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Mediastinoscopy and Mediastinotomy

by Noah Lechtzin, MD, MHS

Mediastinoscopy is introduction of an endoscope into the mediastinum. Mediastinotomy is surgical opening of the mediastinum. The two are complementary. Mediastinotomy gives direct access to aortopulmonary window lymph nodes, which are inaccessible by mediastinoscopy. Both procedures are done to evaluate or excise mediastinal lymphadenopathy or masses and to stage cancers (eg, lung cancer, esophageal cancer), although PET scanning and endobronchial ultrasound-guided transbronchial needle aspiration are decreasing the need for these procedures for cancer staging.

Contraindications

Contraindications include the following:

  • Superior vena cava syndrome

  • Previous mediastinal irradiation

  • Mediastinoscopy

  • Median sternotomy

  • Tracheostomy

  • Aneurysm of the aortic arch

Mediastinoscopy and mediastinotomy are done by surgeons in an operating room using general anesthesia.

For mediastinoscopy, an incision is made in the suprasternal notch, and the soft tissue of the neck is bluntly dissected down to the trachea and distally to the carina. A mediastinoscope is inserted into the space allowing access to the paratracheal, tracheobronchial, azygous, and subcarinal nodes and to the superior posterior mediastinum.

Anterior mediastinotomy (the Chamberlain procedure) is surgical entry to the mediastinum through an incision in the parasternal 2nd left intercostal space, allowing access to anterior mediastinal and aortopulmonary window lymph nodes, common sites of metastases for left upper lobe lung cancers.

Complications

Complications occur in < 1% of patients and include bleeding, infection, vocal cord paralysis due to recurrent laryngeal nerve damage, chylothorax due to duct injury, esophageal perforation, and pneumothorax.

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