Video-assisted mediastinoscopic surgery: clinical feasibility and accuracy of mediastinal lymph node staging.

BACKGROUND: This study was conducted to assess indications, procedures, complications, and clinical feasibility of video-assisted mediastinoscopic surgery (VAMS). It also assessed the accuracy of mediastinal lymph node staging by video-assisted mediastinoscopic lymphadenectomy (VAMLA) with bimanual dissection through the twin-bladed, expanding Linder-Dahan mediastinoscope.

METHODS: From 2000 to 2004, we documented and assessed 226 consecutive procedures in a prospective database.

RESULTS: A total of 144 VAMLAs for the staging of resectable bronchial carcinoma, and 82 less extensive procedures for other indications were performed, combined with extended mediastinoscopy in 72 patients and with mediastinoscopic sonography in 26. Mean operation time was 54.1 minutes for VAMLA and 36.6 minutes for less extensive procedures. We observed nine complications: five recurrent nerve paralyses, one arterial and two venous injuries, and one mediastinitis. The complication rate was 3.98%, which dropped from 5.3% to 2.6% with growing experience. VAMS detected mediastinal lymph node involvement in 61 (32.8%) of 186 patients with bronchial carcinoma (N2, 45; N3, 16). Mediastinal reassessment at open surgery was done in the 130 resected patients and showed for VAMLA a specificity of 93.75%, a sensitivity of 100%, and a false-negative rate of 0.9%.

CONCLUSIONS: In our institutional practice, VAMS has replaced conventional mediastinoscopy for reasons of extended surgical options, safety, precision, education, documentation, and enhanced accuracy of pretherapeutic mediastinal staging. Mediastinal staging of resectable bronchial carcinoma is done by VAMLA, because the accuracy is equal to open lymphadenectomy and the access to the left paratracheal and tracheobronchial lymph nodes is improved. No increase in the complication rate was observed. Prolonged operation time was due to more extended procedures not possible with conventional mediastinoscopy, like VAMLA.