Preoperative Evaluation and Questions: Indication for surgery? (Bronchogenic CA? Lymphoma? Thymoma?) Concern for Airway compression?
Risk: Bleeding, Pneumothorax, Tracheal damage
Induction/Airway: Standard. Mediastinal masses may compress upper airway after induction. If patient has large mass may need careful plan for induction and intubation. Lung CA patients w/ Eaton-Lambert may be resistant to NMB drugs.
Lines and Monitors: Standard ASA. Consider A-line based on health of patient. If an a-line is to be placed, placement in the right radial artery allows for not only monitoring of blood pressure, but also allows the anesthesiologist to be aware of surgical compression on the innominate artery. Some patients may be scheduled for Thoracotomy/Thoracoscopy immediately following Mediastinoscopy. In those cases place A-line and thoracic epidural.
Mode of anesthesia: General Anesthesia
Positioning: Supine. Table rotated 90 degrees.
Surgical Course: Usually preceded by flexible bronchoscopy. Small incision at sternal notch. Surgeon will dissect with cautery and sample lymph nodes at multiple levels. Nodes sent for frozen section, may do more based on pathology results. Quick closure may be a problem because relaxation is necessary for duration Mediastinoscopy. May be followed immediately by Thoracotomy for excision of lung CA.
Intraoperative Goals and Events: Paralysis is required until end of procedure. Coughing or moving will increase risk of damage to nearby structures (major blood vessels, trachea). Pulse-ox on right hand to monitor innominate artery compression. Pain control with opioids.
EBL: less than 100ml. Close proximity to innominate artery and vein, so potential for large rapid blood loss.
Post-Operative Concerns, Transport, Disposition: To PACU Post-op. CXR in PACU to check for PTX. Monitor for hematoma development which can compress airway.