Difference between revisions of "Mediastinoscopy"
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = | | anesthesia_type = GETA | ||
| airway = | | airway = ETT | ||
| lines_access = | | lines_access = large bore PIV x1, +/- A line | ||
| monitors = | | monitors = Standard, BP cuff on left arm, +/- A line | ||
| considerations_preoperative = | | considerations_preoperative = Evaluate for degree of airway compression by mediastinal mass | ||
| considerations_intraoperative = | | considerations_intraoperative = Be prepared for major bleeding. Compression to innominate artery may cause R arm BP or A line to falsely display hypotension or cardiac arrest. | ||
| considerations_postoperative = | | considerations_postoperative = | ||
}} | }} | ||
Mediastinoscopy is a procedure that involves a cervical incision and placements of a rigid scope to view and instrument certain structures of the mediastinum. The most common indication for mediastinoscopy is biopsy of mediastinal lymph nodes in N2 or N3 NSCLC, though any indication for biopsy of mediastinal lymph nodes at stations 2, 4 or 7 is possible with this procedure.<ref name=":0">{{Cite book|last=LaPar|first=Damian|title=Review of Cardiothoracic Surgery|last2=Mery|first2=Carlos|last3=Turek|first3=Joseph|publisher=Thoracic Surgery Resident Association|year=2015|isbn=9781523217168|location=Chicago|pages=184-185}}</ref> Mediastinoscopy may also be performed at the thoracic level to access mediastinal lymph nodes at stations 5 and 6 (transthoracic mediastinoscopy, also known as the Chamberlain procedure). Previous mediastinoscopy, innominante or aortic arch aneurysms, and prior chest radiation are relative contraindications to the procedure.<ref name=":1">{{Cite book|last=Jaffe|first=Richard|title=Anesthesiologist's Manual of Surgical Procedures|last2=Schmiesing|first2=Clifford|last3=Golianu|first3=Brendo|publisher=Wolters Kluwer|year=2014|isbn=9781451176605|edition=2nd|pages=309-315}}</ref> | |||
In the more common cervical mediastinoscopy procedure, a cervical incision is made above the sternal notch and a mediastinoscopy is use to bluntly enter and instrument the middle mediastinum. Care is taken to avoid puncturing the numerous vulnerable neurovascular structures in the area (namely the aorta, innominate artery, innominate vein, azygous vein, recurrent laryngeal nerve, right pulmonary artery)<ref name=":1" />. Meanwhile, in the classic Chamberlain procedure (transthoracic mediastinoscopy), the 3rd costal cartilage is resected through an incision placed in the left 2nd and 3rd intercostal space, taking care not to injure the internal mammary artery or phrenic nerve, and the mediastinum explored without entering the pleura. | |||
== Preoperative management == | == Preoperative management == | ||
| Line 18: | Line 20: | ||
!System | !System | ||
!Considerations | !Considerations | ||
|- | |- | ||
|Cardiovascular | |Cardiovascular | ||
| | |Elderly patients may have comorbid CAD, preop testing to risk stratify is recommended if indicated by history | ||
|- | |- | ||
|Pulmonary | |Pulmonary | ||
| | |Bulky mediastinal lymphadenopathy may make airway management in the anesthetized patient precarious. Ensure that the pt can lie flat without significant airway compression. Patients with lung cancer may develop Lambert-Eaton myasthenic syndrome, quantitative monitoring of neuromuscular blockade is recommended. | ||
|- | |- | ||
|Gastrointestinal | |Gastrointestinal | ||
| | |Bulky mediastinal lymphadenopathy can cause partial esophageal obstruction, increasing the risk of aspiration | ||
|- | |- | ||
|Hematologic | |Hematologic | ||
| | |Malignant processes may induce comorbid anemia | ||
|- | |- | ||
|Endocrine | |Endocrine | ||
| | |Depending on the exact pathology of the anterior mediastinal mass/lymphadenopathy, there may be underlying comorbid thyroid or paraneoplastic syndromes. | ||
|} | |} | ||
=== Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | === Labs and studies<!-- Describe any important labs or studies. Include reasoning to justify the study and/or interpretation of results in the context of this procedure. If none, this section may be removed. --> === | ||
* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P | |||
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start | |||
* in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation | |||
=== Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | === Operating room setup<!-- Describe any unique aspects of operating room preparation. Avoid excessively granular information. Use drug classes instead of specific drugs when appropriate. If none, this section may be removed. --> === | ||
* Standard GETA setup | |||
* Risk stratify airway technique to the degree of anticipated airway difficulty and airway compression from mediastinal mass/lymphadenopathy. | |||
* BP cuff on left arm, pulse oximeter on the right arm. The mediastinoscopy may compress the innominate artery which results in reduced/absent right sided upper extremity pulses. | |||
* Arterial line as indicated by history and physical. If placed, it should be right sided, correlating carefully with the left arm BP cuff as right sided pressures may be inaccurate due to great vessel compression by surgeon. | |||
* If CVP/PA catheter are desired, they should be placed through femoral access if SVC syndrome is present. | |||
=== Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | === Patient preparation and premedication<!-- Describe any unique considerations for patient preparation and premedication. If none, this section may be removed. --> === | ||
* Avoid premedicating with sedating medications if airway compromise from mass compression is a concern | |||
* If awake fiberoptic intubation is planned, ample time should be allocated for administration of antisialogogue and topicalization of the airway | |||
=== Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | === Regional and neuraxial techniques<!-- Describe any potential regional and/or neuraxial techniques which may be used for this case. If none, this section may be removed. --> === | ||
* Epidural placement for postop analgesia is typically not indicated given small incision. Epidurals or peripheral nerve blocks may be placed post op if there is catastrophic conversion to median sternotomy or thoracotomy. | |||
== Intraoperative management == | == Intraoperative management == | ||
=== Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | === Monitoring and access<!-- List and/or describe monitors and access typically needed for this case. Please describe rationale for any special monitors or access. --> === | ||
* standard ASA monitors | |||
* 5 lead EKG | |||
* 1 large bore IV (14-16g) | |||
* +/- arterial line | |||
* ensure blood in OR in case of severe bleeding | |||
=== Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | === Induction and airway management<!-- Describe the important considerations and general approach to the induction of anesthesia and how the airway is typically managed for this case. --> === | ||
* Standard induction if there are no risk factors for aspiration, otherwise RSI w/ cricoid pressure | |||
* Airway management based off of anticipated risk of difficult intubation based off of patient's pathology, history and physical, and imaging. | |||
=== Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | === Positioning<!-- Describe any unique positioning considerations, including potential intraoperative position changes. If none, this section may be removed. --> === | ||
* Supine, 180˚ degree flip, head toward surgeon. | |||
* often some degree of reverse Trendelenburg (head up) is requested | |||
=== Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | === Maintenance and surgical considerations<!-- Describe the important considerations and general approach to the maintenance of anesthesia, including potential complications. Be sure to include any steps to the surgical procedure that have anesthetic implications. --> === | ||
* standard maintenance with volatile and/or intravenous agents | |||
=== Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | === Emergence<!-- List and/or describe any important considerations related to the emergence from anesthesia for this case. --> === | ||
* extubation is anticipated, extubation strategy based off of difficulty of airway and degree of mediastinal mass airway obstruction. | |||
* normal PONV prophylaxis based off of Apfel score. | |||
== Postoperative management == | == Postoperative management == | ||
=== Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | === Disposition<!-- List and/or describe the postoperative disposition and any special considerations for transport of patients for this case. --> === | ||
* PACU -> home vs surgical ward | |||
* cervical mediastinoscopy is typically an outpatient surgical procedure | |||
* transthoracic mediastinoscopy without violation of the pleura can be same-day discharge; if the pleura is entered a chest tube is placed and the patient is typically observed overnight. | |||
=== Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | === Pain management<!-- Describe the expected level of postoperative pain and approaches to pain management for this case. --> === | ||
* Significant pain is not anticipated: multimodal pain control, typically with short course of oral opioids | |||
=== Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | === Potential complications<!-- List and/or describe any potential postoperative complications for this case. --> === | ||
* Major bleeding is the most common complication (0.1-0.6%), though most bleeding can be dealt with packing. Instrumentation near lymph node station 4R is the most common site of major bleeding due to injury to the azygous vien. In severe instances, median sternotomy with possible CPB may be necessary to achieve hemostasis and repair vascular injuries.<ref name=":0" /> | |||
* pneumothorax | |||
* phrenic or recurrent laryngeal nerve damage (occurs most commonly with manipulation at station 4L)<ref name=":0" /> | |||
* tracheomalacia (more often seen in patients with longstanding mediastinal masses) | |||
* esophageal perforation (near lymph node station 7)<ref name=":0" /> | |||
== References == | == References == | ||
<references /> | |||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
Latest revision as of 15:53, 7 December 2023
Mediastinoscopy
| Anesthesia type |
GETA |
|---|---|
| Airway |
ETT |
| Lines and access |
large bore PIV x1, +/- A line |
| Monitors |
Standard, BP cuff on left arm, +/- A line |
| Primary anesthetic considerations | |
| Preoperative |
Evaluate for degree of airway compression by mediastinal mass |
| Intraoperative |
Be prepared for major bleeding. Compression to innominate artery may cause R arm BP or A line to falsely display hypotension or cardiac arrest. |
| Postoperative | |
| Article quality | |
| Editor rating | |
| User likes | 0 |
Mediastinoscopy is a procedure that involves a cervical incision and placements of a rigid scope to view and instrument certain structures of the mediastinum. The most common indication for mediastinoscopy is biopsy of mediastinal lymph nodes in N2 or N3 NSCLC, though any indication for biopsy of mediastinal lymph nodes at stations 2, 4 or 7 is possible with this procedure.[1] Mediastinoscopy may also be performed at the thoracic level to access mediastinal lymph nodes at stations 5 and 6 (transthoracic mediastinoscopy, also known as the Chamberlain procedure). Previous mediastinoscopy, innominante or aortic arch aneurysms, and prior chest radiation are relative contraindications to the procedure.[2]
In the more common cervical mediastinoscopy procedure, a cervical incision is made above the sternal notch and a mediastinoscopy is use to bluntly enter and instrument the middle mediastinum. Care is taken to avoid puncturing the numerous vulnerable neurovascular structures in the area (namely the aorta, innominate artery, innominate vein, azygous vein, recurrent laryngeal nerve, right pulmonary artery)[2]. Meanwhile, in the classic Chamberlain procedure (transthoracic mediastinoscopy), the 3rd costal cartilage is resected through an incision placed in the left 2nd and 3rd intercostal space, taking care not to injure the internal mammary artery or phrenic nerve, and the mediastinum explored without entering the pleura.
Preoperative management
Patient evaluation
| System | Considerations |
|---|---|
| Cardiovascular | Elderly patients may have comorbid CAD, preop testing to risk stratify is recommended if indicated by history |
| Pulmonary | Bulky mediastinal lymphadenopathy may make airway management in the anesthetized patient precarious. Ensure that the pt can lie flat without significant airway compression. Patients with lung cancer may develop Lambert-Eaton myasthenic syndrome, quantitative monitoring of neuromuscular blockade is recommended. |
| Gastrointestinal | Bulky mediastinal lymphadenopathy can cause partial esophageal obstruction, increasing the risk of aspiration |
| Hematologic | Malignant processes may induce comorbid anemia |
| Endocrine | Depending on the exact pathology of the anterior mediastinal mass/lymphadenopathy, there may be underlying comorbid thyroid or paraneoplastic syndromes. |
Labs and studies
- Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P
- At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start
- in patients with a history of cardiac disease or low functional status, consider additional cardiac testing with ECG, echo/stress echo. Any reversible ischemia should prompt further cardiac consultation
Operating room setup
- Standard GETA setup
- Risk stratify airway technique to the degree of anticipated airway difficulty and airway compression from mediastinal mass/lymphadenopathy.
- BP cuff on left arm, pulse oximeter on the right arm. The mediastinoscopy may compress the innominate artery which results in reduced/absent right sided upper extremity pulses.
- Arterial line as indicated by history and physical. If placed, it should be right sided, correlating carefully with the left arm BP cuff as right sided pressures may be inaccurate due to great vessel compression by surgeon.
- If CVP/PA catheter are desired, they should be placed through femoral access if SVC syndrome is present.
Patient preparation and premedication
- Avoid premedicating with sedating medications if airway compromise from mass compression is a concern
- If awake fiberoptic intubation is planned, ample time should be allocated for administration of antisialogogue and topicalization of the airway
Regional and neuraxial techniques
- Epidural placement for postop analgesia is typically not indicated given small incision. Epidurals or peripheral nerve blocks may be placed post op if there is catastrophic conversion to median sternotomy or thoracotomy.
Intraoperative management
Monitoring and access
- standard ASA monitors
- 5 lead EKG
- 1 large bore IV (14-16g)
- +/- arterial line
- ensure blood in OR in case of severe bleeding
Induction and airway management
- Standard induction if there are no risk factors for aspiration, otherwise RSI w/ cricoid pressure
- Airway management based off of anticipated risk of difficult intubation based off of patient's pathology, history and physical, and imaging.
Positioning
- Supine, 180˚ degree flip, head toward surgeon.
- often some degree of reverse Trendelenburg (head up) is requested
Maintenance and surgical considerations
- standard maintenance with volatile and/or intravenous agents
Emergence
- extubation is anticipated, extubation strategy based off of difficulty of airway and degree of mediastinal mass airway obstruction.
- normal PONV prophylaxis based off of Apfel score.
Postoperative management
Disposition
- PACU -> home vs surgical ward
- cervical mediastinoscopy is typically an outpatient surgical procedure
- transthoracic mediastinoscopy without violation of the pleura can be same-day discharge; if the pleura is entered a chest tube is placed and the patient is typically observed overnight.
Pain management
- Significant pain is not anticipated: multimodal pain control, typically with short course of oral opioids
Potential complications
- Major bleeding is the most common complication (0.1-0.6%), though most bleeding can be dealt with packing. Instrumentation near lymph node station 4R is the most common site of major bleeding due to injury to the azygous vien. In severe instances, median sternotomy with possible CPB may be necessary to achieve hemostasis and repair vascular injuries.[1]
- pneumothorax
- phrenic or recurrent laryngeal nerve damage (occurs most commonly with manipulation at station 4L)[1]
- tracheomalacia (more often seen in patients with longstanding mediastinal masses)
- esophageal perforation (near lymph node station 7)[1]
References
- ↑ 1.0 1.1 1.2 1.3 LaPar, Damian; Mery, Carlos; Turek, Joseph (2015). Review of Cardiothoracic Surgery. Chicago: Thoracic Surgery Resident Association. pp. 184–185. ISBN 9781523217168.
- ↑ 2.0 2.1 Jaffe, Richard; Schmiesing, Clifford; Golianu, Brendo (2014). Anesthesiologist's Manual of Surgical Procedures (2nd ed.). Wolters Kluwer. pp. 309–315. ISBN 9781451176605.
Top contributors: Nicolas Quach, Mitchel DeVita and Chris Rishel