Cervical mediastinoscopy is a safe and effective procedure to diagnose mediastinal diseases and to stage lung cancer.1 Complications are rare, ranging from less than 1% to 4%.2–9 The most serious complication is bleeding from great vessels. This complication and its management have been described in the literature. Its rate ranges from <1% to 1%.4–7,9 However, injuries to the tracheobronchial tree seem to be exceptional and have seldom been reported.3,6–9 We present 2 cases of mediastinoscopic injury of the right main bronchus and their mediastinoscopic repair, thus avoiding thoracotomy.
A 67-year-old man with a 2 cm central nodule in the left upper lobe suspicious for bronchogenic carcinoma underwent diagnostic and staging videomediastinoscopy. Hard peritracheal and peribronchial adhesions were found. The anterior surface of the trachea and the left main bronchus were freed from adhesions with the blunt-tipped suction tube and bipolar scissors. While dissecting the anterior surface of the right main bronchus with the bipolar scissors, inadvertently a 1 cm long bronchial tear took place (Fig. 1A). The 2-valve videomediastinoscope (Wolf, Richards Wolf Company, Knittlinger, Germany) allowed enough room to close the hole with two 2-0 absorbable sutures (Fig. 1B). Fibrin glue was spread over the suture line (Fig. 1C). No postoperative complications, such as pneumomediastinum, pneumothorax or mediastinitis occurred. All biopsied nodes were negative. Twenty days later, a left upper lobectomy with systematic nodal dissection was performed uneventfully. Pathologic report was pT1N0M0 papillary squamous cell carcinoma.
A 66-year-old man underwent repeat videomediastinoscopy for restaging lung cancer of the right upper lobe after induction chemoradiation for cT2N2M0 adenocarcinoma. Hard peritracheal and peribronchial adhesions were found due to the previous videomediastinoscopy. While dissecting the anterior surface of the right main bronchus with the bipolar scissors, inadvertently a 0.3 cm long tear occurred (Fig. 2A). The borders of the injury closed tightly and suture was considered unnecessary. Tachosil (Nycomed, Austria GmbH) was applied on the injury as the only therapeutic procedure (Fig. 2B). No postoperative complications occurred. Remediastinoscopy revealed persistent N2 disease and the patient received definitive chemoradiation.
From January 1990 to December 2007, we performed 1743 surgical explorations of the mediastinum, including standard mediastinoscopies or videomediastinoscopies, repeat videomediastinoscopies, extended cervical videomediastinoscopies, and mediastinotomies. The rate of tracheobronchial injury was 0.1% (2 of 1743), similar to the reported rates in series of around 2000 cases,6 and lower than the rate of smaller series,5,9 which is around 0.5%.
Six cases of tracheal injury have been reported3,6,7,9 in the revised literature. However, only 1 case of injury to the right bronchial tree (bronchus intermedius) has been previously described.8 Prior radiotherapy to the mediastinum, prior mediastinal surgery, and a previous mediastinoscopy may increase the risk of complications.5,6 In case 1, the patient had no relevant past medical history, but there were hard peritracheal adhesions that are not usually found at first mediastinoscopy. In case 2, the expected adhesions secondary to prior mediastinoscopy were found. So, in both cases, peritracheal adhesions played their role in complicating the surgical procedure. Additionally, both injuries were caused by the use of the bipolar scissors. Bipolar scissors are useful to section thick adhesions that are difficult to manage with the suction-coagulation-dissector device, especially during repeat mediastinoscopy. In these 2 cases, we feel that adhesions prevented us from recognizing the limit of the bronchial wall, and the sharp tip of the scissors injured the bronchus. This type of injury is different from those previously described at mediastinoscopy. The injuries reported by Schubach et al8 were caused by the biopsy forceps, and those described by Puhakka,6 by the mediastinoscope itself.
Reported mediastinoscopic tracheobronchial injuries have been treated in 3 different ways. In the 3 cases of injuries on the anterior surface of the trachea, reported by Puhakka,6 hemostatic tissue was applied over the injury. This is how we treated the right main bronchus injury in case 2. This was a 0.3 cm injury, predictably not much bigger than those caused by a biopsy forceps. So, conservative management of these small injuries seems advisable. On the other hand, the injury at the tracheal bifurcation reported by Pereszlenyi et al7 and the injury at the bronchus intermedius described by Schubach and Landreneau8 required thoracotomy. In case 1, the injury on the anterior surface of the right main bronchus was 1 cm long, but was amenable to suture through the mediastinoscope, thus avoiding thoracotomy. This was possible because the 2-valve videomediastinoscope allows spreading the valves, providing a wider operative field that, in our case, was large enough to suture the injury with endoscopic needle holder. Finally, the injury at the right tracheobronchial angle reported in the review by Kirschner3 was successfully treated with a combination of hemostatic gauze tamponade followed by thoracotomy 48 hours later.
In conclusion, mediastinoscopic repair of small bronchial injuries caused by bipolar scissors during mediastinoscopy is worth trying, either by application of sealants or by direct suture, before relying on thoracotomy.
1. Rami-Porta R, Mateu-Navarro M. Videomediastinoscopy. J Broncol. 2000;9:138–144.
2. Foster E, Munro D, Dobell A. Mediastinoscopy. A review of anatomical relationships and complications
. Ann Thorac Surg. 1972;13:273–286.
3. Kirschner P. Cervical mediastinoscopy. Chest Surg Clin N Am. 1996;6:1–20.
4. Martín de Nicolás JL, García Barajas S, Marrón C, et al. Complicaciones técnicas de la exploración quirúrgica del mediastino en la estadificación del cáncer de pulmón. Arch Bronconeumol. 1999;35:390–394.
5. Park BJ, Flores R, Downey RJ, et al. Management of major hemorrhage during mediastinoscopy. J Thorac Cardiovasc Surg. 2003;126:726–731.
6. Puhakka HJ. Complications
of mediastinoscopy. J Laryngol Otol. 1989;103:312–315.
7. Pereszlenyi A, Nicks M, Danko J, et al. Complications
of videomediastinoscopy- successful management in four cases. Bratisl Lek Listy. 2003;104:201–204.
8. Schubach SL, Landreneau RJ. Mediastinoscopy injury to the bronchus: use of in-continuity bronchial flap repair. Ann Thorac Surg. 1992;53: 1101–3.
9. Rodríguez P, Santana N, Gámez P, et al. La mediastinoscopia para el diagnóstico en la enfermedad mediastínica: análisis de 181 exploraciones. Arch Bronconeumol. 2003;39:29–34.