Management of calcified hilar lymph nodes during thoracoscopic lobectomies: avoidance of conversions

Abstract

Background: Our objective in this paper is to introduce a new method for handling calcified hilar lymph nodes during lobectomies by video-assisted thoracoscopy that effectively avoids arterial injury and possible conversions.

Methods: The 12 cases in this study were initially evaluated as eligible and were subsequently scheduled for thoracoscopic lobectomies. However, calcification of the hilar lymph nodes was discovered during the operations, and its presence hampered the conventional process of pulmonary artery dissection. To avoid vessel injuries and subsequent massive bleeding, we developed two techniques specific to the position and exposure of the target vessels and nodes. The space between the bronchus and lymph nodes is exposed by sharp dissection ("scissor first") either before or after suturing the artery. These techniques are illustrated in detail.

Results: Seven male and five female patients participated in this study, with an average age of 72.5 years. We performed five right-upper lobectomies, three right-middle lobectomies, three right-lower lobectomies, and a left-lower lobectomy. Using this new technique, no conversions to thoracotomy occurred. The average operation time was 125 minutes, the mean blood loss was 275 mL, and no intra-operative massive bleeding occurred. Two patients experienced minor complications, one pulmonary infection and another postoperative subcutaneous emphysema.

Conclusions: The proposed "scissor first" technique provides an effective solution for the thoracoscopic management of calcified hilar lymph nodes, and is a safe and effective method for avoiding arterial injury and conversion.

Keywords: Thoracoscopy; conversion; nail lymph nodes; surgery.

Figure 1

Schematic drawing of the first proposed technique. The suture can go across the lymph node and tie the artery branch (B). Scissors are then utilized to mobilize the artery branch from the bronchus, along the interspace between the bronchus and lymph node (C,D).

Figure 2

Schematic drawing of the second proposed technique. For cases with inadequate artery exposure, the lobar bronchus can be transected beforehand at the segmental bronchi level (A). The bronchus can be easily freed from the “nail lymph node” with scissors after closure of the distal bronchial stump (B). The lobar bronchus can be closed either with sutures or staples (C). The artery branch is stapled together with the lymph node (D). LL, lower lobe; UL, upper lobe; MLV, middle lobar vein.