Nerve at risk – recurrent laryngeal nerve palsy after left-sided VATS anatomic lung resections

Background:

Intraoperative recurrent laryngeal nerve (RLN) injury reduces quality of life of lung cancer patients with hoarseness and dyspnea. Moreover, it impairs expectoration, causes dysphagia and increases the risk of aspiration with concurrent pneumonia. This study aims to evaluate the rate of RLN injuries after left-sided VATS anatomic resections.

Material and method:

The institutional database was queried for left-sided VATS resections. Medical files were assessed for RLN palsy. A total of 251 consecutive patients treated between 2009 and 2017 were included for further analysis.

Result:

Anatomic resections involved upper lobes in 143 patients (56.2%; lobectomies n = 114; segmentectomies n = 19; pneumonectomies n = 10). 21 of all 251 resections were performed for non-lung cancer reasons (metastasis, benign disease). 15 out of 251 patients (6.0%) did show signs of RLN injury. RLN palsy was only observed in upper lobe cases (p < 0.001). Moreover, it was also only seen in primary lung cancer cases and not in benign cases or patients undergoing metastasectomy. In upper lobe cases, the risk for RLN palsy was higher for patients with nodal positive tumors in clinical staging (cN+) than in nodal negative tumor cases (19.1% vs. 7.2%, p = 0.041).

Conclusion:

RLN palsy is a significant postoperative complication for patients with nodal positive lung cancer in the left upper lobe affecting up to 20% of patients. A lower rate of RLN injury in clinically nodal negative lung cancer patients is suggestive for a more reluctant and thus incomplete lymph node dissection in the aorto-pulmonary window. Only in-depth anatomical understanding of the RLN course on the left side might help to avoid RLN injury during adequate lymph node dissection in this delicate area.