J Cardiothorac Surg 2002;21:348-51
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18 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
19 VAMLA - Results n = 226 staging: 144 diagnostic: 82 Operative time: 54 min Complication: 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
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21 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
22 Thoracoscopy (VATS) Routine VATS as first step of the planned resection for lung cancer N = 1306 ( ) 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:
23 Thoracoscopy (VATS) Intervention: Resection Pleurodesis Pericardial window
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26 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
Video assisted mediastinal lymphadenectomy (VAMLA)
Video assisted mediastinal lymphadenectomy (VAMLA) Gunda Leschber Department of Thoracic Surgery ELK Berlin Chest Hospital, Berlin, Germany Teaching Hospital of Charité Universitätsmedizin Berlin No conflict
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