MEDIASTINOSCOPY
Mediastinoscopy is a surgical procedure that allows a doctor to examine the mediastinum. The mediastinum is the part of the chest that lies between the sternum and the spinal column, and between the lungs. This area contains the heart, esophagus, trachea, lymph nodes, and other vital structures.
The procedure is typically performed to diagnose diseases of the lymph nodes of the chest, such as cancer (especially lung cancer), infections, or other disorders. It's often used when imaging studies like CT scans or PET scans reveal abnormalities in the mediastinum that require further investigation.
Here's how a mediastinoscopy is generally performed:
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Preparation: The patient is given general anesthesia so they will be asleep and pain-free during the procedure. Blood tests and imaging studies may be done beforehand to help plan the surgery.
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Incision: The surgeon makes a small incision (about an inch long) just above the breastbone or on the side of the neck.
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Inserting the Mediastinoscope: A thin, lighted tube called a mediastinoscope is inserted through the incision. This scope may have a camera attached so the surgeon can view the area on a video screen.
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Examination and Biopsy: The surgeon uses the scope to examine the mediastinum. Instruments can be passed through the scope to take tissue samples (biopsies) from lymph nodes or other structures.
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Closure: The incision is then closed with sutures, and a bandage is applied.
Anesthetic Implications for Mediastinoscopy
Anesthesia type: General anesthesia, epidural
Airway: ETT
Preoperative:
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Mediastinoscopy involves endoscopic visualization of the mediastinum
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Anterior mediastinal masses can cause distal airway obstructions
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Patients with anterior mediastinal masses are often unable to lie flat
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If airway collapse is likely with muscle paralysis, maintain patient spontaneously breathing
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Anterior mediastinal masses: Catastrophic airway obstruction or cardiovascular collapse on induction of anesthesia
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Posterior mediastinal masses may cause Horner’s syndrome when excised
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A left radial arterial line should be used
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The pulse oximeter may be placed on the patient’s right hand to monitor possible compression of the right innominate artery
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Enlarged lymph nodes or tumors may compress the trachea and surrounding structures
Intraoperative:
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The lungs possess a rich lymphatic system
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Important to provide adequate muscle relaxation
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The biopsy is sent to pathology (the surgeon may decide to wait for the pathology report prior to closing)
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Position: Supine. The head may need to be flexed or extended
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Duration: 1 hour
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The innominate artery may be compressed by the scope, causing decreased blood flow to the
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right cerebral hemisphere and the right upper extremity
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May encounter vagally mediated reflex bradycardia secondary to compression of the trachea or great vessels
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Avoid nitrous oxide due to potential pneumothorax
Postoperative:
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Pain management
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Assess for airway obstruction
Complications:
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Compression of the innominate artery by the scope
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Cerebral ischemia
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Stroke
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Massive hemorrhage
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Vascular trauma
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Pneumothorax
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Recurrent laryngeal nerve injury
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Vocal cord paralysis
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Phrenic nerve injury
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Venous air embolism
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Arrhythmias
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Vagally mediated reflex bradycardia
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Chylothorax
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Tracheal injury
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Esophageal injury
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Pleural tear
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Airway obstruction
Sources:
Longnecker, D. E., Brown, D. L., Newman, M. F., & Zapol, W. M. (2012). Anesthesiology, 2nd ed.
Macksey, L. F. (2011). Surgical procedures and anesthetic implications: A handbook for nurse anesthesia practice.
Jaffe, R. A. (2020). Anesthesiologist's Manual of Surgical Procedures (6th ed.).
Singh-Radcliff, N. (2013). 5-Minute Anesthesia Consult.