BACKGROUND
An anterior mediastinotomy is performed through a transverse incision in the second intercostal space (ICS). It allows biopsy of mediastinal tumours or enlarged lymph nodes, in particular nodes found in the aortopulmonary window (APW; Figs 1 and 2 [insert]). Video-assisted thorascoscopy (VATS) ‘keyhole’ procedures have dramatically changed thoracic surgical practice. Its role in biopsying mediastinal masses and nodes is well recognised but not universally practised as many surgeons prefer the standard open approaches.1
Figure 1.
Chest computed tomography showing enlarged lymph node adjacent to the aortic arch in the aortopulmonary window.
Figure 2.
Illustration showing position of patient, incision site and placement of VATS, with insert showing vascular structures and target lymph nodes.
TECHNIQUE
The ‘hybrid’ approach requires double-lumen endotracheal intubation allowing for single lung ventilation and collapse of the left lung. The patient is positioned supine with a sandbag under the left shoulder to tip the patient to the right. A 4–5 cm transverse incision is made anteriorly at the second ICS. A second 1-cm incision is made in the fourth ICS lateral to pectoralis major. The VATS camera is positioned to allow for a clear view of the APW (Fig. 2). The surgeon can safely identify and biopsy nodes with the aid of the monitor by passing long instruments through the mediastinotomy incision. At the end of the procedure, the access port can be used to place a chest drain.
DISCUSSION
This simple modification of a standard approach to mediastinal biopsy allows for a smaller anterior incision; gives the surgeon an improved view for safe and accurate biopsy and the opportunity to develop thoracoscopic skills.
References
- 1.Martigne C, Velly JF, Clerc P, Zanotti L, Couraud L. Value and current role of anterior mediastinotomy in the diagnosis of mediastinal diseases. Apropos of a series of 100 cases. Ann Chir. 1989;43:171–3. [PubMed] [Google Scholar]