Editing Mediastinoscopy


== Historical techniques ==

* Harken technique - not favoured due to technical difficulty and complication rate
**
* Radner technique - biopsy of paratracheal lymph nodes through an incision in the suprasternal notch

== Accessible nodes ==

* Highest mediastinal (1)
* Left and right upper paratracheal (2)
* Left and right lower paratracheal (4)
* Subcarinal (7) - only if they poke up above the carina

== Contraindications ==

* Absolute
** Contraindication to GA
** Extreme kyphosis
** Cutaneous tracheostomy after laryngectomy

== Technique ==

* Positioning
** ETT positioned left corner of mouth
** Neck in hyperextension with shoulder roll
** Drape to allow median sternotomy
** Surgeon stands/sits behind patient's head
* 2-3cm transverse incision, one fingerbreadth above the manubrium
* Separate pre-tracheal muscles vertically in the midline, to expose the anterior surface of the trachea, while the isthmus of the thyroid is retracted superiorly. Expose trachea and pre-tracheal fascia incised, to allow that pre-tracheal plane to continue down into the mediastinum
* Blunt dissection in pre-tracheal plane using index finger (stay right on the trachea)
** Palpate for pre-tracheal nodes (easier to feel them than see them)
** Aortic arch to patient's left and innominate artery passing across the top of the operative field
** Develop plane as far down as carina
**
* Insert mediastinoscope, staying right on trachea or main-stem bronchi at all times to avoid vascular injury
* Identify right and left mainstem bronchi, and then systematically dissect the subcarinal space, the ipsilateral paratracheal space, and the contralateral paratracheal space
**
* Biopsy nodal stations as needed
** Generally save subcarinal for last as it bleeds the most
* Closure
** Approximate strap muscles
** Drain usually not required
** Obliterate dead space if needed
** Close skin

== Complications ==

* Bleeding
** Most frequently small bronchial arteries running across the subcarinal region
** More serious bleeding from azygos or RUL branch of PA
** Injury to aorta or innominate artery may require sternotomy
* Injury to left RLN
* Injury to oesophagus or trachea

[[Category:Thoracics]]