New developments in videomediastinoscopy: video-assisted mediastinoscopic lymphadenectomy and mediastinoscopic ultrasound.

Background: Mediastinal lymphadenectomy is usually performed at thoracotomy together with lung resection. It is a prerequisite for accurate nodal staging and has an impact on survival.

Methods: VAMLA (video-assisted mediastinoscopic lymphadenectomy) dissection is guided by anatomical landmarks. It includes en bloc resection of the right and central compartments, and dissection and lymphadenectomy of the left-sided compartment.

Results: VAMLA harvested significantly more mediastinal lymph nodes than open lymphadenectomy (p < 0.001). Mean duration was 54 min, the complication rate 4.6%, sensitivity 93.8%, specificity 100%, and the false-negative rate 0.9%. 16 of 24 cT4 tumors were correctly predicted to be resectable by MUS (mediastinoscopic ultrasound). For minimally invasive oncological lung resections, combined VATS + VAMLA harvested significantly more lymph nodes than VATS alone without impact on operation time and complication rate (p < 0.05).

Conclusion: VAMLA is a well-tolerated minimally invasive method for accurate mediastinal staging and radical mediastinal dissection. VAMLA can be carried out independently from tumor resection. We suggest its application together with neoadjuvant strategies, trials, VATS lobectomy, and radiation therapy for curatively intended involved field radiation. Additional MUS is helpful to detect resectable cT4 cases, and offer them curative treatment.