Perioperative management - Uniportal VATS mediastinal lymphadenectomy right

• Material acquisition for pretherapeutic staging

Clarification of the mediastinal lymph node status in cases of imaging morphological abnormalities and negative fine needle aspiration using endobronchial ultrasound.

• In the context of lung resection

During the operation of a lung carcinoma, systemic lymph node dissection is required. This involves the removal of mediastinal tissue along with the lymph nodes contained within, following anatomical structures.

• Lack of cardiopulmonary reserve for lung ventilation
• General anesthesia intolerance
• Coagulation disorder or use of anticoagulants
  • The permanent use of ASA 100mg does not constitute a contraindication.
  • In cases of higher-grade anticoagulation such as platelet aggregation inhibitors (e.g., Clopidogrel), NOACs (e.g., Xarelto), or Vitamin K antagonists (e.g., Falithrom or Marcumar), an interdisciplinary consultation should develop a therapeutic plan regarding the indication for anticoagulation, the possibility of bridging with heparin, and the surgical bleeding risk.

In cases of clinical suspicion of bronchial carcinoma, a contrast-enhanced computed tomography of the thorax and upper abdomen with visualization of the liver (with portal venous phase) and adrenal glands should be performed. The addition of preoperative diagnostics with FDP-PET-CT diagnostics significantly improves lymph node diagnostics.

In a curative treatment strategy, histological clarification should be performed if changes in the mediastinal lymph nodes are detected in imaging. Initially, a fine needle aspiration using endobronchial ultrasound should be performed. If no malignancy is detectable despite morphologically conspicuous lymph nodes, a surgical procedure, such as VATS lymph node resection or mediastinoscopy with lymph node biopsy, should be performed.

Note: Tumor involvement of the mediastinal lymph nodes represents an N2 involvement and is classified as at least stage IIIa according to the UICC classification. Here, in addition to primary surgery, a multimodal therapy concept is possible, and the therapy algorithm in the guideline is not yet definitively defined. Treatment in centers and within the framework of studies is recommended.

• Shaving of the right thoracic wall, if necessary
• Single-shot antibiotic with Cefuroxime 1.5g intravenously approximately 30 minutes before the skin incision.

In addition to the general surgical risks such as thrombosis, embolism, allergy, infection, bleeding, and wound healing disorder, specific risks must be clarified:

• Injury to adjacent structures, particularly the trachea and main bronchi, large vessels, and the esophagus, necessitating corresponding extension of the procedure
• Damage to the phrenic nerve with diaphragmatic elevation on the affected side and injury (especially in left-sided surgery) to the recurrent laryngeal nerve with vocal cord paralysis on the affected side
• Postoperative air fistula due to mobilization-related lesions of the lung parenchyma
• Postoperative bronchial fistula due to thermal damage requiring intervention, possibly including surgical treatment
• Postoperative lymph fistula with chylothorax
• Postoperative hemorrhage with potentially necessary re-operation
• Cardiac arrhythmias
• Positioning injuries

Treatment alternative: Endobronchial fine needle aspiration

Intubation anesthesia with one-lung ventilation of the opposite side.

The standard positioning for minimally invasive thoracic surgical procedures is the hyperextended lateral position.

• Bending of the operating table at the level of the scapula tip
• Horizontal alignment of the thoracic wall using a slight anti-Trendelenburg position
• Stabilization of the position using padded side supports in the area of the abdomen and lumbar spine, as well as a U-shaped pillow between the legs. It may occasionally be helpful to use an additional shoulder support.

Finally, ensure that pressure-sensitive areas are padded and the head is placed on a gel ring to avoid excessive bending of the cervical spine. The arm on the operating side is positioned laterally using an arm holder and should be placed below shoulder level to avoid potential obstruction during the subsequent operation.

The arrangement as shown in the picture of the surgeon and assistant ventrally and opposite the OR nursing staff was described by the Copenhagen working group led by Hendrik Hansen. Especially in uniportal VATS but also in 3-port VATS, optimal work can be performed here through the anterolateral minithoracotomy.

• Wound protection ring film (wound retractor)
• Standard VATS instruments with curved instruments
  • An ultrasonic shear can be helpful for bloodless and thus clear preparation.
• Endoscopic stapling device
  • Staple magazines with a curved tip assist in the gentle bypassing of smaller vessels.
  • In emphysematous lung tissue, staple reinforcement before parenchyma transection is advisable.
• Titanium clip applicator

• Postoperative Analgesia

Due to the pain caused by the indwelling chest drain, a combination analgesia of a non-opioid analgesic (e.g., Metamizole) in combination with a low-dose opioid (e.g., Tilidine) is advisable. Follow the link to PROSPECT (Procedures Specific Postoperative Pain Management) and to the current guideline Management of acute perioperative and post-traumatic pain.

• Medical Follow-up
  • X-ray control on the operating table
  • Chest drain with suction 20mmHg for approximately 2 days postoperatively, removal after X-ray control if secretion volume is under 250ml/24h and without evidence of an air fistula
• Thrombosis Prophylaxis

Standard thrombosis prophylaxis for 14 days with low molecular weight heparin subcutaneously, considering comorbidities, renal function, and laboratory control to exclude HIT. Link to the current guideline: Prophylaxis of venous thromboembolism (VTE)

• Mobilization

Full mobilization possible from the 1st postoperative day

• Physical Therapy

Mobilization, deep breathing exercises, and secretion mobilization

• Diet Advancement

Full diet

• Bowel Regulation

Accompanying opioid analgesia

• Work Incapacity

Approximately 14 days, considering the type of work and patient situation