Transection of the arterial ligament for extended mediastinal lymph node dissection by video-assisted thoracoscopic surgery: invaluable technique for the right patient

Lung cancer remains the leading cause of cancer-related deaths worldwide, with non-small cell lung cancer (NSCLC) accounting for 85% of cases (1). Five-year survival is heavily dependent upon cancer stage and follows the tumor, node, and metastasis staging model (TNM), with lymph node (LN) metastasis being an important determinant of prognosis (2). Stage I NSCLC includes tumors less than 4 cm in diameter without metastasis to LNs. Published practice guidelines recommend preoperative staging with positron emission tomography (PET) or PET-computed tomography (CT), with subsequent preoperative pathologic tissue diagnosis for mediastinal staging in centrally located tumors, tumors >3 cm, and for enlarged or PET-positive LNs (2,3). Endobronchial ultrasonography (EBUS) with fine needle aspirate is the recommended first choice where available; if unavailable or if aspirate is negative in the setting of high suspicion for involved LNs, recommendations are to proceed with cervical mediastinoscopy.