Expanded right-sided pneumonectomy in lung cancer within the cancer-based limits involves the removal of its regional lymphatic reservoirs, including the lymph nodes of several groups located in the mediastinum: right tracheobronchial and paratracheal, prevenal, bifurcation, and esophageal.
Features of extended right-sided pneumonectomy are determined by a number of circumstances, among which are complex topographic-anatomical relationships and the individual variability of lung root elements located within
mediastinum, varying degrees of expression of fascial-cellular structures of this area. In patients with advanced stages of lung cancer, certain difficulties in orientation are brought about by the frequent involvement of these structures in the blastomatous process, damage to lymphatic collectors by tumor metastases, as well as changes that develop as nonspecific lymphadenitis and periadenitis.
This differs from the mandatory removal of lymph nodes and mediastinal cellulose in a single unit with the affected lung, performed in the initial stage of cancer, in some patients with advanced stages of the disease, lymphadenectomy can be performed after lung resection.
When performing lymphadenectomy within the mediastinum for ease of dissection of the cellular spaces, the stump of the main bronchus of the right lung is retained with a bronchial fixator. The central stumps of the pulmonary vessels — the pulmonary artery, the upper and lower pulmonary veins — after their prior ligation — place reliable hemostatic clamps (such as Kocher). With their help in the course of fiber extraction with lymph nodes of the mediastinum they access and open it deeply located parts.
Mediastinotomy — The opening of the mediastinum is performed using several techniques. First, an unpaired vein is isolated. On its central (at the superior vena cava) and peripheral (at the chest wall) areas impose ligatures. After tying them, a fragment of the unpaired vein thus isolated on the lateral surface of the mediastinum is crossed. On the central stump impose a clip by analogy with the vessels of the root of the lung. These clamps are subsequently used when working in the mediastinum for abduction of the superior vena cava and other anatomical structures in this area. The mediastinal pleura is peeled off from the underlying mediastinal tissue and is widely dissected below and parallel to the phrenic nerve up to the dome of the pleural cavity and down to the diaphragm .
With the help of clamps imposed on the stump of blood vessels, the mediastinum is widely opened. The stump of the right bronchus with light trachea Traction of the broncho-fixer is shifted to the pleural cavity and held in this position. Carry out the preparation of mediastinal fiber along the right lateral surface of the trachea in the direction from the bronchus stump upward, highlighting the right tracheobronchial and paratracheal lymph nodes, forming the posterior surface of the cellular tissue unit. Mobilizing it in this way, it is captured with a clamp (such as Luer) and gradually, from the bottom up, including the preventive lymph nodes, separated from the posterior surface of the wall of the superior vena cava. The 1-venous trunks departing from it are ligated and crossed. The medial surface of the cellular tissue block with lymph nodes is adjacent to the pericardium, which covers the ascending part of the aortic arch. When dissecting and separating the lymph nodes in this area, care should be takenin order not to damage the recurrent branch of the left vagus nerve, which passes near the lateral surface of the trachea — in the furrow between it and the esophagus.
Fully allocated fiber block in the upper section of the mediastinum, at the place of its transition to the neck, in the chain of paratracheal and lower deep jugular lymph nodes, is captured with a hemostat and clamped. A ligature is placed above the clamp — a small venous vessel passing here is often in it.
With the help of a bronchial fixer, the stump of the right main bronchus is retracted, providing access to the bifurcation and peri-esophageal groups of lymph nodes. Starting from the bronchial stump, on the lower surface of its wall in the direction to the bifurcation of the trachea and the initial section of the left main bronchus, the bifurcation lymph nodes located here undergo a dissection, which at the bottom often, without a pronounced border, passes into the peri-esophageal. A part of the epesophageal nodes may be located in the mediastinal tissue of the posterior mediastinum somewhat in isolation, as a separate group, adjacent to the anterior and right surface of the esophagus. It is carefully prepared and removed.
Complete removal of cellulose bifurcation and peri-esophageal lymph nodes makes it possible to examine the trachea bifurcation, the initial section of the left main bronchus, the esophagus, and the posterior surface of the pericardium above the right and partly left sections of the heart .
Complete removal of the lymph nodes and fiber of the mediastinum by fixing the bronchus stump, additional flashing and ligation of the stump of the vessels of the lung root, stitching, bringing together the anterior and posterior sheets of the dissected m of the anastinal pleura .