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Transaxillary access to aortopulmonary window and paraaortic nodes Alberto Terzi, Andrea Viti and Luca Bertolaccini Asian Cardiovascular and Thoracic Annals published online 6 December 2013 DOI: 10.1177/0218492313516326 The online version of this article can be found at: http://aan.sagepub.com/content/early/2013/12/06/0218492313516326
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How to Do It
Transaxillary access to aortopulmonary window and paraaortic nodes
Asian Cardiovascular & Thoracic Annals 0(0) 1–3 ß The Author(s) 2013 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0218492313516326 aan.sagepub.com
Alberto Terzi1, Andrea Viti2 and Luca Bertolaccini2
Abstract A minimally invasive video-assisted thoracic surgery procedure to biopsy paraaortic and aortopulmonary window nodes is presented. In contrast to the standard 3-ports procedure, the transaxillary route we describe allows very good visualization of these anatomical zones. This procedure is safe and quick, and also cosmetic and painless.
Keywords Biopsy, Lung neoplasms, Lymph nodes, Neoplasm staging, Thoracic surgery, video-assisted
Introduction Mediastinal lymph node biopsy for staging of lung cancer or for diagnostic purposes in patients with enlarged mediastinal nodes, is commonly carried out by mediastinoscopy, the Chamberlain procedure, video-assisted thoracic surgery (VATS), or more recently by endo-bronchial ultrasound/endoscopic ultrasound fine needle ago-biopsy.1–3 However, all of these techniques have blind spots. For left-sided nodes on the aortopulmonary window or for paraaortic nodes, endo-bronchial ultrasound/endoscopic ultrasound fine needle ago-biopsy is not suitable. VATS is commonly undertaken by placing the patient in the right lateral position, as used for a posterolateral thoracotomy. A 3-port technique using the triangulation rule is usually performed, one for the camera and the other two for dissecting instruments and the biopsy forceps. We decided to modify the approach using the same position and accesses that we use for minimally invasive sympathectomy for treatment of palmar hyperhidrosis, because we noted that in the left side, the camera port placed in the 3rd intercostal space on the anterior axillary line gives a formidable view of the aortopulmonary window and paraaortic area.
Technique The patient is placed supine, a double-lumen endotracheal tube is inserted, and single-lung ventilation is instituted. The patient is then placed in a sitting
Figure 1. Position of the patient on the operating table.
position at approximately 40 degrees (Figure 1). In this position, the left lung falls down, allowing us to visualize the areas of interest. The left arm is abducted and patient slightly rotated on the right side, with two body supports properly placed to maintain the correct position (Figure 1). Initially, a 6-mm port is placed in 1 Department of Surgery, Section of Thoracic Surgery, Sacro Cuore Hospital, Negrar, Verona, Italy 2 Division of Thoracic Surgery, S. Croce e Carle Hospital, Cuneo, Italy
Corresponding author: Luca Bertolaccini, MD, PhD, Division of Thoracic Surgery, S. Croce e Carle Hospital, Via Michele Coppino 26, 12100 Cuneo, Italy. Email:
[email protected]
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Figure 2. (A) Left intrathoracic anatomy as it appears with the camera in the third intercostal space on the anterior axillary line. Aa: aortic arch; Pa: pulmonary artery; Pn: phrenic nerve; Sc: sympathetic chain; Vn: vagus nerve. (B) Chest computed tomography demonstrating enlarged nodes. (C) Intraoperative view of the same case.
the 3rd intercostal space on the anterior axillary line and another 6-mm port is placed in the 4th intercostal space on the mid-axillary line. Alternatively, the camera can be placed in the first or second port as well as dissector or biopsy forceps. A straightforward view of the aortopulmonary window and paraaortic area is shown in Figure 2A, with enlarged nodes detected by computed tomography (Figure 2B). As a further modification, now we make a 10-mm incision in the axillary area to place an 11-mm trocar for an operative thoracoscope, and perform node biopsies. Should it be necessary (apical or mediastinal adhesions), we enlarge the incision up to 20 mm to introduce further instruments such as endoscopic scissors or a hook (Figure 2C). At the end of the procedure, a flexible spiral drain (Redax Srl, Poggio Rusco, Italy) is placed,4 and removed the following day.
cases, and cannot be considered a minimally invasive procedure. Moreover, the operative view is far worse than with a VATS procedure. Three-port VATS has thus become the preferred method to obtain biopsy specimens from stations #5 and #6. The transaxillary approach that we use, mainly the uniportal type,5 is safe and quick, it is painless compared to the classic 3-port access, gives good cosmetic results, and allows the patient to be discharged on the day after the operation.
Discussion
References
Accessing stations #5 and #6 for lung cancer staging or any other reason can be made only with an invasive procedure because endo-bronchial ultrasound/ endoscopic ultrasound fine needle ago-biopsy cannot reliably assess these nodal stations.2 Anterior mediastinotomy, different to that described by McNeill and Chamberlain,2 is an anterior thoracotomy in most
1. McNeill TM and Chamberlain JM. Diagnostic anterior mediastinotomy. Ann Thorac Surg 1966; 2: 532–539. 2. Cerfolio RJ, Bryant AS and Eloubeidi MA. Accessing the aortopulmonary window (#5) and the paraaortic (#6) lymph nodes in patients with non-small cell lung cancer. Ann Thorac Surg 2007; 84: 940–945. 3. Eloubeidi MA, Tamhane A, Chen VK and Cerfolio RJ. Endoscopic ultrasound-guided fine-needle aspiration in
Funding This research received no specific grant from any funding agency in the public, commerical, or not-for-profit sectors.
Conflict of interest statement None declared.
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patients with non-small cell lung cancer and prior negative mediastinoscopy. Ann Thorac Surg 2005; 80: 1231–1239. 4. Terzi A, Feil B, Bonadiman C, et al. The use of flexible spiral drains after non-cardiac thoracic surgery.
A clinical study. Eur J Cardiothorac Surg 2005; 27: 134–137. 5. Bertolaccini L, Rocco G, Viti A and Terzi A. Geometrical characteristics of uniportal VATS. J Thorac Dis 2013; 5(Suppl 3): S214–S216.
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