• A mediastinoscopy facilitates mediastinal exploration in a less invasive manner than a sternotomy or thoracotomy.
• The lungs possess a rich lymphatic system that drains into the subcervical, paratracheal, and supracervical nodes.
• The procedure is mainly performed to biopsy mediastinal lymph nodes to assess the spread of bronchogenic carcinoma; it is considered as the gold standard for mediastinal lymph node staging.
  • A cervical approach can be employed for pretracheal, paratracheal, and anterior subcarinal nodes.
  • A transthoracic or anterior approach is commonly used for aortopulmonary nodes.
• The procedure entails dissection between the trachea and pretracheal fascia. A mediastinoscope (lighted instrument) is inserted and advanced along this plane to the level of the carina; it remains behind the aortic arch, the innominate artery, and the innominate vein.
  • Needle aspiration and biopsy may be performed
  • Clips may be placed to facilitate X-ray visualization
  • A drain may be inserted to allow for blood, fluid, or air collection
  • Often performed in conjunction with a bronchoscopy
• Other indications for mediastinoscopy include:
  • Biopsies when sarcoidosis, Hodgkin's disease, or tuberculosis are suspected
  • Excision of mediastinal masses

• Supine
• Reverse Trendelenburg
• Shoulder roll with neck extension

• Suprasternal transverse for cervical mediastinoscopy; approximately 1–2 cm above the sternum and 4 cm long.
• Parasternal, usually left second interspace for transthoracic mediastinoscopy (Chamberlain's procedure or anterior mediastinotomy).

Less than one hour

• Minimal
• Risk of significant hemorrhage if vascular injury occurs.

Outpatient versus 23-hour observation.

Mediastinoscope: A handle with a blade that appears similar to a laryngoscope (Miller blade). The instrument is lighted and can either have a lens that allows for direct visualization or can be attached to a cable that allows for video-assisted display onto a monitor screen. Biopsy instruments are passed through a large channel alongside the scope.

Incidence

for use in lung cancer evaluation most commonly

• Bleeding (0.73%)
• Pneumothorax (0.66%)
• Recurrent laryngeal nerve injury (0.34%)
• Cerebral ischemia
• Esophageal perforation
• Pleural tear
• Laceration of trachea
• Acute tracheal collapse
• Tension pneumomediastinum

Overall: 0.09%

History

• Usually performed for lung cancer with enlarged nodes or mediastinal lymph node enlargement due to lymphoma, thymoma, or retrosternal goiter.
• Commonly performed for sarcoidosis, tuberculosis, or therapeutic excision of a mediastinal mass.
• Therapy: Chemotherapy and/or radiation.

Signs/Physical Exam

• Tracheal deviation
• Vein engorgement

Labs/Studies

• Chest CT: To look for any airway obstruction or distortion, or any vascular (superior vena cava) obstruction
• Carotid studies: To determine if there is an increased risk for cerebral malperfusion during surgical manipulation
• Type and cross: Blood should be available in the event of vascular injury

Anxiolysis may be considered if there is no evidence of airway obstruction.

• Awake fiberoptic intubation may be planned when there is a risk for airway obstruction (mass is encroaching into the trachea) or potential for anterior mediastinal mass collapse. Discuss the indications and reasonable sedation goals.
• Massive blood loss, requiring transfusion of blood products.

A third generation cephalosporin for skin organisms

General endotracheal anesthesia with neuromuscular blockade offers a more controlled environment, especially with surgical manipulation

• Standard monitors
• Radial arterial line
• Large bore peripheral IV (14–16G)
• Arterial line and/or pulse oximeter should be placed on the right upper extremity in order to immediately recognize compression of the innominate artery by surgical manipulation.

• Awake fiberoptic intubation if there is an anticipated difficult airway or risk of airway obstruction with induction and muscle relaxant. This technique will allow for the maintenance of airway patency and spontaneous ventilation while securing the airway.
• IV induction with muscle relaxant (short acting) if the patient has no signs or symptoms of airway compression or obstruction.
• Mask induction to maintain spontaneous ventilation may also be used if there is concern about airway obstruction with muscle relaxant and no contraindications such as GERD.

• Volatile anesthetic or total intravenous anesthesia may be chosen. Volatile agents are chosen when spontaneous ventilation is desired and should be considered in patients with reactive airway disease (potent bronchodilators).
• Muscle relaxants can aid with surgical manipulation and visualization as well as prevent coughing and venous engorgement in the chest. However, it should be avoided when attempting to keep the patient spontaneously ventilating.
• Avoid nitrous oxide due to the potential for pneumothorax and pneumomediastinum.

• Plan for extubation in the operating room.
• If the surgeon identifies potential damage to the recurrent laryngeal nerve, assess injury after extubation by having the patient vocalize the letter "e."