Vats Nodal Dissection - How To Avoid Damage To The Recurrent Laryngeal Nerves
Khalid Amer, FRCS(C Th).
Southampton General Hospital, Southampton, United Kingdom.
OBJECTIVE: Complete nodal dissection as part of mediastinal nodal staging in lung surgery has been historically hampered by the technical inability to harvest stations 4L and 2L. The main impediment is the devastating complication of loss of voice due to recurrent laryngeal nerve (RLN) damage. No wonder the majority of node dissecting thoracic surgeons deliberately avoid this group, as the price of complications is high. This video clip describes the detailed anatomy of the course of this nerve through the right and left chest, with emphasis on what is safe and what is not during nodal dissection.
METHODS: VATS mediastinal adenopathy described in minute details like it has never been described before in the history of medicine. The emphasis is on describing the course of the left recurrent laryngeal nerve and show the areas of danger where it can be damaged during nodal dissection. The right RLN is briefly demonstrated in relation to harvesting stations 2-4R and 3p.
RESULTS: There was no RLN damage after resorting to a flexible bipolar energy device to harvest nodes around the right and left RLN. By improving exposure of the RLN and armed with knowledge of detailed anatomy it was possible to point out a safe way to harvest nodes in stations 2-4R, 3p, 4L and 2L
CONCLUSIONS: Absolute mastery of the RLN anatomy is mandatory to avoid damaging it. Despite its complex interaction with station 4L nodes it is always possible to harvest this group with consistent good results. Finally complete adenectomy is a practical tool in the hands of thoracic surgeons who believe in its worth.
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