The features of performing extended pneumonectomy in cancer of the left lung in advanced stages of the disease differ from the similar operation on the right. The differences are most pronounced when the mediastinal stage of the intervention is performed. This is due to the peculiarities of the anatomical structure and the interposition of organs that form cellular spaces with groups of lymph nodes of the left half of the mediastinum located in them.
To remove the mediastinal part of the regional lymphatic collectors of the left lung, the mediastinal pleura is widely dissected upward — to the dome of the pleural cavity between the phrenic and vagus nerves that pass through here. In the lower direction, an incision is made from the root of the lung to the diaphragm posterior to the pericardium. In the case of the formation of a well-pronounced semi-unpaired vein under the pleura in the upper mediastinum, it is isolated, tied up and crossed, as is done on the right with respect to the unpaired vein.
Dissected sheets of the mediastinal pleura are widely bred. Such access provides a good overview and dissection of the pre-orthocrotic group of lymph nodes, grouped on the front surface of the aortic arch and extending backwards into the so-called “aortic window” formed by it. Here the recurrent branch departs from the left vagus nerve — the left lower laryngeal nerve. Then it goes around the aortic arch, passes in the upward direction along the left lateral wall of the trachea and reaches the larynx and vocal cords. Damage to the lower laryngeal nerve can cause paresis of the left half of the larynx, accompanied by hoarseness, a violation of the normal expectoration of sputum.Therefore, when performing mediastinotomy and preparation of this group of lymph nodes, special attention should be paid to the preservation of the recurrent branch of the left vagus nerve.
For dissection of lymph nodes located in the depth of the “aortic window” and providing access to the nodes of the left tracheobronchial and paratracheal groups, the aortic ligament (overgrown Botallov duct) is isolated and crossed . Preparauya on the upper surface of the wall of the left main bronchus in the direction of the trachea, the left tracheobronchial and paratracheal lymph nodes are isolated, complete the separation of the lymph nodes of the pre- ortho-rothrotic gland .
Several withdraw the left heart over the diaphragm. Starting from the root of the lung, along the lower surface of the wall of the left main bronchus, they separate in the direction to the bifurcation of the trachea and the initial parts of the right main bronchus and remove the bifurcation and perioesophageal groups of regional lymph nodes. Due to the fact that bifurcation lymph nodes of the main mass are grouped more along the right main bronchus, when they are removed, the probability of damage to the opposite side of the pleura with the formation of right-sided pneumothorax should be foreseen.
The removal of lymph nodes and mediastinal tissue with advanced left-sided pneumonectomy is completed with suture restoration of the dissected mediastinal pleura.