SECTION V I I

I Mediastinum

CHAPTER 57

I Anatomy and Surgical Access

of the Mediastinum
Paul A. Kirschner

This chapter on the anatomy of the mediastinum is pre-
sented from a meaningful, functional, surgical aspect
rather than in terms of "traditional," often artificial, static
diagrams of "compartments" and the recital of the gamuts
of their contents. The true anatomic relationships of
the various structures, organs, and other processes (i.e.,
infections) are emphasized on the basis of fascial continu-
ity, whether in the mediastinum itself or between it and
the neck above and the abdomen below. Such a presenta-
tion deals with anatomically determined routes of surgi-
cal access and structural localization. It serves as an
anatomic basis for the diagnosis and management of the
many aspects of mediastinal pathology that are presented
elsewhere in more detail in this volume. The terms de-
scribing the topography of the mediastinum (i.e., supe-
rior, inferior, anterior, middle, and posterior) are in-
grained and are used for gross orientation rather than
precise anatomic localization.
ations that can be displayed by an intraesophageal
recording device. The mediastinum is bounded on either
side by the mediastinal pleurae, which are intact except
for where they are pierced by the pulmonary hila. Other
than this, there is no mediastinopleural continuity.
Superiorly, the mediastinum is in free communication
with the neck via three distinct fascial planes (see later).
The superior "aperture" of the mediastinum is obliquely
disposed, being higher posteriorly than anteriorly, corres-
ponding to the obliquity of the first rib. There is no
precise structural line of demarcation between the medi-
astinum and the neck. Rather, it is a zone that varies as
much as 2.5 to 5.0 cm depending on the degree of flexion
or extension of the neck. Even organs, such as a low-
lying thyroid gland or a hyperplastic thymus, may bob
up and down between the neck and mediastinum within
their fascial planes, especially with changes of position
of the head and strong respiratory efforts. This superior

BASIC TOPOGRAPHY
The mediastinum is a bulkhead-like median partition of
the thorax that separates the lungs in their respective
pleural cavities. It is a three-dimensional, interpleural
space shaped roughly like a squat irregular pyramid (Fig.
57-1). It ranges in thickness from a membranous antero-
superior commissure above, just under the manubrium
where the right and left mediastinal pleurae coapt, to a
broad almost amorphous space below. It contains all of
the thoracic organs except for the lungs. It can be re-
garded as the "third space" of the thorax or, as Wilson
(1884) has said, "The space between the spaces." Its
contour and extent vary, particularly posteriorly, de-
pending on how the "posterior" mediastinum is defined
(see later). The density and character of the contents of
the mediastinum vary from solid (parenchymal organs) to
liquid (blood, lymph, swallowed saliva, serous pericardial
fluid) to gaseous (trachea and main bronchi and intermit-
tently the esophagus). Dynamically, it reflects the in- FIGURE 57-1 • Three-dimensional reconstruction of a normal
trapleural subatmospheric pressure with respiratory vari- mediastinum derived from a computed tomography scan.

1563
1564 CHAPTER 57 • Anatomy and Surgical Access of the Mediastinum
aperture has been called the critical space of Grawitz
because enlarging unyielding masses or displaced organs
(such as those mentioned) may exert pressure on the
surrounding normal structures and conduits traversing
this space.
Inferiorly the mediastinum is sharply delimited by the
diaphragm. The foramina for the inferior vena cava and
the aorta are well sealed. However, within the esophageal
hiatus, there is a looseness that provides a pathway of
communication and dissection between the abdomen be-
low and the posterior mediastinum above. Anteriorly, the
lower part of the anterior mediastinum can be accessed
from just under the xiphoid process, and the anteroinfer-
ior aspect of the pericardium lies just beyond this.
Posteriorly, there is no unified concept of this area of
the mediastinum. Traditionally, it is delimited by the
anterior spinal ligament of the vertebral column, but in
a reappraisal by Shields (1991) the posterior extent in-
cludes the paravertebral sulci, thus giving the mediasti-
num a bilateral wing-like (alar) configuration (Fig. 57-2).
CONTENTS OF THE MEDIASTINUM
The mediastinum is tightly packed with intertwined or-
gans and conduits that include (1) cardiovascular struc-
tures (heart and great vessels), (2) airways (trachea and
main bronchi), (3) alimentary tract (esophagus), (4) neu-
ral tissue (nerves and ganglia), and (5) lymphatic tissue
(lymph nodes, thoracic duct, and thymus gland). It con-
tains a serous cavity—the pericardium. The intervening
tissue, combining tougher fibrous tissue and looser areo-
lar tissue, defines fascial planes in the mediastinum
proper and its communication with the neck and abdo-
men.
COMPARTMENTS
It has been customary for anatomists, surgeons, and radi-
ologists to divide the mediastinum arbitrarily into
"spaces" or "compartments." This artifice is used to aid
FIGURE 57-2 • Three-dimensional reconstruction of a normal
mediastinum including the paravertebral sulci (bracket and
arrow).
in the localization of structures and organs and lesions
derived from them (i.e., cysts, tumors, displaced organs,
and anomalies along with abscesses and spread of infec-
tions). However, several different "compartmental mod-
els" have been proposed, some with only scant reference
to basic anatomy.
In 1889, even before the discovery of x-rays, Hare
commented that "anatomists divide this region into an
anterior, middle, and posterior space, although, as usual
in such instances the lines of demarcation between each
of the spaces are not rigidly marked."
Even after the advent of x-rays in 1895, the demarca-
tions and "partitions" of the mediastinum remained
largely artificial. Because the mediastinal structures are
mainly "stacked" in the anteroposterior axis, it has been
customary to display them on the lateral view of the
chest radiograph. However, the demarcation of these
compartments was based to a great extent on imaginary
lines and planes superimposed on the x-ray picture.
There has been no universal agreement about the topog-
raphy of the mediastinum, and hence several different
compartment models have been created. These vary from
three-compartment models, including the newer one pro-
posed by Shields (1991), to a six-compartment model
described by the radiologist Heitzman (1977). An ex-
treme example of a nonanatomic demarcation is one
suggested by Felson (1969), a noted chest radiologist,
who stated: "The divisions of the mediastinum defined
by the anatomists are not suitable for the roentgen diag-
nosis of mediastinal lesions . . . with gall born of despera-
tion I have ignored the great anatomic teachings of the
past and use a new anatomic classification based on
roentgen projection rather than anatomic dissection." An
extreme example of Felson's nonanatomic "desperation"
is his characterization of the "boundary" between the
"middle" and "posterior" compartments as a "line" con-
necting a point on each thoracic vertebra 1 cm behind
its anterior margin!
Traditional Four-Compartment Model
Most dictionaries and anatomy textbooks use a four-
compartment model of the mediastinum (Fig. 57-3).
Based on the lateral radiograph, these compartments are
demarcated by dividing the mediastinum as a whole into
a superior and an inferior division, with the latter being
divided into anterior, middle, and posterior compart-
ments.
The "superior" mediastinum is the area above an imag-
inary plane extending from the manubriosternal junction
(angle of Louis) posteriorly to the inferior border of the
T4 vertebra. This plane corresponds roughly to the aortic
arch and the tracheal bifurcation. It contains all of the
structures passing through the superior inlet (i.e., the
great vessels, trachea, esophagus, veins, lymphatics,
lymph nodes, thoracic duct, and thymus). No mention is
made of the three distinct anatomic cervicomediastinal
fascial planes that exist in this compartment: the prevas-
cular plane, retrovascular (postvascular) pretracheal
plane, and posterior peri-pharyngoesophageal plane.
The rest of the mediastinum is divided into three more
compartments—the anterior, middle, and posterior. The
 CHAPTER 57 • Anatomy and Surgical Access of the Mediastinum
Superior
Posterior
FIGURE 57-3 • Traditional four-compartment model of the
mediastinum. (From Dresler CM: Anatomy and classification. In
Pearson FG (ed): Thoracic Surgery. New York, Churchill
Livingstone, 1995, p 1326.)
"anterior" mediastinum is located between the back of
the sternal body (gladiolus) and the anterior surface of
the pericardium. It contains the main body of the thymus
and preaortic lymph nodes (stations 5 and 6) embedded
in fibrofatty tissue.
The "middle" mediastinum, located between the ante-
rior and posterior, is occupied by the pericardium and its
contents—the carina, the proximal main bronchi, and
the tracheobronchial lymph nodes (stations 2R and L, 4
R and L, and 7).
The "posterior" mediastinum, located between the
back of the pericardium and the anterior spinal ligament,
contains the esophagus, the aorta, the nerves, the ganglia,
and the thoracic duct.
Traditional Three-Compartment Model
This designation (Fig. 57-4) combines the anterior two
thirds of the superior mediastinum and the entire anterior
mediastinum; the middle includes the heart and pericar-
dium and the posterior extends the entire length of the
spine. This model also ignores anatomic cervicomediasti-
nal fascial planes.
Shields' Three-Compartment Model
This description of the mediastinum (Fig. 57-5) is the
most truly anatomic of all. In the words of Shields
(1991), "it consists of an anterior compartment, a visceral
compartment, and the paravertebral sulci bilaterally."
Each compartment extends from the thoracic inlet to the
diaphragm. At their cervical aspect, these three compart-
ments correspond to true anatomic dissection zones. The
anterior compartment, located between the undersurface
1565
Anterosuperior
mediastinum
Posterior
mediastinum
Middle
mediastinum
FIGURE 57-4 • Traditional three-compartment model of the
mediastinum. (From Dresler CM: Anatomy and classification. In
Pearson FG (ed): Thoracic Surgery. New York, Churchill
Livingstone, 1995, p 1326.)
of the sternum and the anterior surface of the great
vessels, can be called the "prevascular" zone. The visceral
compartment, located behind the great vessels between
them and the trachea, can be called the "retrovascular"
(postvascular, pretracheal) zone. Posterior to these two
zones is a retrovisceral zone (periesophageal), which
Shields has combined with the paravertebral sulci, the
latter being the only paired component of the mediasti-
num. Note that the words superior, anterior, middle, and
posterior are not used at all.
Anterior
compartment
Para-
vertebral
sulcus
FIGURE 57-5 • Shields' three-compartment model of the
mediastinum. (From Dresler CM: Anatomy and classification.
In Pearson FG (ed): Thoracic Surgery. New York, Churchill
Livingstone, 1995, p 1326.)
1566 CHAPTER 57 • Anatomy and Surgical Access of the Mediastinum
PRACTICAL APPLIED SURGICAL
ANATOMY
The "true" anatomy of the mediastinum emerges when
there is disease (i.e., tumors, anomalies, displaced organs,
and infections) that requires diagnosis and treatment.
As Neuhof and Jemerin (1943) put it, "This customary
anatomical classification [i.e., the traditional "compart-
ments"] is artificial and gives no impression of the conti-
nuity which exists not only between the superior and
inferior mediastinum but also between the superior medi-
astinum and the neck." This continuity is defined by
cervicomediastinal fascial planes that delineate the true
anatomic compartments. Such anatomic information was
derived in the past from (1) a study of pathways of
"descending" cervicomediastinal infections and (2) a
study of cross-sectional anatomy in the cadaver (Eycles-
hymer and Shoemaker, 1911). Today, the availability of
computerized imaging techniques in multiple planes and
parameters facilitates the acquisition of such critical
cross-sectional anatomic information. However, the com-
partment concept is so ingrained in our thinking that it
serves a useful purpose for a means of expression.
SURGICAL ACCESS TO THE
MEDIASTINUM
Prevascular Zone (Anterior
Compartment)
Cervical Approach (Extended Mediastinoscopy)
A transverse incision in the suprasternal notch traverses
the superficial layer of the deep cervical fascia including
the strap muscles (Fig. 57-6). Just beneath these, the
cervical cornua of the thymus can be identified in the
prevascular plane. Downward dissection allows transcer-
vical thymectomy and exposure to other tumors in this
plane along with lymph nodes in stations 5 and 6. Explo-
ration of this zone is called "extended" mediastinoscopy
(Kirschner, 1991) (see Fig. 57-6).
FIGURE 57-6 • A computed tomography scan showing
adenopathy in the "prevascular" zone (anterior compartment).
(From Kirschner PA: Cervical mediastinoscopy. Chest Surg Clin
North Am 6:9, 1996.)
FIGURE 57-7 • "Chamberlain" procedure. (A, aorta; II, 2nd
costal cartilage and rib; LLL, left lower lobe; LUL, left upper
lobe; M, manubrium; RLL, right lower lobe; RUL, right upper
lobe; SVC, superior vena cava.) (From McNeill TM, Chamberlain
JM: Diagnostic anterior mediastinotomy. Ann Thorac Surg
2:532, 1961.)
Parasternal Approach (Anterior Mediastinotomy)
This approach is commonly known as the Chamberlain
procedure (McNeill and Chamberlain, 1966) and consists
of entering the prevascular substernal zone on either side
via a parasternal incision carried through the interchon-
dral interspace or through the space of the excised second
costal cartilage. It is particularly useful for biopsies of
preaortic lymph nodes in stations 5 and 6. Although a
left-sided Chamberlain procedure is the best route to
these preaortic nodes, either side of the sternum can be
used to gain access to other tumors and other pathology
(Fig. 57-7).
Postvascular (Pretracheal) Zone (Visceral
Compartment)
By deepening the suprasternal notch incision beyond the
great vessels and traversing the next layer of deep cervical
fascia, the pretracheal layer, it is now possible to enter
the "retrovascular pretracheal" plane (the "visceral"
compartment of Shields) (Fig. 57-8). This is the plane of
classic cervical mediastinoscopy (Carlens, 1959; Kirsch-
ner, 1996) (Fig. 57-9). By digital blunt dissection be-
tween the innominate artery and the trachea and with
the aid of the mediastinoscope, access is obtained to the
pretracheal and paratracheal areas, the subcarinal area,
and the two main bronchi. Lymph nodes of stations 2 R
and L, 4 R and L, and 7 are located in these areas. Other
neoplastic lesions may be encountered as well.
Posterior (Prevertebral Periesophageal)
Zone (Posterior Longitudinal Sulci)
This zone is the deepest of the three compartments that
are accessible through the neck and is best approached
from either side rather than from the midline. It is this
zone that is considered by most to be the "posterior"
mediastinum. It is here that deep infections of the neck
are located. In this zone, also, so-called descending necro-
 CHAPTER 57 • Anatomy and Surgical Access of the Mediastinum 1567

FIGURE 5 7 - 8 • A c o m p u t e d t o m o g r a p h y scan s h o w i n g
a d e n o p a t h y in t h e "postvascular" z o n e (visceral compartment).
(From Kirschner PA: Cervical mediastinoscopy. Chest Surg Clin
North Am 6:9, 1996.)

tizing mediastinitis occurs (Ris et al, 1996; Seybold et al,

1950; Wheatley et al, 1990).

Cervical Approach
Depending on the localization (left or right) of a posterior
mediastinal abscess, the cervical incision is made along
the anterior border of the sternocleidomastoid muscle,
deepening it by ligating and dividing the middle thyroid
vein and traversing the buccopharyngeal fascia to enter
the peripharyngoesophageal space. This exposure often FIGURE 5 7 - 9 • Classic Carlens' mediastinoscopy s h o w i n g t h e
scope in t h e "postvascular" z o n e (visceral compartment). (From
suffices for superiorly located abscesses (Fig. 57-10).
Carlens E: Mediastinoscopy: A m e t h o d f o r inspection and tissue
biopsy in t h e superior m e d i a s t i n u m . Dis Chest 36:343, 1959.)
Paravertebral Approach
In some instances, exposure via the neck may be inade-
quate (Wheatley et al, 1990) and a lower paravertebral down the mediastinum from the neck down to the retro-
approach is necessary, resecting posterior segments of peritoneum and even into either or both pleural cavities
one or more ribs and entering the retropleural plane (Fig. 57-11). Localized small incisions, notwithstanding
leading to the posterior mediastinum (Seybold et al, their anatomic correctness, often do not suffice. It may
1950). be necessary to perform a wide-open, transpleural thora-
cotomy, possibly including a "clamshell" incision to con-
"Extended" Approach to Posterior Mediastinum trol the infection (Ris et al, 1996).
(Various Forms of Thoracotomy)
The virulence of mediastinal infections, especially those Inferior Access to the Posterior Mediastinum
secondary to esophageal perforations or other anaerobic The inferior part of the posterior mediastinum is accessi-
infections, results in extensive and rapid spread up and ble transabdominally through the esophageal hiatus. Such

Omohyoid m.
Pretracheal space

Angle of dissection

Carotid sheath
FIGURE 5 7 - 1 0 • Cervical approach to t h e
prevertebral p e r i p h a r y n g o e s o p h a g e a l plane. The
d i f f e r e n t fascial planes in t h e neck by w h i c h
infections may spread i n f e r i o r l y i n t o t h e m e d i a s t i n u m
are s h o w n . The arrow demonstrates t h e standard
surgical a p p r o a c h t o t h e p r e v e r t e b r a l fascia medial t o
the sternocleidomastoid muscle a n d carotid sheath
and lateral to t h e strap muscles and t h y r o i d g l a n d .
(From W h e a t l e y MJ, Stirling MC, Kirsh MM et al:
Descending n e c r o t i z i n g mediastinitis: Transcervical
drainage is n o t e n o u g h . A n n Thorac Surg 49:780, Retrovisceral space Buccopharyngeal fascia
1990.) Prevertebral fascia
1568 CHAPTER 57 • Anatomy and Surgical Access of the Mediastinum
FIGURE 57-11 • Spread of virulent infection throughout the
mediastinal planes. (From Kornblum K, Osmond LH:
Mediastinitis. AJR Am J Roentgenol 32:33, 1934.)
procedures include various antireflux operations and hia-
tal hernia repairs as well as the inferior mobilization of
almost the entire esophagus in the operation of trans-
hiatal esophagectomy (Fig. 57-12). Such inferior mobili-
zation combined with an appropriate corresponding cer-
vical incision and mobilization from above provides the
opportunity for removing the esophagus extrapleurally
without traversing the pleural cavities or bony thorax. It
can be used as a bed to transplant the stomach, colon, or
small bowel to restore alimentary continuity.
Knowledge of the anatomy of the mediastinum based
on fascial planes facilitates precise and efficient access to
the many tumors and other pathologic processes affecting
this complex thoracic space.
• REFERENCES
Carlens E: Mediastinoscopy: A method for inspection and tissue biopsy
in the superior mediastinum. Dis Chest 36:343, 1959.
Eycleshymer AC, Shoemaker DM: A Cross-section Anatomy. New York,
Appleton-Century-Crofts, 1911.
Felson B: The mediastinum. Semin Roentgenol 4:41-58, 1969.
FIGURE 57-12 • Esophageal mobilization for transhiatal
esophagectomy. (From Orringer MB: Transhiatal
esophagectomy without Thoracotomy. New York, Churchill
Livingstone, 1995, p 689.)
Hare HA: The Pathology, Clinical History and Diagnosis of Affections
of the Mediastinum. Philadelphia, Blakiston, 1889.
Heitzman ER: The Mediastinum: Radiologic Correlations with Anatomy
and Pathology. St. Louis, CV Mosby, 1977.
Kirschner PA: Cervical substernal "extended" mediastinoscopy. In
Shields TW (ed): Mediastinal Surgery. Philadelphia, Lea & Feb-
iger, 1991.
Kirschner PA: Cervical mediastinoscopy. Chest Surg Clin North Am
6:1-20, 1996.
McNeill TM, Chamberlain JM: Diagnostic anterior mediastinotomy. Ann
Thorac Surg 2:532-539, 1966.
Neuhof H, Jemerin EE: Acute Infections of the Mediastinum. Baltimore,
Williams & Wilkins-, 1943, p 294.
Ris H-B, Banic A, Furrer M et al: Descending necrotizing mediastinitis:
Surgical treatment via clamshell approach. Ann Thorac Surg
62:1650, 1996.
Seybold WD, Johnson MA III, Leary WV: Perforation of the esophagus:
An analysis of 50 cases and an account of experimental studies.
Surg Clin North Am 30:1155-1183, 1950.
Shields TW (ed): Mediastinal Surgery. Philadelphia, Lea & Febiger,
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Wheatley MJ, Stirling MC, Kirsh MM et Al: Descending necrotizing
mediastinitis: Transcervical drainage is not enough. Ann Thorac
Surg 49:780-784, 1990.
Wilson JC: On the diagnosis of tumors of the anterior mediastinum.
JAMA 3:113, 1884.