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.
image

Figure 20-1 Incision for introducing the mediastinoscope.

Step 2. Level 7 Nodes

♦ Bluntly dissect the anterior surfaces of the right and left mainstem bronchi.
♦ An artery can usually be seen passing from the aorta to the carina. Clip the artery to reduce bleeding during removal of the subcarinal nodes (Figure 20-2).
♦ Bluntly dissect along the posterior aspect of the pulmonary artery.
♦ Dissect along the medial aspect of the left mainstem bronchus inferiorly to the carina. The blunt-tipped suction then sweeps the subcarinal nodes from left to right and off the surface of the esophagus.
♦ Similarly, dissect along the medial aspect of the right mainstem bronchus.
♦ Hold the subcarinal nodes to the right to allow blunt dissection between the nodes and the esophagus (Figure 20-3).
♦ Remove all the subcarinal nodes until both mainstem bronchi and the esophagus have been completely exposed (Figure 20-4).
♦ Place a Surgicel hemostat in the subcarinal space for hemostasis.
image

Figure 20-2 The artery travels from the aorta (left) to the carina. It can be clipped as shown.

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Figure 20-3 The forceps holds the subcarinal nodes to the right as the suction dissects along the medial aspect of the left mainstem bronchus.

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Figure 20-4 Empty subcarinal space after node dissection.

Step 3. Left Level 10 Nodes

♦ Bluntly dissect along the lateral aspect of the left mainstem bronchus to avoid pressure on the left recurrent laryngeal nerve, which can be seen (Figure 20-5).
♦ Bluntly mobilize the level 10 nodes with as little pressure on the nerve as possible.
image

Figure 20-5 Level 10 nodes.

Step 4. Right Level 10 Nodes

♦ Bluntly dissect along the lateral aspect of the right mainstem bronchus.
♦ Laterally, dissect along the azygous vein to the superior vena cava anteriorly.
♦ Remove the right level 10 nodes along the mainstem bronchus.
♦ Dissect along the pulmonary artery in this area. The right truncus anterior often can be identified (Figure 20-6).
image

Figure 20-6 A, Left recurrent laryngeal nerve. B, Right mainstem bronchus, azygous vein, and anterior trunk.

Step 5. Level 4 and 2 Nodes

♦ With the biopsy forceps, grasp the fatty tissue anterior to the distal trachea, and pull posteriorly away from the superior vena cava.
♦ With the suction tip, bluntly dissect horizontally to identify the superior vena cava.
♦ Remove all nodes and fatty material (Figure 20-7).
♦ There is often a small vein from the nodes to the superior vena cava. Identify and clip the vein (Figure 20-8).
♦ Continue dissection until all of the tissue between the azygous vein to the innominate artery has been removed (Figures. 20-9 and 20-10).
image

Figure 20-7 A, Level R4 node. B, Exposure of the superior vena cava and azygous vein.

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Figure 20-8 Clipped vein from the nodes to the superior vena cava.

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Figure 20-9 Empty space from the carina to the innominate artery.

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Figure 20-10 The innominate artery.

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