subject: Mediastinoscopy and mediastinotomy [print this page] These techniques are mainly used to diagnose and stagebronchogenic carcinoma, but occasionally are required toconfirm other malignancies (e.g. lymphoma) or to diagnosethe causes of adenopathy (e.g. sarcoidosis or tuberculosis).At mediastinoscopy an incision is made above thesuprasternal notch, the tissues anterior to the trachea aredissected and the mediastinoscope is inserted. Hilar, subcarinaland paratracheal nodes can be inspected, biopsiedor removed. The involvement of mediastinal nodes inbronchogenic carcinoma is common (40% of all cases) anda positive diagnosis is achieved in sarcoidosis in more than80% of cases.
Mediastinotomy is occasionally required to evaluateareas of the mediastinum not accessible at mediastinoscopy, particularly the subaortic fossa on the left side,and most commonly the surgeon gains access through thesecond left costal cartilage.The development of CT scanning has reduced the need for mediastinoscopy and mediastinotomy. In carcinoma ofthe bronchus a CT scan which demonstrates a normalmediastinum obviates the need for surgical evaluationprior to thoracotomy. However, if the CT scan demonstrates adenopathy, such an evaluation may still berequired to confirm that the nodes are involved by tumourand are not enlarged due to reactive hyperplasia.
Thoracoscopy
The development of video-assisted thoracoscopy hasresulted in a great increase in 'keyhole' thoracic surgery.
Open lung biopsy
Open lung biopsy is most commonly undertaken fordiffuse interstitial lung disease, atypical tumours and,occasionally, serious pulmonary infections. A limited submammarythoracotomy allows biopsy of the anterior segmentsof all lobes, as well as inspection of the pleura andmediastinum. Complications (approximately 5%) includeinfection and chronic pneumothorax, and there is a smallmortality (less than 4%), reflecting for the most part theserious nature of the underlying illness in many of thepatients. For peripheral lesions in the lung, or diffuse lungabnormalities, thoracoscopic minimally invasive techniquesallow access not just to the pleura but to the under lying lung.
