How is right upper lobe mediastinal lymphadenectomy performed?

Updated: Feb 16, 2021
  • Author: R James Koness, MD, FACS; Chief Editor: Erik D Schraga, MD  more...
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When a right upper lobectomy is planned, the operator starts in front of the patient. The hilar pleura is opened, the phrenic nerve is identified and retracted to prevent injury, and the superior pulmonary vein is isolated, ligated, and divided. The lung is then retracted anteriorly; the pleura is incised posterior to the hilar structures. The vagus nerve is exposed and retracted, while pulmonary branches are divided.

Next, the bifurcation of the trachea is retracted anteriorly to allow visualization of lymph node stations 10R, 7, and 10L. The mediastinal tissue between the inferior pulmonary vein, the two mainstem bronchi and the carina, the pericardium, and the esophagus is dissected en bloc. At this point, the inferior pulmonary ligament is divided, and lymph node stations 9 and 8 are dissected between the esophagus and pericardium from the diaphragm to the inferior pulmonary vein.

The surgeon then moves to the back of the patient to complete the superior mediastinal dissection. If not previously divided, the azygos vein is now transfixed and divided. When station 4 nodes are grossly involved, the vein should be divided proximally as it enters the superior vena cava (SVC). The distal portion of the azygos over the transbronchial lymph nodes (station 4) is left attached to this nodal group and excised en bloc.

The dissection is then completed by removing the right paratracheal, pretracheal, and tracheobronchial nodes (stations 2, 3, and 4) lateral and anterior to the trachea, the ascending aorta, and the posterior aspect of the SVC, from the brachiocephalic artery to the right pulmonary artery.

The lobectomy is completed by ligation and division of the right pulmonary artery and removal of lymph nodes attached to the anterior aspect of the upper-lobe bronchus (station 12) in continuity with the tracheobronchial lymph nodes (station 4). The procedure is completed with isolation, division, and closure of the right-upper-lobe bronchus.

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