Lymphadenectomy during thoracoscopy: techniques and efficacy

Nowadays several studies have shown that, in the management of patients with early-stage lung cancer, video-assisted thoracoscopic surgery (VATS) lobectomy compared to open surgery is associated with many clinical short-term benefits, such as less post-operative pain and shorter hospital stay. Despite the advantages described earlier, some authors have expressed concern about the effectiveness of the procedure arguing that the lymph node harvest performed during VATS lobectomy is inferior to that performed through thoracotomy access. Experience from a multicentre database, with a more balanced number of VATS versus open patients, actually has shown that there is no difference in the efficacy of mediastinal lymph node dissection during lobectomy for lung cancer by thoracoscopy and thoracotomy. In expert hands the technique of VATS lymphadenectomy is the same as that performed by thoracotomy: instrumentation and tricks can change but not the oncologic principles. We believe that is necessary to follow a learning curve not only for VATS lobectomy but also for thoracoscopic lymph node dissection. However even experienced VATS surgeons should keep in mind that the metastatic lymphadenopathy with extracapsular lymph node spread requires great caution during dissection and that a preoperative plan for conversion to thoracotomy can be useful in this case.