Surgical exploration of the mediastinum by mediastinoscopy, parasternal mediastinotomy and remediastinoscopy: indications, technique and complications.

Imaging diagnostics often fail to provide enough certainly to make therapeutic decisions, since radiological images do not always correlate well with the pathological condition of the lesions. Surgical exploration of the mediastinum by mediastinoscopy allows to obtain very accurate information from inspection, palpation and biopsies of lymph nodes or tumors directly affecting the mediastinum. Mediastinoscopy assesses the upper mediastinum, including nodal stations 1, 2R, 2L, 3, 4L, 7, 10R and 10L. It can also assess direct invasion of the mediastinum from adjacent tumors. Parasternal mediastinoscopy is a complementary technique to reach nodal stations 5 and 6, which cannot be reached with standard cervical mediastinoscopy. Remediastinoscopy has been performed to restage tumors after delayed treatment and to stage second primary and recurrent tumors. It has proved useful, too, to restage N2 lung cancer after induction chemotherapy. In all these indications, remediastinoscopy was technically possible. All these techniques are associated with very few complications (around 3%) and a low mortality rate of less than 1%.