Video assisted mediastinal lymphadenectomy (VAMLA)

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2 Video assisted mediastinal lymphadenectomy (VAMLA) Gunda Leschber Department of Thoracic Surgery ELK Berlin Chest Hospital, Berlin, Germany Teaching Hospital of Charité Universitätsmedizin Berlin

3 No conflict to be disclosed for this presentation Seite 3

4 Mediastinoscopy - history 1959 Carlens: Mediastinoscopy 1987 Ginsberg: extended mediastinoscopy 1994 Sortini (I), Lerut (B): Video-mediastinoscopy 2002 Huertgen: VAMLA: Video-assisted mediastinal lymphadenectomy Seite 4

5 VAMLA by Huertgen 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 LN 7, 10R+L, 4 R+L, (LN 8) Hürtgen M et al. Eur J Cardiothorac Surg 2002;21: Seite 5

6 VAMLA technique Video-mediastinoscope with spreadable blades (Linder-Dahan by R. Wolf Co., Germany) Cameraholder (Assistant or instrument) Creation of a large working space in the mediastium Bimanual dissection Bipolar scissors Suction device with a curved tip Hürtgen M et al. Eur J Cardiothorac Surg 2002;21: Seite 6

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9 Lymph node resection by Mediastinoscopy or VAMLA Leschber G et al. Eur J Cardiothoracic Surg 2003;24: Mediastinoscopy VAMLA Seite 9

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11 Preparation of lymph node station 7 (subcarinal)

12 Preparation of lymph node station 7 and 8 (paraesophageal)

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15 Video-Mediastinoscopy VAMLA Seite 15

16 VAMLA - Indication Exact mediastinal staging (two-step-procedure: no frozen section in Germany, mediastinoscopy is an additional operation) VAMLA will constitute a new reference standard for preresection staging of NSCLC * Prior to VATS lobectomy**/*** Complete removal of isolated mediastinal lymph node metastasis *Yendamuri S and Demmy TL. J Thorac Cardiovasc Surg 2012; 144: S14-7 **Leschber G et al. Eur J Cardiothoracic Surg 2003;24: ***Yoo DG et al. Eur J Cardiothorac Surg 2011;40: Seite 16

17 VAMLA precondition for VATS-Lobectomy Complete resection of LN 7 is easy by VAMLA Resection of LN 7 by VATS is technically cumbersome En-bloc resection of LN 4 R and 7 by VAMLA saves time during VATS-lobectomy Leschber G et al. Eur J Cardiothoracic Surg 2003;24: Seite 17

18 VAMLA - Results Witte B and Huertgen M: 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: Seite 18

19 Lymphadenectomy in ct1n0 VATS-Lobectomy versus VAMLA+VATS-Lobectomy Prospective studie Appointment by clinical criteria n = 32 (VATS 14, VAMLA+VATS 18) Results VATS VAMLA+VATS Operative time 202 min 200 min LN-Stations (#) LN-weight (g) Witte B et al. Eur J Cardiothoracic Surg 2009;35: Seite 19

20 Learning curve and complication n = 226 Video-mediastinoscopies, including 144 VAMLA ( ) Complications: Total 9 (3.9%) Pat. # (5.3%) Pat. # (2.6%) Recurrent laryngeal nerve palsy 5 lesion of V. azygos 2 mediastinitis 1 lesion of the Aorta 1 mortality 0 Witte B et al. Ann Thorac Surg 2006; 82: Seite 20

21 Conclusion for VAMLA Videoassited mediastinal lymphadenctomy is possible by bimanual dissection of all mediastinal tissue/structures Higher rate of resected lymph nodes by VAMLA compared to conventional or video-mediastinoscopy Standardisation of lymphadenectomy by VAMLA No higher complication rate due to VAMLA VAMLA as a precondition for VATS-lobectomy Seite 21