Surgical Mediastinal Lymph Node Sampling for Staging of Non-Small Cell Lung Carcinoma

(A) Anterior view of the patient positioned in the supine position. The patient should be prepped for a full sternotomy in case uncontrollable bleeding is encountered. A 3-cm incision is made one finger-breath above the sternal notch. (B) Lateral view of positioned patient. A roll is place between the scapulae and the neck is in extension.

The platysma is divided and the strap muscles are split. The inferior portion of the thyroid is retracted cranially exposing the pretracheal fascia. m. = muscle.

(A) Digital dissection is used to expose the left and right paratracheal and subinnominate spaces. (B) Anterior view showing the mediastinal lymph nodes and their relation to the tracheobronchial tree and major vessels. a. = artery; Ao = aorta; PA = pulmonary artery; pulm. lig. = pulmonary ligament; SVC = superior vena cava; v. = vein.

Right paratracheal space showing the innominate artery, azygous vein, and station 4R. a. = artery; Az = azygous vein; SVC = superior vena cava.

Video-mediastinoscopy images of (A) right paratracheal dissection, (B) an enlarged station 4R lymph node, (C) needle-aspiration of the 4R node, and (D) cold-cupped biopsy of the 4R node.

Lateral view of the trachea showing the left recurrent laryngeal nerve in the groove between the trachea and esophagus. n. = nerve.

Left paratracheal space showing stations 2L and 4L and the recurrent laryngeal nerve. The subcarinal space containing station 7 and its proximity to the right pulmonary artery is also shown. n. = nerve.

Incision is made over the left second rib.

Operator view looking posteriorly with the lung retracted laterally. The patient's head is beyond the bottom of the image and feet beyond the top. The aortopulmonary window is in the field. Stations 5 and 6 are shown. The internal thoracic vessels are medial. PA = pulmonary artery.

Lateral view showing PA, aorta, stations 5 and 6, phrenic, vagus, and recurrent laryngeal nerves. n. = nerve; PA = pulmonary artery.

Port sites and patient position for VATS. Two 5-mm ports are placed—one in the third intercostal space at the lateral edge of the pectoralis major muscle and one in the fifth intercostal space at the tip of the scapula. A 10-mm port for the camera is placed in the fifth intercostal space in the anterior axillary line.

A lung retractor is placed to aid visualization. Camera and biopsy forceps are placed in the two other ports. n. = nerve.