Good head position allows adequate exposure. The neck should be in full extension with the shoulders elevated. The entire neck and chest should be prepared into the surgical field in case a more extensive exposure is quickly required. As with any neck scar, asymmetry leads to an unaesthetic result, and marking the intended site often results in a more pleasing closure. Make the skin incision about two fingerbreadths cephalad to the suprasternal notch. The incision need only be 2 to 3 cm long, enough to accommodate the mediastinoscope, extending only to the anterior borders of the sternocleidomastoid muscle. Carry the incision down by electrocautery through the subcutaneous tissue to the level of the strap muscles. Sizable veins (anterior jugular veins) can run in this tissue and may require formal ligation with silk ties. Identify the midline as a fine, pale-yellow line. Incise this connective tissue with electrocautery or Metzenbaum scissors superiorly and inferiorly, and retract the strap muscles vertically. Divide the connective tissue of the midline by sharp dissection or electrocautery until the trachea is encountered. Incise the pretracheal fascia to allow access to the correct tissue plane, just anterior to the trachea itself.

When making the incision, the trachea will be exposed at about the same location as in tracheostomy, caudal to the thyroid. The inferior thyroid vein can often pass cephalad in the midline and requires careful mobilization and lateral retraction.

As the surgeon’s finger passes under the manubrium, the back of the aortic arch is palpated just as it gives off the brachiocephalic (innominate) artery. Place a pulse oximeter on a finger of the patient’s right hand to monitor compression of this artery during the procedure.