Video-assisted mediastinoscopic lymphadenectomy.

Systematic mediastinal lymphadenectomy is usually done at thoracotomy together with lung resection. It is a prerequisite for accurate nodal staging and has an impact on survival. With the introduction of neoadjuvant therapy for stage III lung carcinoma, mediastinal staging before therapy became more important. Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is a minimally invasive technique of systematic mediastinal dissection that equals radicality of open lymphadenectomy, and can be carried out before neoadjuvant treatment and independently from tumour resection. The VAMLA dissection technique follows the anatomical mediastinal structures, and includes the stations 7, 4R+L, 2R+L, and 3. Compared to open dissection, VAMLA harvested significantly more nodes. Dissection rates of 96%, 92%, 100% and 100% for the stations 2R, 4R, 7 and 4L were reported. In routine clinical use, the mean duration was 54 min, the complication rate was 4.6%. Accuracy data in 130 patients with radiologically normal mediastinum were: sensitivity 93.8%, specificity 100%, false negative rate 0.9%. VAMLA is an extremely accurate staging tool as well as definitive mediastinal surgery. Thus, VAMLA is valuable if neoadjuvant therapy is considered for minor mediastinal involvement, to avoid re-mediastinoscopies after induction treatment, to define the exact involved radiation field in functionally unresectable patients, for highly accurate pre-therapy staging in trials, and to improve mediastinal dissection with VATS lobectomy and left-sided tumours.