Mediastinotomy

One of the procedures of thoracic surgery is mediastinotomy (Latin mediastinum - mediastinum  ₊  Greek tome - section), which consists in opening direct access to the anatomical structures located in the central parts of the chest cavity.

Indications for the procedure

A direct approach involves an incision (surgical incision, tissue dissection), and a mediastinotomy is an incision in the upper chest, resulting in a small opening leading to the  mediastinum .

The main indications for this surgical procedure are related to diagnosis. Firstly, it is the need to visualize pathological formations and lymph nodes using an endoscope inserted into the mediastinal space or palpation by a doctor. And this procedure is called mediastinoscopy. [1]

Secondly, this is a histological (morphological) study of tissues - a biopsy, for which it is necessary to take its sample (biopsy). Only a biopsy makes it possible to determine the nature of the neoplasms of the mediastinum, and its implementation by the method of transthoracic aspiration is far from always successful. [2]

Thus, mediastinotomy may be necessary for histological confirmation of the diagnosis or identification of suspected diseases and suspected pathological conditions, including:

• lung cancer - specifying the stage, degree of metastases to the lymph nodes and tumor resectability (in accordance with the generally accepted nomenclature of lymph node involvement - staging map MD-ATS);
• lymphomas localized in the mediastinum (lymphoblastic, T-cell, Hodgkin's);
• bronchogenic carcinoma;
• an increase in the lymph nodes of the mediastinum  (which may indicate a malignant neoplasm);
• sarcoidosis of the lungs ;
• expansion of the mediastinum of unknown etiology;
• purulent  mediastinitis ;
• hyperplasia and swelling of the thymus (thymus gland);
• neurogenic tumors localized in the paravertebral (paravertebral) sulcus.

In addition, the mediastinotomy access is performed for resection of the affected lymph nodes, as well as treatment (by removing suppuration and drainage) of the mediastinal abscess and infections of the pharyngeal space, which often spread to the mediastinum - to its anterior and posterior parts. [3]

Through a mediastinotomy in the neck area, the thymus gland is removed - transcervical thymectomy, and an anterior mediastinotomy is used to insert pacemaker electrodes.

Preparation

This procedure is carried out in a planned manner, and preparation for it consists in the delivery of a general clinical blood test and a coagulogram. Mediastinotomy is performed under general anesthesia (intubation), so patients undergo electrocardiography.

Also, a preoperative CT scan or positron emission tomography (PET) of the chest is done to clarify the individual characteristics of the location of the anatomical structures of the mediastinum, determine metastases (if the patient has a malignant neoplasm) and select the optimal technique for performing in accordance with the diagnosis (established or assumed). [4]

It is recommended not to take anticoagulants and non-steroidal anti-inflammatory drugs a week before the procedure, and stop eating 6-10 hours before it.

Technique of the mediastinotomy

There are several basic techniques for surgical opening of direct access to the mediastinum.

Anterior or parasternal mediastinotomy: a small transverse incision is made in the upper left peri-sternal region, above the second intercostal space, with costal cartilage resection. This opens up access to the extrapleural space (aortopulmonary window) and areas of the anterior mediastinum below the aortic arch. And to assess the condition of the right-sided, anterior mediastinal or hilar lymph nodes, an anterior approach can be performed in the upper right parasternal zone. [5]

After carrying out all the necessary manipulations, the incision is sutured in layers with a bandage.

Cervical mediastinotomy - suprasternal cervical mediastinotomy according to Razumovsky or collar, that is, colar mediastinotomy - is performed by a transverse incision above the sternum - along the sternocleidomastoid muscle to the anterior surface of the trachea, parallel to the edge of the suprasternal (jugular) fossa. The superficial fascia and the superficial leaflet of the own fascia of the neck are dissected, the sternohyoid and sterno-thyroid muscles are pushed apart, and the deep leaf of its own fascia is exfoliated (using a finger or a blunt instrument), entering the slit-like space with loose fiber and moving downward - directly into the anterior part mediastinum. [6]

Posterior mediastinotomy is most often performed to the right of the spine - to the side of the paravertebral muscles.

Contraindications to the procedure

Mediastinotomy is contraindicated in patients with a history of:

• aneurysm or dissection of the ascending aorta;
• radiation therapy in the mediastinal area;
• surgical operations with dissection of the sternum (sternotomy).

Superior vena cava syndrome is considered a relative contraindication; a significant increase in the thyroid gland (goiter); a history of mediastinitis; previously performed mediastinoscopy and tracheostomy. [7]

Complications after the procedure

Mediastinotomy can be complicated by bleeding, difficulty swallowing, and infection and inflammation - with tissue redness and swelling. Infection can be accompanied by fever and the formation of an inflammatory infiltrate, which, when enlarged, can compress the aorta or pulmonary artery.

During the procedure, damage to the recurrent nerves of the larynx is possible, which is manifested by hoarseness (passing over time). [8]

Obesity, diabetes, smoking, and excessive alcohol consumption increase the risk of complications.

There are such possible consequences after the mediastinotomy and mediastinoscopy procedure, such as:

• pneumothorax (if the pleura is damaged and air enters the pleural cavity);
• chylothorax (leakage of lymphatic fluid into the chest when the thoracic lymphatic duct and pleura are damaged);
• damage to the chest organs - perforation of the trachea or esophagus;
• shortness of breath and paralysis of the diaphragm (in case of irritation or damage to the phrenic nerve of the cervical plexus).

Care after the procedure

Depending on the goals of the mediastinotomy and the diagnosis, the duration of the procedure ranges from 30 minutes to two hours.

After its completion - if there are no complications - patients are in a hospital for 24-48 hours. Post-procedure care includes hardware monitoring of respiration, pulse and heart rate, and body temperature monitoring. For severe pain, analgesics or NSAIDs are used. [9]

At home, according to the instructions given by the doctor, you should follow the rules of antiseptics and monitor the cleanliness of the dressing. Until the suture at the site of the incision has healed, taking a hot bath, increased physical activity and any sports activities are contraindicated. [10]

Reviews

Mediastinotomy with biopsy can provide important information about lung and chest diseases that cannot be obtained with other methods. And the reviews of oncologists confirm the importance of histological confirmation of the regional nodal spread of a malignant lung tumor performed during mediastinotomy with mediastinoscopy - for choosing the most adequate treatment strategy.