NCBI Bookshelf. Peter A. McNally ; Mary E. Authors Peter A. McNally 1 ; Mary E.
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NCBI Bookshelf. Peter A. McNally ; Mary E. Authors Peter A. McNally 1 ; Mary E. Arthur 2. This new rigid instrument allowed a surgeon to enter the mediastinum through a suprasternal incision and biopsy paratracheal and hilar lymph nodes.
To understand mediastinoscopy, one must know the anatomy of the mediastinum. The superior and inferior borders are the thoracic inlet and diaphragm, respectively.
The middle mediastinum contains the pericardium and all that it encloses. The pathological results obtained from the procedure are very important in tailoring care for the patient amongst the surgeon, oncologist, and radiation oncologist. Other indications for mediastinoscopy include the diagnosis and removal of mediastinal masses and enlarged lymph nodes.
A mediastinal mass, such as a thymoma may be excised via mediastinoscopy depending on its size. A sampling of lymph nodes may diagnose infectious processes such as tuberculosis and fungal infections. Finally, mediastinoscopy is used in the diagnosis and treatment of mesothelioma.
Contraindications to mediastinoscopy can be classified as either absolute or relative. Mediastinoscopy is a surgical procedure that is performed in the operating room. The procedure also requires general anesthesia and thus requires an anesthesiologist and operating room support staff.
Mediastinoscopy can be performed under local or general anesthesia. General anesthesia is the technique of choice at most institutions if the patient has no preoperative signs or symptoms of airway obstruction. A preoperative evaluation of a patient undergoing a mediastinoscopy is important in decreasing morbidity and mortality.
An intravenous line must be in place before proceeding to the operating room. The general anesthetic technique can involve inhalational or intravenous agents, or most commonly, a combination of the two. Following induction and intubation, the use of muscle relaxants provides the surgeon with an operative field safe from sudden movements, which might lead to injury of the adjacent organs by the mediastinoscope.
Blunt dissection down to the anterior trachea allows entrance into the superior mediastinum. A mediastinoscope is then inserted and advanced along the tract allowing for the sampling of lymph nodes and masses. Intraoperative complications can occur with mediastinoscopy and include bleeding, which is the most common complication of this procedure. Some recommend the use of precordial Doppler to monitor for any venous air embolism.
Instrumentation can lead to airway rupture; however; this complication requires an immediate thoracotomy. The left is at more risk because of its more caudal path under the aorta.
Damage to the thoracic duct can lead to chylothorax. It is important that surgeon, anesthesiologist, and operating room staff appreciate potential complications of the mass. Changing patient position from to supine or either lateral or prone may be a temporizing measure that relieves the obstruction of the mass on the airway.
Patients who have suspected airway obstruction due to a mediastinal mass on physical examination should undergo pulmonary function tests PFTs with flow-volume loops. In patients with a large mediastinal mass, SVC syndrome may be present. Obstruction of the superior vena cava will cause facial swelling, distension of neck, development of collateral venous drainage along the thoracic wall. It associated with dyspnea and dysphagia commonly. It is important to have intravenous access in these patients in the lower extremities because of the resistance of upper extremity drainage being recirculated.
Many centers are using video-assisted mediastinoscopy as it improves surgical visualization and allows the surgeon to use multiple instruments at once. These are both methods for staging non-small cell lung cancer. A single institution study showed that mediastinoscopy was marginally cheaper than the endobronchial ultrasound biopsy. Mediastinoscopy is a well-known and common procedure.
It is paramount to educate the patient, physicians, all others that are involved in mediastinoscopy cases what to expect before, during, and following the procedure. In many instances, there is a close association of the procedure with a lung cancer diagnosis, and patient care must be well coordinated with other physicians and care staff to make sure the patient is optimized for the procedure.
To access free multiple choice questions on this topic, click here. This book is distributed under the terms of the Creative Commons Attribution 4. Turn recording back on. National Center for Biotechnology Information , U.
StatPearls [Internet]. Search term. Mediastinoscopy Peter A. Author Information Authors Peter A. Affiliations 1 Augusta University. Anatomy and Physiology To understand mediastinoscopy, one must know the anatomy of the mediastinum. Aberrant vessels, e. Contraindications Contraindications to mediastinoscopy can be classified as either absolute or relative. Personnel Mediastinoscopy is a surgical procedure that is performed in the operating room.
Preparation A preoperative evaluation of a patient undergoing a mediastinoscopy is important in decreasing morbidity and mortality. Enhancing Healthcare Team Outcomes Mediastinoscopy is a well-known and common procedure.
Questions To access free multiple choice questions on this topic, click here. References 1. The current role of mediastinoscopy in the evaluation of thoracic disease. A review of anatomical relationships and complications. Clinical updates of approaches for biopsy of pulmonary lesions based on systematic review.
BMC Pulm Med. Present indications of surgical exploration of the mediastinum. J Thorac Dis. Role of thoracoscopy, mediastinoscopy and laparoscopy in the diagnosis and staging of malignant pleural mesothelioma. J Vis Surg.
Vaughan RS. Anaesthesia for mediastinoscopy. Weissberg D, Herczeg E. Perforation of thoracic aortic aneurysm. A complication of mediastinoscopy. Petty C. Right radial artery pressure during mediastinoscopy. Video-assisted mediastinoscopy is safe in patients taking antiplatelet or anticoagulant therapy. J Minim Access Surg. Management of major hemorrhage during mediastinoscopy. Endobronchial ultrasonography versus mediastinoscopy: a single-institution cost analysis and waste comparison.
Ozturk A, Gullu YT. Minim Invasive Ther Allied Technol. In: StatPearls [Internet]. In this Page. Related information. Similar articles in PubMed. Thoracoscopic mediastinal lymph node sampling: useful for mediastinal lymph node stations inaccessible by cervical mediastinoscopy. J Thorac Cardiovasc Surg. Simultaneous double video mediastinoscopy and video mediastinotomy--a step forward. Eur J Cardiothorac Surg.
Combination video-assisted mediastinoscopic lymphadenectomy and transcervical thoracoscopy. Multimed Man Cardiothorac Surg. Epub Jan Review Initial surgical staging of lung cancer. Passlick B. Lung Cancer. Vilmann P, Puri R. Minerva Med. Recent Activity.
Anesthesiology pp Cite as. Mediastinoscopy is widely utilized for the diagnosis and staging of diseases of the mediastinum. Most procedures are performed via a cervical incision. Patients may have significant co-morbidities related to their mediastinal disease such as large anterior mediastinal masses or Lambert-Eaton Syndrome. Anesthetic challenges include potential difficult ventilation and intubation, compression of the innominate artery and major hemorrhage. Knowledge of the implications of co-morbidities, mediastinal anatomy, surgical technique and associated complications are vital in the safe anesthetic care of patients for these procedures. Table
Anesthesia for Mediastinoscopy and Mediastinal Surgery
Mediastinoscopy is a diagnostic procedure, which was first described by Carlens in Despite the availability of sophisticated imaging techniques e. The mediastinum is the region between the two pleural cavities extending from the thoracic inlet to the diaphragm. It is divided into the superior and inferior mediastinum by the transverse thoracic plane, which is an imaginary plane extending horizontally from the sternal angle anteriorly to the inferior border of the T4 vertebra posteriorly. The inferior mediastinum is subdivided into anterior, middle, and posterior compartments by the heart and pericardium Fig.
This is an elective surgical procedure for the purpose of obtaining a tissue diagnosis for a mediastinal mass, typically mediastinal lymphadenopathy. Comorbidities govern the patient-specific problems you will encounter, which typically are associated with lung cancer the most common diagnosis made , such as hypertension, COPD, CAD, diabetes, and peripheral vascular disease. Perioperative problems include the potential for a mass effect impinging on vascular or airway structures depending on the size and location of the individual mass. This can be typically visualized on the CT scan that all these patients should have. More generally, the proximity of major vascular or airway structures explains the procedure-related complications from inadvertent biopsy of or direct injury with the mediastinoscope to vascular structures leading to sudden, severe bleeding. Airway injury and, rarely, esophageal injury can also result from similar mishaps; thus, a postoperative CXR required to rule out pneumothorax, pneumomediastinum, or subcutaneous emphysema.