Mediastinoscopy & mediastinotomy indications & techniques

MEDIASTINOSCOPY AND
MEDIASTINOTOMY
Professor
Abdulsalam Y Taha
School of Medicine
Faculty of Medical Sciences
University of Sulaimaniyah
Sulaimaniyah
Region of Kurdistan/ Iraq
1
https://sulaimaniu.academia.edu/AbdulsalamTah
a

Introduction
 The mediastinum is the central
compartment of the chest. Its
boundaries and compartments
are well known.
 Although, it contains the most
vital organs of the body; it is
often a forgotten compartment.
2

Introduction:
 Involvement of mediastinal nodes has a
dramatic prognostic and therapeutic impact in
patients with non-small cell lung cancer.
 Cervical mediastinoscopy remains the most
important technique for staging of the
mediastinum.
 The technique of extended mediastinoscopy
and redo mediastinoscopy are described as
well. Indications, technique and complications
are discussed.
3

Introduction
4
* Lymph node sampling is an important
intervention for the diagnosis and
management of the mediastinal nodal
disease, including benign
and malignant etiologies.
* The cervical mediastinoscopy is
the ( gold standard) for the
assessment of mediastinal lymph
nodes and it remains the
clinical method with the highest
sensitivity and specificity
for exclusion of mediastinal
lymph node involvement.

Nodal zones
 Peripheral 12-14
 Hilar 10 & 11
 Upper 1-4
 Aorto-pulmonary
window 5 & 6
 Subcarinal 7
 Lower 8 & 9

8
Although cervical mediastinoscopy is used in the
diagnosis of lymphoma, sarcoidosis and mediastinal
tumors, it is mainly used as an invasive staging
method in patients with non-small cell lung cancer
(NSCLC). Surgical exploration of the mediastinum was
first developed by Harken et al. Through a
supraclavicular incision, a Jackson laryngoscope was
inserted into the mediastinum and lymph node
biopsies were taken. They reasoned that the presence
of involved mediastinal lymph nodes in patients with
lung cancer would preclude successfull resection of
the cancer. More than fifty years later, their reasoning
still proves to be very valid. Cervical mediastinoscopy
through a pretracheal suprasternal incision was
developed by Carlens in Sweden and subsequently
popularized by Pearson in North-America. The
prognostic importance of the level and extent of nodal
involvement has led to the development of an
internationally used lymph node map

Indications
 Lymph nodes or masses in the middle
mediastinum of unknown origin
(sarcoidosis, lymphoma, …).
 Mediastinal staging in patients with
NSCLC.
9

There remains controversy regarding the selected use of
mediastinoscopy in patients with NSCLC. Before PET scan became
available, many centers used to perform cervical mediastinoscopy
in every patient since it has been proved that small nodes on CT
scan can harbor metastatic disease of clinical importance . There is
consensus that the positive predictive value of both CT as well as
PET scan is low and that positive mediastinal findings on CT or PET
scan need to be proven histologically. Other less invasive
techniques such as transbronchial fine needle aspiration and
esophageal and tracheal endoscopic ultrasound needle aspiration
have become available in specialized centers with high sensitivity
in clinically obviously involved mediastinal nodes. The sensitivity
and negative predictive value (NPV) of these techniques are,
however, significantly lower when compared to mediastinoscopy
and mediastinoscopy remains the gold standard.
10

11
* Cervical mediastinoscopy has a high accuracy. Its
specificity is 100%, the sensitivity is dependent upon
the surgeons experience but sensitivity rates of 90%
are usually reported. Therefore, cervical
mediastinoscopy remains the gold standard to which all
other techniques are to be compared.
* However, because PET scan has a high
NPV up to 93% in primary mediastinal
staging in patients with NSCLC [3] cervical
mediastinoscopy can nowadays be omitted in
some circumstances (peripheral tumor, N0
on PET and CT scan).

12
Contraindications:
Absolute contraindications for cervical
mediastinoscopy are very rare.
1. Contraindication for general anesthesia
2. Extreme kyphosis
3. Cutaneous tracheostomy (after
laryngectomy)
4. Superior vena cava syndrome, previous
sternotomy and enlarged goiter do not
preclude mediastinoscopy as well as previous
radiotherapy and mediastinoscopy. Due to
fibrosis and adhesions the intervention can be
much more challenging and is more time
consuming.

13
Accessible lymph node stations
by cervical mediastinoscopy
By cervical mediastinoscopy the following
nodal stations (according to the Mountain–
Dresler modification (1997) from
Naruke/ATS-LCSG Map) can be searched for
and biopsied: the left and right upper
paratracheal nodes (station 2L and 2R), left
and right lower paratracheal nodes (station
4L and 4R) and the subcarinal nodes (station
7).

The endotracheal tube is positioned at the left corner of the mouth, with the anesthesia
equipment at the patients left side.
Leyn P D , Lerut T MMCTS 2005;2005:mmcts.2004.000158
© 2005 European Association for Cardio-thoracic Surgery

Station 1 nodes are not routinely accessed by cervical mediastinoscopy.

A horizontal line drawn tangential at the upper margin of the aortic arch delineates the lower
border of station 2 nodes.

Station 3 nodes are also not accessible by conventional cervical mediastinoscopy.

The posterior subcarinal nodes (station 7p), the para-esophageal nodes (station 8), the
inferior pulmonary ligament nodes (station 9) are not accessible by conventional media-stinoscopy.

The subaortic nodes (station 5) and para-aortic nodes (station 6) cannot be biopsied through
a standard cervical mediastinoscopy.

A bolster is placed under the patients shoulders and the neck is extended.

Operation room setup for conventional mediastinoscopy.

For mediastinoscopy, only few instruments are needed.

Conventional mediastinoscope.

A 3 cm transverse cervical incision is made one-finger breadth above the suprasternal notch.

Illustration of the anatomy of this region.

Sharp dissection exposes the pretracheal muscles which are separated vertically in the
midline to expose the anterior surface of the trachea.

Incision of the pretracheal fascia.

The surgeon's middle finger is advanced along the pretracheal plane and blunt dissection is
carried out along the anterior surface of the trachea down to the carina.

The mediastinum is carefully palpated for the presence of nodal disease.

The finger is withdrawn and the mediastinoscope is advanced.

The plane in front of the mediastinoscope is developed with the use of blunt dissection,
using a metal sucker through the channel of the mediastinoscope.

33
• Prior to biopsying the lymph node, the node should
be mobilized as much as possible to ensure that it is a
lymph node and not a vessel. This mobilization is
performed by the use of the suction device.
• For the upper paratracheal lymph nodes this can be
safely performed with the finger.
• In case of doubt, a long aspiration needle can be
placed in the lymph node and suction is applied to the
attached syringe, to ensure that the structure to be
biopsied is not a vessel. An experienced surgeon will
find this seldom necessary when the nodes were
adequately mobilized and the anatomical structures
are clearly identified.
• The lymph node is grasped with a biopsy forceps. In
case of resistance, one should be cautious not to pull
too strongly because the diseased lymph node may be
attached to an adjacent vascular structure such as the
azygos vein, the first branch of the right PA or the
innominate artery. This may lead to a vascular tear
with major bleeding

To avoid and to handle major complications, it is important to visualize the anatomical
landmarks such as the azygos vein, the right and left main bronchus and the first branch of
the right pulmonary artery before biopsies are taken.

The left recurrent nerve lies approximately 1 cm lateral to the trachea and can usually be
visualized in the mid tracheal plane.

Sequentially, the paratracheal tissues are entered to expose the lymph nodes at the various
stations.

37
• One starts to biopsy the obvious enlarged
nodes and those nodes that felt firm by
palpation.
• However, small lymph nodes may also
contain metastatic deposits.
• Routine sampling of all accessible
mediastinal nodal stations is advised.
• The standard is that biopsies of the
subcarinal nodal station, two ipsilateral
nodal stations and one contralateral nodal
station are biopsied or removed.
• The author uses adhesive labels on which
the stations according to the Mountain–
Dressler map are printed. This increases the
accuracy in labelling

The biopsies are stored in separate vials, labelled with these adhesive labels and sent for
pathology.

When biopsies are taken from the different nodal stations the biopsy forceps is cleaned each
time to prevent contamination and false positive results.

Mediastinoscopy.

41
• In the subcarinal area, bronchial arteries are
frequently encountered and bleeding
frequently occurs from the subcarinal lymph
node biopsy sites.
• This bleeding, although usually modest,
obscures clear vision and further dissection
and sampling.
• In case a bronchial artery is visualized, a
vascular clip can be placed.
• Pushing the scope deeper into the subcarinal
space the bleeding will stop which allows to
take more representative biopsies before the
bleeding sites are electrocoagulated.
• Sufficient tissue has to be removed. In case of
doubt, frozen section can be performed to
confirm that sufficient tissue will be available.
• When there is no histological diagnosis part
of the lymph node is sent for culture.

42
Small bleedings from biopsy sites can be
electrocoagulated. Bleeding is best handled with
resorbable hemostatic resorbable gauze placed
through the mediastinoscope.
When a major bleeding occurs, packing is the first
thing to do. By packing for at least 10 minutes, most
of the even dramatic bleedings will stop. A long strip
of wide gauze packing should always be available in
the operating room for such instances. In case of
uncontrollable hemorrhage (for instance injury of
aorta or innominate artery), the mediastinum is
packed or the bleeding site is compressed with the
surgeon's finger, or the mediastinoscope, and the
decision is made whether thoracotomy or
sternotomy will be performed. Decision is based on
the location of the bleeding and the location of the
tumor if resection is indicated. Right thoracotomy
might be indicated when the bleeding is from the
first branch of the right pulmonary artery or from
the azygos vein. In all other cases sternotomy offers
the best chances to control the bleeding.

43
Closure
• The strap muscles are approximated
with one suture.
• Drainage of the mediastinal bed is
usually not required.
• A subcutaneous interrupted suture will
obliterate the dead space.
• The skin is closed according to the
surgeon,s preferences.

44
Morbidity & Mortality
• Cervical mediastinoscopy is a low-risk
procedure but the potential for
catastrophic complications is apparent.
• Unless additional or more extensive
procedures are done under the same
general anesthesia, and the patient's
condition permits, the procedure can be
performed on an outpatient basis.
• In experienced hands, cervical
mediastinoscopy has no mortality and
minimal morbidity.

• In a recent review of over 20000 cases complications did
not surpass 2.5% and mortality was under 0.5%.
• Only 0.1 to 0.5% of complications are considered major.
•The most important major complication is
a.severe hemorrhage. On the right side, the azygos vein
and the anterior branch of the right pulmonary artery are
at risk of injury. The azygos vein can be mistaken for an
anthracotic lymph node.
b.Other major complications are injury of the esophagus,
c.damage to the recurrent laryngeal nerve (usually the
left) and
d.tracheobronchial tree injuries.
45
Morbidity & Mortality…

46
• In a twenty-year period, we performed well
over 4000 cervical mediastinoscopies.
• There was no hospital mortality.
• Major bleeding requiring immediate
intervention occurred in four patients,
• injury to the esophagus was seen in one
patient in whom the mediastinum was drained
through the mediastinoscopy incision and this
fistula dried up after a few days of conservative
treatment.
•In one case a tear of the left main bronchus
was made by the biopsy forceps. This was
sutured by the endoscopic suturing technique
using the videomediastinoscope and healed
without any problems.

Left upper lobe tumors may metastasize to the
subaortic lymph nodes (station 5) and
paraaortic nodes (station 6). These nodes
cannot be biopsied through routine cervical
mediastinoscopy. Ginsberg and associates
described a technique to explore these stations
through the cervical incision. This technique is
an alternative for the anterior-second interspace
mediastinotomy which is more commonly used
for exploration of these nodal stations. The
advantage of the extended mediastinoscopy is
the saving of an additional incision.
47
Extended Cervical
Mediastinoscopy

*If the standard cervical mediastinoscopy is
negative, a plane is developed anterior to the
aortic arch, down to the subaortic space.
• To do so, blunt dissection is performed with
the finger anterior to the innominate artery,
between the innominate artery and the
innominate vein.
• The mediastinoscope is introduced through the
cervical incision above the aortic arch.
• The scope is advanced over the top of the
aortic arch down to the aorto-pulmonary
window.
48
Extended Cervical Mediastinoscopy; Technique

If the standard cervical mediastinoscopy is negative, a plane is developed anterior to the
aortic arch, down to the subaortic space.

Biopsies of lymph nodes in the aortopulmonary window are taken.
In experienced
hands the procedure
has a high accuracy
and minimal
morbidity.
It is important to
state that this
procedure is far less
easy and therefore is
less routinely
performed compared
with the conventional
mediastinoscopy.

Repeat Mediastinoscopy
 It is done for restaging of the mediastinal LNs after induction
chemotherapy.
 Induction chemotherapy is given to patients with N2 disease in order
to achieve down staging of the tumour.
 Precise restaging of the mediastinum after induction therapy for
patients with involved mediastinal nodes (N2 or N3) disease is of
utmost importance since confirmation of downstaging of mediastinal
nodes is a very important prognostic factor in these patients.
 Although PET scan has a high accuracy in primary staging of the
mediastinum, its accuracy is much less in restaging of the
mediastinum after induction therapy.
 So, thoracic surgeons will be faced more and more frequently with
the need to repeat the mediastinoscopy.
 Several authors have shown that repeat mediastinoscopy is feasible
with an accuracy of 85% and a sensitivity of 73%.
51

Technique of repeat mediastinoscopy
52
*Positioning of the patient is not different
from mediastinoscopy but the whole
sternum is disinfected in case a
sternotomy or hemiclamshell would be
necessary.
* The primary incision is reopened.
Usually the isthmus or even the thyroid
may be adherent to the trachea. Sharp
dissection is performed to find the
anterior surface of the trachea. The
brachiocephalic trunk is adherent to the
anterior surface of the trachea due to
fibrosis.

Repeat Mediastinoscopy.
Blunt
dissection is
started on the
left side of the
trachea.
This region
was usually not
extensively
dissected at the
previous
mediastinoscop
y and thus
contains less
fibrosis.

A left paratracheal tunnel is created (medial border is trachea, the surface is part of the
esophagus) and the scope is inserted.

55
Repeat Mediastinoscopy: Technique…..
* Dissection is continued on the left side until the left tracheo-bronchial
angle is visualized.
• From this tunnel, blunt dissection to the right side is performed
from below in a retrograde fashion.
• The anterior surface of the trachea is freed from the adherent
major vascular structures. Initially this is perfomed with a
dissection pledget. Once additional space is gained this can be
continued by finger dissection. One has to do this carefully to
avoid injury to the brachiocephalic artery.
• The pretracheal space now being liberated, the scope can be
changed in its normal position. Dense fibrosis and adhesions
render the thorough exploration of all nodal stations very difficult
or even impossible.
• To reach the subcarinal region, the pulmonary artery has to be
pushed away. Adhesions can be divided with the endoscopic
shears. When there is a lot of precarinal fibrosis, we advise to
dissect as far as possible on the left main bronchus. From there
the sub-carinal space can be dissected and biopsied.

Staging Lung Cancer - Mediastinoscopy

Rigid video-mediastinoscopy
65
Case History:
* An elderly man with enlarged
paratracheal, subcarinal and aorto-pulmonary
LNs.
* Rigid video-mediastinoscopy was done
under GA.
* Needle aspiration of right paratracheal
LN revealed a caseous material
consistent with TB.
* Multiple biopsies were taken.

66
Enlarged AP window
Lymph nodes
Enlarged para-tracheal
Lymph nodes.

67
Enlarged sub-carinal
Lymph nodes.

Video assisted mediastinoscopy

Anterior Mediastinotomy
Indications & Technique
71

Staging Lung Cancer - Mediastinotomy

Case
A man of 30 presented with shortness of breath,
chest pain and dry cough for few months.
Neck veins were distended. No lymphadenopathy.

Chest radiograph: greatly widened mediastinum
with a smooth lobulated outline.

Lateral chest film: anterior mediastinal mass.
Fiberoptic bronchoscopy revealed a mucosal
redness.
Percutaneous transthoracic FNAC was
inconclusive.

CT scan of mediastinum: anterior mediastinal
mass mainly to the right side.

Diagnostic Anterior
Mediastinotomy
Large cell Lymphoma

Take Home Message
 The (forgotten compartment) is no longer (forgotten)
with the availability of many efficient and safe
diagnostic techniques like conventional cervical and
video-mediastinoscopy and the extended cervical
mediastinoscopy which can be done routinely with high
level of safety and minimum morbidity and mortality.
 The primary role of mediastinoscopy lies in the
evaluation of paratracheal and subcarinal
lymphadenopathy.
 Anterior mediastinotomy , the Chamberlain procedure,
offers access to the aortic window and the anterior
mediastinum.
81

Mediastinoscopy & mediastinotomy indications & techniques

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