Mediastinoscopy and Mediastinotomy

Both mediastinoscopy and mediastinotomy are performed to:

• Evaluate or excise mediastinal lymphadenopathy or masses

• Stage cancers (eg, lung cancer, esophageal cancer)

Positron emission tomography (PET) scanning and endobronchial ultrasound-guided transbronchial needle aspiration have decreased the need for mediastinoscopy or mediastinotomy in cancer staging (1).

Contraindications, both absolute and relative, to mediastinoscopy and mediastinotomy include the following:

• Severe coagulopathy

• Active mediastinal infection

• Aneurysm of the aortic arch, or other large anterior mediastinal masses

• Previous median sternotomy

• Previous mediastinal irradiation with residual fibrosis

• Superior vena cava syndrome

• Tracheostomy

Mediastinoscopy and mediastinotomy are performed 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 occur in approximately 1% of patients and include (1):

• Bleeding

• Chylothorax due to lymphatic duct injury

• Esophageal perforation

• Infection

• Pneumothorax

• Vocal cord paralysis due to recurrent laryngeal nerve damage