glass cannula for puncture test may be connected to a syringe to puncture and aspirate lymph nodes. This is especially useful when the nodes are fxed to vessels. In this case, pulling or taking biopsies from the nodes may injure the attached vessel. The aspirate is then sent for cytological examination.

The paratracheal muscles are not sutured to the midline. This facilitates remediastinoscopy, if it is needed. The incision is closed in two layers: platysma and subcutaneous tissue together with 2-0 continuous absorbable suture, and skin with 3-0 absorbable intradermal suture. Drainage is not necessary. The wound is dressed with gauze that can be removed in 24 h.

Postoperative Care

The patient is awakened and extubated in the operating room, and sent to recovery room till the patient is fully conscious and the vital constants are normal and stable. Then the patient is transferred to the normal ward or to the outpatient surgery room. Oral intake is started 6 h after the operation. The patient can be discharged on the same day, if an outpatient surgery programme is active in the hospital, or next day. The admission rate after outpatient mediastinoscopy for all indications ranges from 1 to 4%, and the main reasons are supraventricular arrhythmias, pneumothorax, bleeding from bronchial artery, or late end of the operation [33]. Postoperative chest x-rays are not necessary unless something unusual has occurred during (opening of the mediastinal pleura or bleeding) or after surgery (fever, dyspnoea or chest pain).

Complications

Intraoperative complications are infrequent, ranging from 0.6% to 3.7% [34, 35]. The occlusion of the innominate artery and bleeding from the most common sites have been described above. Other complications are wound infection, pneumothorax, mediastinitis, left recurrent laryngeal nerve palsy, oesophageal perforation, bron-

chial injury, chylomediastinum, haemothorax and incisional metastasis [36–41]. Mortality is below 0.5% [4, 42, 43].

Technical Variants

Technical variants of mediastinoscopy have been devised over the years to reach mediastinal locations beyond the range of the standard exploration and to expand the possibilities of this transcervical approach.

Extended Cervical Mediastinoscopy

Subaortic and para-aortic nodal stations cannot be reached with mediastinoscopy. Left parasternal mediastinotomy, performed over the second or third intercostal space, facilitates the exploration of this area, but requires an additional incision and very often the removal of a costal cartilage [44, 45]. In 1987, Ginsberg et al. [46] reported their experience in extended cervical mediastinoscopy as a staging procedure for cancers of the left upper lobe, using the approach frst described by Specht in 1965 [47]. To stage cancers of the left lung, after mediastinoscopy has been completed and from the same cervical incision, a passage is created by fnger dissection over the aortic arch, between the innominate artery and the left carotid artery, either in front or behind the left innominate vein. Once the fascia between these two vessels is torn with the fnger, the fnger can be advanced easily over the aortic arch. Then, the mediastinoscope is inserted and the lymph nodes in the subaortic station can be explored and biopsied. By moving the mediastinoscope medially, the para-aortic nodes also can be explored, although differentiating between subaortic and para-aortic nodes is not easy because mobilization of the mediastinoscope is limited by the bony structures of the chest wall. Extended cervical mediastinoscopy does not allow the surgeon to palpate the subaortic space well. If palpation is needed to differentiate between mere contact and tumour invasion in this area, then parasternal mediastinotomy is a much better approach. The para-

Fig. 27.8  Bimanual palpation from the collar incision of mediastinoscopy (blue arrow) and the left parasternal mediastinotomy (yellow arrow)

sternal incision allows the surgeon to inspect the subaortic space directly, but the mediastinoscope can also be used to facilitate the exploration. Additionally, a small rib spreader can be inserted to widen the operative feld. Bimanual palpation from the collar incision and from the parasternal incision is useful to explore the integrity of the aortic arch (Fig. 27.8). Access to the pericardium, pleural space and lung is also possible from this incision. Right parasternal mediastinotomy is useful to assess the superior vena cava, the azygos vein, the right pulmonary artery, the right superior pulmonary vein and the right anterior mediastinal nodes [48].

The European Society of Thoracic Surgeons guidelines recommend the exploration of the subaortic and para-aortic lymph nodes in left-­ lung cancers [19]. The extended cervical mediastinoscopy can be performed with no additional incisions, does not require a chest tube and is not limited by pleural adhesions, which are advantages over parasternal mediastinotomy and thoracoscopy. Its yield is highest when there are abnormal nodes by CT and/or PET in the subaortic space: sensitivities of 0.44 and 0.76 for routine (all cases regardless of the CT and/or PET fndings) and selective (abnormal CT and/ or PET) indications, respectively, have been reported [49].

Mediastinoscopic Biopsy of Scalene Lymph Nodes

From the cervical incision of mediastinoscopy, the mediastinoscope can be passed under the insertions of the sternocleidomastoid muscle on one or both sides of the neck to reach the scalene lymph nodes. There is one publication on this technique, only, but the reported results are clinically relevant: 15% of patients with N2 disease and 63% of those with mediastinal N3 diagnosed at mediastinoscopy had subclinical N3 disease in the scalene lymph nodes [50]. These results have to be taken into account when selecting patients for clinical trials on N2 disease.

Inferior Mediastinoscopy

The mediastinoscope is inserted into the antero-­ inferior mediastinum from a subxiphoid approach. Although this is rarely needed, inferior mediastinoscopy is useful to explore mediastinal lesions beyond the reach of mediastinoscopy [51, 52]. The opening of the pericardium and the insertion of the mediastinoscope into the pericardial space allow the surgeon to perform a subxiphoid pericardioscopy, which is useful to diagnose pericardial effusions and establish the anatomic extent of locally advanced cancers [53].

Mediastino-Thoracoscopy

From the superior mediastinum, at the time of mediastinoscopy, the mediastinal pleura can be opened and the pleural space, explored. On the right side, this can be performed either between the trachea and the superior vena cava or between the superior vena cava and the anterior chest wall. On the left, the supra-aortic approach is the most direct one, as used for extended cervical mediastinoscopy. Single-lung ventilation facilitates the exploration of the pleural space in patients with pleural effusion, lung nodules, parietal pleura nodules and diaphragmatic and pericardial lesions. If the target lesions cannot be reached with the mediastinoscope, a thoracoscope can be passed through it; by doing so, even the diaphragm can be reached. Pleurodesis also can be performed through this approach [54, 55]. The two-bladed video-mediastinoscopes also allow the insertion of endoscopic staplers to perform

Fig. 27.9  Mediastino-thoracoscopy. (a) The mediastinal pleura is opened by endoscopic scissors. (b) View of the right lung through the incision of the mediastinal pleura. (c) Exploration of the pleural space with single-lung ven-

tilation. Pleural effusion of clear uid is identifed and it is suctioned with suction cannula. (d) Small bore chest tube is inserted with endoscopic forceps

wedge resections of the lung in case of lung cancer and additional peripheral lung nodules [56] (Fig. 27.9).

Transcervical Mediastinal

Lymphadenectomies

Video-Assisted Mediastinoscopic Lymphadenectomy

Video-assisted mediastinoscopic lymphadenectomy (VAMLA) is a very thorough mediastinoscopy with the objective to remove the upper mediastinal lymph nodes. It is performed with the two-bladed video-mediastinoscope through

the standard collar incision for mediastinoscopy. A holder can be used to fx the video-­ mediastinoscope so that the surgeon can work with two hands, holding the specimen with a forceps with one hand and the dissector with the other. The subcarinal and the right inferior paratracheal lymph nodes are removed en bloc with the mediastinal fatty tissue. Those located in the left inferior paratracheal station are removed one by one to prevent injury of the left recurrent laryngeal nerve [10, 11]. VAMLA can be com-

(Fig. 27.10). As with mediastinoscopy, it can also be combined with transcervical thoracos-

Fig. 27.10  Video-assisted mediastinoscopic lymphadenectomy (VAMLA). (a and b) The surgeon can work with two hands because the video-mediastinoscope is fxed by an articulated holder. (c) View of the subcarinal space after removing all subcarinal lymph nodes. Black arrows

show the oesophagus completely dissected. (d) View of the right mediastinal pleura after removing the right inferior paratracheal lymph nodes en bloc with the mediastinal fatty tissue. Black arrows show the superior vena cava. Green star shows the mediastinal pleura

copy to explore the mediastinum and the pleural space in the same procedure and through the same incision [58].

Adhesion to the standardized technique and anatomic limits is important in VAMLA to avoid complications. The subcarinal space is explored frst. The fatty tissue containing nodes is dissected off the margins of the main bronchi and the carinal angle. Once this is done, the bloc is grasped with forceps on one side and its dissection is continued towards the other using the dissection-­suction-coagulation cannula, endoscopic scissors or energy devices. The bloc has to be freed from the adhesions that keep it attached to both main bronchi, laterally, to the pulmonary arteries, anteriorly, and to the oesophagus, posteriorly. During this manoeuvre, clipping of the bronchial artery that usually runs anterior to the left main bronchus may be necessary, if coagulation is not enough to control bleeding around this bloc of fatty tissue and lymph nodes. Once the bloc is removed, the oesophagus protrudes ante-

riorly. A wet gauze is left in the subcarinal space for haemostasis while the procedure is continued in other nodal stations.

On the right paratracheal nodal station, dissection is started from the inferior margin of the innominate artery. The bloc of fatty tissue and lymph nodes is detached from the mediastinal pleura and the superior vena cava and moved medially and caudally towards the azygos vein. This manoeuvre can be facilitated by fnger dissection or by inserting a gauze and pushing it caudally. Finally, the bloc is detached from the ascending aorta with coagulation, scissors or energy devices. It is important to remove the nodes that are located anterior to the trachea between the ascending aorta and the superior vena cava. They can pass unnoticed, hidden by the mediastinoscope. On this side, the procedure can be completed with the exploration of the right hilar nodes, that is, those caudal to the inferior margin of the azygos vein around the right main bronchus.