Troubleshooting hilar and interlobar lymphadenopathy during thoracoscopic lobectomy for benign disease-case report

The completion of thoracoscopic lobectomy can be more difficult in the setting of clinically positive lymph nodes, which may be found in the setting of a proximal tumor causing bronchial obstruction or a larger tumor which may create an inflammatory state, both of which cause benign significant enlargement of hilar lymph nodes. Knowledge of the typical locations of these enlarged nodes facilitates the conduct of the operation. For all video-assisted thoracoscopic surgery (VATS) lobectomies, it is prudent to remove all visible lymph nodes prior to arterial and bronchial dissection. Moreover, in cases of significant hilar adenopathy, this strategy becomes more important and effective. For left upper lobectomy, the removal of level 11 lymph node anteriorly improves visualization of both bronchi, the interlobar pulmonary artery, the arterial aspect of the fissure, and the lingular artery. Subsequent dissection of the level 10 lymph node superior to the upper lobe bronchus exposes the main pulmonary artery and the truncal branches. For right upper lobectomy, dissection of the level 11 lymph node posteriorly not only exposes the upper lobe bronchus, but also the adjacent posterior ascending pulmonary artery. Dissection of the level 10 lymph node at the superior hilum facilitates exposure of the right pulmonary artery.