Video-assisted mediastinoscopic lymphadenectomy (VAMLA)

The development of a two-bladed spreadable videomediastinoscope in 1992 allowed increased exposure and bimanual dissection of mediastinal structures. Concurrent with technical progress in mediastinoscopy, neoadjuvant treatment of stage III lung cancer was introduced, and accuracy of pretreatment mediastinal staging became a topic at issue. In this setting, development of a videomediastinoscopic technique for complete mediastinal lymphadenectomy was the obvious thing to do.

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) dissection is guided by anatomical landmarks, very similar to open lymphadenectomy. It includes en bloc resection of the right and central compartments and dissection and lymphadenectomy of the left-sided compartments. In a preliminary case-control study of 40 patients, VAMLA technique was standardized and evaluated against open lymphadenectomy. A second study investigated 130 patients with resectable lung cancer and radiographically normal mediastinum who underwent VAMLA and consecutive lung resection with mediastinal reexploration.

VAMLA harvested significantly more nodes than open lymphadenectomy. With a mean duration of 54 minutes and a complication rate of 4.6%, VAMLA appeared applicable to clinical routine. We noted a sensitivity of 93.8%, a specificity of 100%, and a false-negative rate of 0.9%.

In our experience, VAMLA is a feasible method of mediastinal staging. Its accuracy and radicality can equal open lymphadenectomy. However, VAMLA is minimally invasive and therefore pretherapeutically available. Its advantages might be of interest with neoadjuvant strategies, trials, involved field radiation, video-assisted thoroscopic lobectomy, and left-sided tumors.