单孔胸腔镜纵膈淋巴结清扫的应用体会

Clinical experience of uniportal video-assisted thoracoscopic mediastinal lymphadenectomy

目的探讨单孔胸腔镜（SPT）治疗Ⅰ期非小细胞肺癌（NSCLC）时纵膈淋巴结清扫的技术特点。方法2015年1月-2015年12月，该中心采用SPT治疗63例临床Ⅰ期的NSCLC患者。其中，男35例，女28例，年龄45～79岁，右胸手术37例，左胸手术26例。手术方式为肺叶切除＋系统性肺门纵膈淋巴结清扫。纵膈淋巴结的分区以国际肺癌协会（IASLC）为标准，即右胸2-4、7、8和9组，左胸4、5、6、7、8和9组。主要评估指标包括纵膈每组淋巴结清扫的数目和时间，并发症的发生率，胸管引流时间和引流量以及住院时间等。以无疾病生存时间（DFS）为指标随访3～15个月。结果全部患者均顺利完成SPT手术，无中转开胸或转三孔手术发生，无死亡率发生。纵膈淋巴结清扫的总数目（术中系统性淋巴结清扫后术侧各站淋巴结的总和）：右胸（15.3±4.4），左胸（17.7±5.6）。其中，右侧2-4组（6.3±2.1），7组（9.5±4.3），8组（4.5±2.3），9组（2.5±1.7）；左侧4组（3.7±1.1），5组（3.7±1.5），6组（4.1±2.0），7组（5.7±3.4），8组（3.6±2.6），9组（2.7±1.3）。纵膈淋巴结清扫的时间：右胸（20.7 ±11.2）min，左胸（45.2±18.5）min，特别是在清扫第4，7组淋巴结时左、右胸比较差异有统计学意义（P 〈0.05）。术后在并发症的发生率、胸管引流时间、胸管引流总量以及住院时间的比较上，左、右胸手术差异无统计学意义（P 〉0.05）。术后随访未见肿瘤复发和转移。结论SPT下行纵膈淋巴结清扫在技术上是安全和有效的，合理的放置镜头和器械，充分的显露和规范的操作流程是手术成功的关键。

ObjectiveTo investigate the technical characteristics of uniportal video-assisted thoracoscopic mediastinal lymphadenectomy. Methods63 patients with clinical stageⅠ NSCLC underwent lobectomy and systematic mediastinal lymphadenectomy by uniportal video-assisted thoracoscopic January to December in 2015. The number and resection time of each station of mediastinal lymph nodes were assessed. Mediastinal Lymph nodes were classified according to the International Association for the Study of Lung Cancer classification （IASLC）. For right-sided tumors, lymph nodes number 2-4, 7, 8 and 9 were dissected, and for left-sided tumors, lymph nodes number 4, 5, 6, 7, 8, and 9 were dissected. We analyzed the perioperative parameters. ResultsThere was no operative death. All procedures were successful accomplished without conversion to conventional multi-port VATS or open approach. The number of mediastinal lymph nodes removed was as follows： （right side） （15.3 ± 4.4） lymph nodes/patient, （left side） （17.7 ± 5.6） lymph nodes/patient. According the IASLC, we found the following results： 2R-4R （6.3 ± 2.1）, 7R （9.5 ± 4.3）, 8R （4.5 ± 2.3）, 9R （2.5 ± 1.7）; 4L （3.7 ± 1.1）, 5L （3.7 ± 1.5）, 6L （4.1 ± 2.0）, 7L （5.7 ± 3.4）, 8L （3.6 ± 2.6）, 9L （2.7 ± 1.3）. Compared with the time of mediastinal lymphadenectomy, there were statistically significant differences between the right and left side, especially in 4L vs 4R and 7L vs 7R. There were no statistically significant differences among the procedures, such as the complication incidence, drainage time and volume, length of hospital stay. No signs of tumor recurrence or metastasis was found in the postoperative follow-up time. ConclusionUniportal video-assisted thoracoscopic mediastinal lymphadenectomy is feasible safe and effective. Reasonable placement of lens and instruments, adequate exposure and standard procedure may be the key points of the surgery.