What is mediastinal surgery?
Mediastinal surgery includes several different types of procedures, which are used to biopsy or remove abnormal growths that form in the area that separates the lungs in the middle of your chest. This area, called the mediastinum, is surrounded by the breastbone in front, the spine in back, and the lungs on each side. The mediastinum contains the heart, aorta, esophagus, thymus and trachea.
Mediastinal tumors are mostly made of reproductive (germ) cells or develop in neurogenic (nerve), lymphatic, or mesenchymal (soft) tissue. In some cases, such as myasthenia gravis, the mass is caused by an increase of thymus cells, called thymic hyperplasia.
Why is mediastinal surgery needed?
Due to their location in the mediastinum, mediastinal tumors (both benign and malignant) that are left untreated can cause serious complications, including invading the heart, pericardium (the lining around the heart), and great vessels (the aorta and vena cava.) Tumors located in the posterior (back) mediastinum can cause compression of the spinal cord. A thorough evaluation and diagnosis of each mass are necessary for the best surgical outcome.
Who is a candidate for mediastinal surgery?
While the determination for surgery is based on each patient’s particular medical situation, patients diagnosed with cancerous tumors or with tumors that are invading the area surrounding the mediastinum are most likely to be candidates for mediastinal surgery.
What tests are performed before mediastinal surgery?
A pre-surgical evaluation that includes a complete physical exam and medical history evaluation will be performed to make sure that mediastinal surgery is the right treatment for you. In general, preoperative tests may include:
- Chest x-ray
- Computed tomography (CT) scan of the chest or CT-guided needle biopsy
- Magnetic resonance imaging (MRI) of the chest
Your surgeon will determine if additional preoperative tests are needed, based on the type of procedure that will be performed.
In addition to pre-surgical tests, you may meet with several health care providers, including your surgeon, who will ask questions about your condition and health history.
Prior to mediastinal surgery, your thoracic surgeon may recommend that a biopsy be performed to diagnose the type of mass or tumor.
A biopsy is the removal of a sample of tissue for examination. The tissue that is removed is examined by a pathologist, a physician who specializes in examining tissue and cells under a microscope, for a diagnosis. The following biopsy procedures may be performed:
- Percutaneous biopsy – Performed by a radiologist, this procedure is completed through a computed tomography (CT)-guided needle biopsy while the patient is awake. During the procedure, a needle is placed through a small incision between the ribs to remove a sample of the mass.
- Mediastinoscopy with biopsy – Performed under general anesthesia, mediastinoscopy is a minimally invasive method to examine the chest cavity. A lighted tube is inserted through a small incision under the chest bone and a sample of tissue is taken to determine if cancer or other tissue abnormality is present. Mediastinoscopy with biopsy allows doctors to accurately diagnose 95 to 100 percent of mediastinal tumors.
- Thoracoscopic mediastinal biopsy – A procedure performed in the operating room under general anesthesia, this procedure uses video-assisted technology to minimize trauma. A thoracoscope (small video-scope) and special instruments are inserted through small incisions between the ribs to examine the mass and to guide the removal of a small piece of tissue for examination.
- Mediastonotomy (Chamberlain procedure) – Used for masses that are not accessible through a mediastinoscopy, a mediastonotomy is performed under general anesthesia in the operating room. A small incision is made next to the sternum (breastbone) to approach and remove a small piece of the mass for examination.
After completing a thorough evaluation and diagnosis, your thoracic surgeon will determine the safest surgical approach to treat your medical condition. While some types of mediastinal tumors and lymphomas (cancerous growths) usually respond best to medical treatments such as chemotherapy or radiation, other types of masses, including neurogenic tumors or thymomas, may be best managed with surgery.
Surgery approaches to remove mediastinal tumors or masses include:
- Sternotomy – A traditional open-surgery approach that uses an incision to divide the breast bone to resect or remove large mediastinal masses or tumors. A sternotomy allows access to the entire chest cavity including the heart, great vessels and lungs, and may be necessary for larger tumors and masses.
- Thoracotomy – A traditional open-surgery approach that uses an incision to divide the ribs to resect or remove large mediastinal masses or tumors. Similar to a sternotomy, this procedure allows access to the entire chest cavity and enables the thoracic surgeon to safely and effectively remove the tumors or masses.
Minimally Invasive Surgery
While sternotomies and thoracotomies are commonly used to treat larger mediastinal masses, a mediastinoscopy or videothoracoscopy may be used to treat smaller mediastinal tumors.
Minimally invasive surgical techniques decrease postoperative pain, reduce the length of stay in the hospital, and allow a more rapid recovery and return to work and regular activities. Other possible benefits include reduced risk of infection and less bleeding.
Minimally invasive approaches include:
Video-assisted thoracoscopy is a procedure that uses video-assisted technology to minimize trauma. This procedure is performed in the operating room under general anesthesia. A thoracoscope (small video-scope) is inserted through a small incision between the ribs to view the mass. Special instruments are inserted through two other small incisions to remove the mass.
While thoracoscopic surgery offers benefits over the more traditional sternotomy or thoracotomy procedures, video-assisted techniques are most successful when completed by advanced thoracoscopic and minimally invasive thoracic surgeons.
What are the risks of mediastinal surgery?
There are risks of any surgical procedure, including mediastinal surgery. However, the rate of complications from mediastinal surgical procedures is low, with various mediastinoscopy studies reporting overall complication rates of 1.3 to 3 percent.
How long will it take to recover from mediastinal surgery?
Patients who had minimally invasive mediastinal surgery may be able to go home 1 to 2 days after surgery. Patients who had a sternotomy or thoracotomy may be able to go home 3 to 5 days after surgery.
Your thoracic surgery team will follow your progress and help you recover as quickly as possible. During your recovery, you and your family will receive updates about your progress so you’ll know when you can go home.
You will receive specific instructions for your recovery and return to work, including guidelines for activity, driving, incision care and diet. If minimally invasive surgery was performed, you may be able to return to work within 3 to 4 weeks after surgery.
A follow-up appointment will be scheduled 7 to 10 days after your surgery. Your surgeon will assess the wound sites and your recovery at this follow-up appointment and provide guidelines about your activities and return to work.
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