Video-Assisted Mediastinoscopy—Video 20

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CHAPTER 20 Video-Assisted Mediastinoscopy—Video 20

Robert J. McKenna, Jr.

Introduction

Mediastinoscopy is an important staging procedure for lung cancer. Development of video-assisted mediastinoscopy has greatly improved the quality and safety of the procedure that can be performed. Node dissection can be performed with the standard video mediastinoscope.

Approach to Video-Assisted Mediastinoscopy

Order of Operative Steps

Mediastinoscopy can be performed inferiorly to superiorly or vice versa. Usually, surgeons start inferiorly, and the steps of the procedure are as follows: subcarinal nodes, pretracheal nodes, level 4 nodes, and level 2 nodes.

Key Points

♦ Work inferiorly to superiorly.
♦ Before inserting the mediastinoscope, bluntly dissect with a finger to separate matted nodes from major vessels.
♦ Dissect on named structures to perform a complete node dissection.
♦ An assistant can hold the mediastinoscope so the surgeon may use two instruments for dissection: biopsy forceps and the suction tip.

image Video-Assisted Mediastinoscopy

Step 1. Incision

♦ Make a 2-cm incision (Figure 20-1) transversely in the base of the neck that is 1 or 2 fingerbreadths above the sternal notch.
♦ With electrocautery, cut transversely through the platysma muscle and then vertically in the midline between the strap muscles.
♦ With a closed Kelly clamp, bluntly dissect in the midline between the muscles to expose the trachea.
♦ Sweep the widely spread clamp along the surface of the trachea.
♦ Place an Army-Navy retractor between the fascia and the surface of the trachea. Lift anteriorly.
♦ Bluntly dissect with a finger on the surface of the trachea as far as possible into the chest.
♦ The finger breaks through the pretracheal fascia to mobilize the lymph nodes as much as possible. This often is the safest method to dissect matted nodes away from vessels.
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