The use of cervical mediastinoscopy in retrosternal goiter surgery

Abstract

Background. Retrosternal goiter presents a complex surgical challenge due to its anatomical location and potential for significant complications. Modern surgical techniques, including cervical mediastinoscopy, aim to optimize outcomes while minimizing invasiveness. Objective. To evaluate the clinical and surgical outcomes of patients undergoing contemporary surgical management of retrosternal goiters, emphasizing the role of cervical mediastinoscopy and video-endoscopic assistance. Methods. A retrospective analysis of 68 patients (52 females, 76.5%; 16 males, 23.5%; mean age: 50 years) treated surgically for retrosternal goiter between 2014 and 2024 was conducted. Surgical approaches included standard cervicotomy (n=42), video-endoscopic-assisted surgery (n=26), and combined techniques, including cervical mediastinoscopy, for intraoperative bleeding management (n=9). Preoperative computed tomography (CT) was used for all patients to assess goiter size and surgical risk, based on G. Mercante criteria (2011). Postoperative outcomes, including complications and histopathological findings, were evaluated. Results. No cases of postoperative bleeding required revision surgery. Temporary tracheostomy was performed in 4 patients and reversed successfully. Hypocalcemia occurred in 13 patients (19.1%), with 12 cases resolving transiently. Transient recurrent laryngeal nerve paresis was reported in 9 patients (Group 1: n=4; Group 2: n=3; Group 3: n=2), with one permanent case in Group 3. In Group 3, 2 patients required manubriotomy to achieve adequate exposure and control of significant intraoperative bleeding. The use of cervical mediastinoscopy and video-endoscopic assistance in this group improved visualization, enabling precise vascular control and safer preservation of critical structures. Histopathological analysis revealed thyroid carcinoma in 24 patients (20 papillary, 4 follicular). Video-endoscopic techniques, combined with cervical mediastinoscopy, reduced the need for sternotomy and enhanced surgical outcomes. Conclusions. The integration of cervical mediastinoscopy and video-endoscopic assistance into cervical approaches significantly enhances safety and efficacy in retrosternal goiter surgery. These techniques minimize invasiveness, preserve critical structures, and reduce complication rates. Preoperative CT remains essential for surgical planning. The cervical approach, complemented by cervical mediastinoscopy and video-endoscopic techniques, represents a preferred strategy for managing retrosternal goiters, with manubriotomy reserved for selected complex cases.