Ann Thorac Surg 1998;66:1427-1428
© 1998 The Society of Thoracic Surgeons
How To Do It
Subxiphoidal videomediastinoscopy for diagnostic access to the anterior mediastinum
Joerg Hutter, MDa,
Werner Junger, MDa,
Karl Miller, MDa,
Erich Moritz, MDa
a Second Department of Surgery, Landeskrankenanstalten Salzburg, Salzburg, Austria
Accepted for publication May 27, 1998.
Address reprint requests to Dr Hutter, Second Department of Surgery, Landeskrankenanstalten Salzburg, Müllnerhauptstr 48, 5020 Salzburg, Austria
e-mail: (j.hutter{at}lkasbg.gv.at)
 |
Abstract
|
|---|
Access to the anterior mediastinum from the epigastric region through the retrosternal space, performed with a videomediastinoscope, is described. The method can be used to release the lower lobes of the thymus in transcervical thymectomy as well as for the diagnosis of retrosternal masses of uncertain origin on either side of the anterior mediastinum.
|
Introduction
|
|---|
Besides sternotomy, various techniques of access to the anterior mediastinum have been described in the recent literature. Although the technique was first described by Specht [1] in 1965, the term "extended cervical mediastinoscopy" was coined by Kirschner [2] in 1971. Kirschner described an access to the anterior mediastinum for obtaining biopsy specimens. The inadequate exposure, poor cosmetic appearance, and morbidity associated with the standard Chamberlain technique (parasternal mediastinotomy) introduced in 1966 [3] led surgeons to further develop the procedure.
Anterior (parasternal) mediastinoscopy was reported by Jolly and associates [4] in 1980. Ginsberg and colleagues [5] reported their experience with extended cervical mediastinoscopy as a method of staging lung cancers of the left upper lobe, primarily for detecting lymph nodes in level V (subaortic) and level VI (anterior mediastinal). In recent literature, thoracoscopy [6, 7] was found to be useful for the diagnosis and treatment of anterior mediastinal disorders. Here we describe subxiphoidal retrosternal mediastinoscopy.
|
Technique
|
|---|
The patient is in the supine position on the operating table, as for standard median sternotomy. General anesthesia is induced and the patient is intubated with a single-lumen endotracheal tube. An inflatable pillow placed under the thoracolumbar junction elevates the epigastrium and facilitates access to the retrosternal space.
Through a longitudinal 4-cm incision near the xiphoid, the surgeon’s index finger perforates the white line of the abdomen to create a tunnel into the retrosternal space without opening the abdominal cavity. After blunt dissection with the finger or a peanut dissector, the videomediastinoscope is introduced into the anterior mediastinum. Between the heart and the body of the sternum, the region behind the manubrium sterni is approached under direct videoscopic vision (Fig 1).
We evaluated the feasibility of this technique in patients with a normal thymus in the setting of myasthenia gravis. The patients were intended to undergo consecutive sternotomy. We were able to obtain access to all regions of the anterior mediastinum, especially the lower lateral lobes of the thymus for blunt dissection and diagnostic biopsy. Before the sternotomy the regions of interest were stained with methylene blue, and the findings were confirmed by performing a standard median sternotomy.
|
Comment
|
|---|
Before the videomediastinoscope was developed (ETB; Endoskopische Technik GmbH Berlin, Germany; usable length, 19 cm), the variable length of the sternum did not permit access to and viewing of all parts of the upper anterior mediastinum with a standard mediastinoscope (eg, Storz mediastinoscope with a usable length of 13 cm and 17 cm, Wolf mediastinoscope with a usable length 14 cm) from a subxiphoidal incision.
One indication for this access is to release the lower lobes of the thymus in transcervical thymectomy. In this setting the technique permits total thymectomy without the necessity to perform a sternotomy or thoracoscopy. Further indications are diagnosis of anterior mediastinal masses suggestive of lymph node metastases, lymphoma, or other hematopoietic disorders (germ cell, seminoma) on either side of the anterior mediastinum. The advantages of the method are (1) minimal trauma and (2) access to both sides of the mediastinum by a single incision under magnification through the videoscope. Although the setting for these indications might be rare, the procedure warrants further clinical evaluation in larger series of patients.
|
Acknowledgments
|
|---|
We thank Nikolaus Lechenbauer for drawing the illustration.
|
References
|
|---|
- Specht G. Erweiterte Mediastinoskopie. Thoraxchirurgie 1965;13:401-407.
- Kirschner P. Extended mediastinoscopy. In: Jepson O., Ruhbek-Sorensen H., eds. Mediastinoscopy. Odense, Denmark: Odense University Press, 1971.
- McNeill T.M., Chamberlain J.M. Diagnostic anterior mediastinoscopy. Ann Thorac Surg 1966;2:532-539.[Medline]
- Jolly P.C., Li W., Anderson R.P. Anterior and cervical mediastinoscopy for determining operability and predicting resectability in lung cancer. J Thorac Cardiovasc Surg 1980;79:366-371.[Abstract]
- Ginsberg R.J., Rice T.W., Goldberg M., et al. Extended cervical mediastinoscopy: a single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1987;94:673-678.[Abstract]
- DeCamp M.H., Jaklitsch M.T., Mentzer S.J., et al. Safety and versatility of videothoracoscopy: a prospective analysis of 895 cases. J Am Coll Surg 1995;181:113-120.[Medline]
- Landreneau R.J., Dowling R.D., Castillo W.M., Ferson P.F. Thoracoscopic resection of an anterior mediastinal tumor. Ann Thorac Surg 1992;54:142-144.[Abstract]
This article has been cited by other articles:
|
|
|
|
 
C. Medrano, S. R. Hazelrigg, R. J. Landreneau, T. M. Boley, T. Shawgo, and A. Grasch
Thoracoscopic resection of ectopic parathyroid glands
Ann. Thorac. Surg.,
January 1, 2000;
69(1):
221 - 223.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
