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104 Mediastinotomy
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Mediastinoscopy
Mediastinal fat usually fills this space, so that a medi-
6
astinoscope must be introduced to adequately visualize
the aortopulmonary region for safe lymph node biopsy. The
scope is introduced and directed as dictated by the mental
image of the mediastinum that the surgeon has established
from tactile cues. Again, the surgeon should not hesitate to
probe and aspirate the area of interest with a thin-gauge
spinal needle if any question exists about the safety of performing the biopsy. The biopsy is performed using the same
technique and guidelines as those used for cervical mediastinoscopy. In addition to the major arteries, the recurrent
laryngeal nerve is the structure at greatest risk during this
portion of the operation.
The pleural envelope can be disrupted to allow the surgeon
to introduce the mediastinoscope into the left pleural space.
Through the mediastinoscope some limited information can
be obtained regarding the status of the parietal pleura and
lung. If evaluation of the lung and pleural space is the
principal goal of the operation, however, then VATS is likely
to be a better operative approach.
6
Closure
Intentional or unintentional transgression of
7a,b
a pneumothorax. If an air leak is present, then a small-bore
chest tube should be placed. If any question exists as to
whether an air leak is present, it is a simple matter to have the
anesthesiologist deliver and hold a large breath while the incision is flooded with saline. An air leak will result in a persistent stream of bubbles. If no air leak from inadvertent lung
injury is present, this complication can be treated without a
chest tube. At the time of closure, the rent in the pleura is
identified, and a 12- or 14-Fr red rubber catheter is passed
into the pleural space. The incision is then closed in layers
the pleura during mediastinotomy will result in
7a
7b
Further reading 105
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with absorbable sutures. Each successive layer is closed
around the red rubber catheter so that it describes an oblique
course as it exits from the chest. The goal is to have the
catheter exit through a tissue ‘flap valve’ that will collapse and
form an airtight seal when the catheter is removed. The skin
is closed with a running subcuticular absorbable stitch until
the catheter is encountered. At this point, the catheter is
occupying the last several millimeters of the skin incision that
remain to be closed. The anesthesiologist is then asked to give
the patient several large breaths while suction is applied to the
catheter. The catheter is gradually withdrawn as the breaths
are given. As the last several centimeters of the catheter are
approached, a large breath is held to produce constant positive pressure to keep the lung fully expanded while suction is
maintained on the catheter and it is slowly withdrawn. The
remaining corner of the skin incision is then completed,
Steri-Strips are applied, and the area occupied by the SteriStrips is then covered with a sterile gauze to prevent the SteriStrips from being dislodged when the outer dressing is
removed. A waterproof clear bandage, such as a Tegaderm, is
then placed over the gauze. The patient is then extubated and
recovered.
POSTOPERATIVE CARE
In the recovery room, an upright chest film, to rule out pneumothorax or hemothorax, and any other routine studies
requested by the surgeon are obtained. The usual postoperative check should also make note of the quality of the patient’s
voice to assure that recurrent laryngeal nerve injury has not
occurred. If the operation proceeded without incident and no
issues of concern arise in the recovery room, the patient may
be discharged home with the appropriate precautions, pain
medication and follow-up instructions. The patient is
instructed to leave the waterproof dressing in place for 2 days
and then remove it, leaving only the Steri-Strips. The patient
may shower on the day of discharge with the waterproof
dressing in place. Any postoperative issues, particularly suspicion of bleeding, are an indication for hospital admission and
close observation along with performance of the indicated
tests and studies.
OUTCOME
Mediastinotomy shares the same high sensitivity and specificity as cervical mediastinoscopy. Mediastinotomy is a small
procedure that can yield diagnostic information for mediastinal tumors or dramatically alter the staging and subsequent
approach to treatment of a patient with lung cancer.
Reported complications are rare, mortalities are exceedingly
rare and the procedure can generally be performed on an outpatient basis.
FURTHER READING
McNeill TM, Chamberlain JM. Diagnostic anterior mediastinotomy.
Annals of Thoracic Surgery 1966; 2(4): 532–9.
Olak J. Parasternal mediastinotomy (Chamberlain procedure). Chest
Surgery Clinics of North America 1996; 6(1): 31–40.
Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Matsuoka H. Prognosis
of completely resected pN2 non-small cell lung carcinomas: what is
the significant node that affects survival? Journal of Thoracic and
Cardiovascular Surgery 1999; 118(2): 270–5.
Patterson GA, Piazza D, Pearson FG, et al. Significance of metastatic
disease in subaortic lymph nodes. Annals of Thoracic Surgery 1987;
43(2): 155–9.
Ponn RB, Federico JA. Mediastinoscopy and staging. In: Kaiser LR, Kron
IL, Spray TL eds. Mastery of cardiothoracic surgery. Philadelphia:
Lippincott–Raven, 1998: 11–27.
Watanabe M, Takagi K, Aoki T, et al. A comparison of biopsy through a
parasternal anterior mediastinotomy under local anesthesia and
percutaneous needle biopsy for malignant anterior mediastinal
tumors. Surgery Today 1998; 28(10): 1022–6.
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12
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Intercostal drainage
NORIAKI TSUBOTA MD, PHD
Clinical Professor, Department of Thoracic and Cardiovascular Surgery, Kobe University School of Medicine, Kobe, Hyogo, Japan; Vice
President, Department of General Thoracic Surgery, Hyogo Medical Center, Akashi, Hyogo, Japan
PRINCIPLES AND JUSTIFICATION
The rather simple but important procedure of intercostal
drainage must be correctly taught to young surgeons.
Indications for insertion, size of the tubes, site of placement,
number of tubes, use or nonuse of suction, grade of negative
pressure, and timing of removal should be carefully specified.
If these are poorly judged, the patient may face a more complicated and even dangerous situation.
PREOPERATIVE ASSESSMENT AND
PREPARATION
Spontaneous pneumothorax
Spontaneous pneumothorax is one of the most common
indications for intercostal drainage. Rapid re-expansion of
the lung may produce pain, coughing, and even serious reexpansion pulmonary edema, which must be kept in mind
especially when the lung has been completely collapsed for a
few days. The equipment and drugs for an emergency should
be kept ready in the room. To avoid these complications, the
vacuum system is not used initially; the chest tube is just left
in the water seal bottle for a while and then suction may be
slowly added.
Tension pneumothorax is an emergency and usually
results from rupture of a bulla in patients with emphysema.
Urgent insertion of a chest tube with suction may relieve a
patient’s acute dyspnea. The lung fistula is frequently large.
nied by tension and is associated with injury in the contralateral side, the patient will surely be in a very precarious state.
A proper diagnosis must be made, and procedures should
be started immediately. If the emergency chest radiograph
shows an opaque appearance and deviation of the mediastinum, the attending doctor should consider the possibility
of performing thoracentesis, which is described earlier.
Other injuries, such as ruptured bronchus and esophagus or
damage to other vital organs, must be considered if the condition is serious.
Postoperative drainage
After lung resection, two tubes with a moderate negative
pressure of approximately 10–20 cm H
been recommended for proper drainage, one tube for air and
the other for fluid. Now, in the thoracoscopic era, however, if
the endoscopic procedure is not complicated, a single tube
might be sufficient, even for postlobectomy drainage. In such
instances, postoperative drainage is routinely provided by
using the scope port. Usually, the opening is larger than
needed by the tube, so that an additional skin stitch around
the tube is required to prevent leakage of fluid and air.
When air leakage is not massive, some thoracic surgeons
prefer not to suction the air and just leave in the tube connected to a water seal. In general, one should wait until
absolutely no air leakage remains to remove the tube.
However, in a very limited number of cases with minor leakage, the tube can be removed without any problem.
O have traditionally
2
Post-traumatic drainage
Pneumo- or hemothorax is a common acute condition
encountered after thoracic injury. If the condition is accompa-
Postpneumonectomy drainage
Postpneumonectomy drainage differs somewhat from that
described earlier. Neither fluid nor air is suctioned out. Some
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surgeons may not even leave a chest tube in the postpneumonectomy space. In my opinion, however, use of a chest
tube sealed with water for 1–3 days after the operation is helpful in recognizing postoperative bleeding. Sudden discharge
of a bloody content, which often surprises the attending doctor, may be caused by posture change and may be followed by
chest pain or even faintness. Proper management easily
resolves these symptoms.
Postpneumonectomy air leakage is a very serious condition. Two types are seen: one that develops early in the acute
recovery phase and another that develops late after discharge.
When a patient begins to expectorate sanguineous sputum
and an accompanying decrease of fluid is seen on the chest
radiograph, prevention of aspiration to the contralateral lung
is mandatory. Immediate bronchoscopy may disclose an
opening at the stump. If this occurs early after the operation
and it is still in the nonempyema stage, reopening the thorax
and reclosing the bronchus may be successful. If it develops at
a late stage, open-window thoracostomy should be chosen as
a temporary procedure.
Postresection drainage
Air leakage after lung resection usually ceases within several
days. Sometimes, when a large free space remains, such as in
the case of middle and lower lobectomy or left upper lobectomy, it may be prolonged, especially if the patient has an
emphysematous lung.
The first attempt is to reduce the chest tube pressure to a
level low enough to preserve lung expansion. Then, the tube
may be withdrawn 2 or 3 cm in a second attempt to allow the
air leak spot on the lung touched by the tube to change to
native tissue. By appositioning the parietal pleura, one may
facilitate healing of the leakage spot. Repeated trials of withdrawing the tube while watching the side hole position, lowering the suction pressure, and even instituting a water seal trial
are sometimes very helpful. In fact, in the era when operation
for tuberculosis was common, suction was not a standard
practice.
Changing the tube for a smaller one with a Heimlich-valve
bottle is another option and is very attractive, as the patient is
kept ambulatory. Sclerotherapeutic agents such as tetracycline hydrochloride, OK-432, and asbestos-free talc may serve
to stop both air leakage and effusion. They may be ineffective,
however, if the space is relatively large. Otherwise the discharge will become turbid, and the patient will develop
empyema. At this stage, thoracoscopic closure of the lung fistula using a sealant or stitches is easily tried with minimal
invasion and is effective, so that one should not hesitate to
choose this procedure.
Empyema
Parapneumonic empyema may be recognized when the discharge changes from serous to fibrinous or turbid during the
course of pneumonia with chest tube care. Rupture of a
severely infected lung or tumor produces pyopneumothorax
with multiple air-fluid level.
When the patient presents with these symptoms, closedtube drainage is no longer effective, and the discharge soon
becomes purulent. If the chest tube is not properly managed
at this stage, the patient easily enters the purulent phase with
a multi-loculated space, which can no longer be managed by
conservative methods and requires operative procedures such
as rib resection drainage and even the Eloesser procedure.
The reasons for failure during treatment of the parapneumonic space are as follows. Nondependent drainage is most
often a cause for chronicity. Tube size may not be large
enough to drain thick and large amounts of fluid, the tube
may be inserted late after the formation of a thick peel or
bronchopleural fistula, or drainage may be choked up with
coagula or foreign bodies.
Video-assisted thoracoscopy is another alternative for
treatment of this condition. Debridement and compact
decortication at the beginning of the organizing phase may be
achieved by this maneuver. Fibrin and loculations are swept
under endoscopic vision, and the peel is dissected from the
parietal and visceral surfaces of the pleura.
Acute exacerbation of a silent tuberculous empyema may
be encountered in a patient known to have a silent empyema
who is thin and has been in relatively good condition despite
having restricted lung function. To prevent pneumonia due
to aspiration to the opposite side through a bronchopleural
fistula, open thoracostomy drainage with a large window is
the first choice rather than closed tube drainage and must be
performed immediately after admission.
Malignant effusion
The tube insertion technique for malignant effusion does not
differ from the basic one; however, some points should be
remembered. Generally, patients with this condition are
undernourished, chronically ill, and even cachectic. Drainage
must be started slowly without suction. The attending doctor
should remain watchful for 20–30 minutes until the patient
becomes stable. If the patient develops any acute distress,
such as dyspnea, chest pain, or collapse, drainage should be
ceased immediately, and a chest radiograph should be taken.
If the chest radiograph discloses major mediastinal shift, this
may be corrected by the entrance of air, accompanied by
measures to alleviate the acute symptoms.
Although massive bloody, wine-like effusion is a typical
sign of malignant disease, such as lung cancer or diffuse
mesothelioma, negative results of cytological examination for
malignant cells and thin serous yellow fluid do not mean the
absence of malignancy. One should not make a quick diagnosis of tuberculosis and should not prescribe a long course of
antitubercular drugs without performing thoracoscopy.
Biopsy of the pleura must be carried out at this stage using
this technique.
Operation 109
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Instillation of an anticancer drug into the thoracic cavity is
often indicated for this condition after complete evacuation
of fluid and good re-expansion of the lung is achieved.
Effusion may be temporarily stopped with this procedure.
ANESTHESIA
Local anesthesia is started with a sufficient amount of intradermally injected anesthetic followed by subcutaneous infiltration and anesthesia of the muscles. Intercostal vessels run
beneath the ribs at the posterior and lateral thorax. After feeling the rib with the tip of the needle, one slides it upward
along the upper edge of the rib to avoid an injury to the vessels. Because the pleura is very sensitive, an adequate amount
of anesthetic must be infiltrated around it. A lower intercostal
space must not be entered. One must be aware that when a
pathological condition develops, such as post-traumatic or
parapneumonic pleuritis, the diaphragm is usually at a higher
than normal position.
OPERATION
Basic technique of thoracentesis and chest tube
insertion
Thoracentesis is one of the most common procedures
1
and may be carried out very easily. One must remember,
however, that it can be more dangerous than tube insertion.
Use of the wrong site for introduction of a sharp needle and
repeated trials may produce unnecessary complications such
as bleeding and iatrogenic pneumothorax, liver injury, and
even cardiac injury.
The surgeon waits several minutes until analgesia develops
well. The needle is introduced slowly, following the route of
the local anesthesia infiltrated. As soon as fluid is observed,
the needle is fixed using a hemostat. The hemostat is attached
along the skin to make sure that the tip of the needle remains
within the thoracic cavity at the same depth. Once the content
is determined, the content is slowly and carefully withdrawn.
When the patient begins to complain of dyspnea or chest
pain, the procedure is halted, and the needle is replaced with
a chest tube if necessary.
The chest tube is inserted through a 2-cm skin incision
over the second intercostal space in the midclavicular line or
fourth space in the anterior axillary line after ascertaining that
sufficient anesthesia has been attained. This site is adequate
for air drainage. A lower site, that is, the fifth or sixth intercostal space in the posterior axillary line, is chosen for fluid
drainage. A free pleural space is recognized through direct
vision of the pleural cavity. Some adhesion between the parietal and visceral pleura may be opened by finger dissection. A
No. 24–28 tube held with a large curved hemostat is introduced into the affected space. This support is helpful to guide
the tube to the place where it is needed.
A tube containing a rigid stent may be quickly introduced
into the chest cavity through a smaller skin incision and with
little exploring. This technique should be used only in a
patient with a completely collapsed lung. Using this type of
tube is not recommended, however, because it requires force
when inserted. This technique may result in a serious injury
to the lung or other structures.
Sufficient analgesia
Insertion along upper
edge of the rib
Breaking adhesion
and loculation
Directing towards
site where the
lesion presents
1
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Drainage device
The traditional three-bottle drainage system,
2, 3
bottle, and a suction-regulating bottle, is now available as a
which includes a collection bottle, a water seal
provided with a large No. 28 chest tube, adequately manages
relatively large volumes of air leak and discharge in the acute
postoperative period. In the chronic stage, however, when little air leakage and small amounts of discharge are present, it
might be replaced by simpler systems of drainage with smaller
No. 20–24 tubes, which allow the patient to walk around. One
of these is a collecting bottle equipped with a one-way
Heimlich valve; the other is the smallest unit, an aspiration
kit, which can inform the patient by a piping sound when an
air leak persists. The No. 8–10 tube of this unit is easily
inserted into the space with little discomfort. The patient can
even be sent home with the simpler unit. If the attending doctor can manage three different types of drainage devices
according to the patient’s condition, the patient can enjoy
freedom from a chain of drainage tubes. Needless to say, early
ambulation is one of the most important factors promoting
recovery.
2
3
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POSTOPERATIVE CARE
The whole route of the chest tube, from the site of insertion to
the bottle, must be inspected. Every day one must check for
smooth and moderate swinging of the fluid in the tube synchronized with the breathing cycle (tidaling) and for adequate water level in the sealed column, as well as noting both
the character and amount of the air leakage and the discharge.
Large swinging in the chest tube, as is usually observed after
pneumonectomy, indicates poor reaeration of the underlying
lung. Aggressive transbronchial suctioning or bronchoscopy
might be required to prevent the affected lung from developing microatelectasis. Sudden cessation of the discharge might
be a sign of tube trouble, especially if the content is bloody.
Massive development of subcutaneous emphysema, which is
seldom life threatening although it greatly worries the patient,
indicates a need to increase the suction flow by adding
another tube, or kinking of the tube behind the patient’s
back.
FURTHER READING
Cerfolio RJ, Tummala RP, Holman WL, et al. A prospective algorithm for
the management of air leaks after pulmonary resection. Annals of
Thoracic Surgery 1998; 66: 1726–31.
Kirsh MM, Rotman H, Behrent DM, Orringer MB, Sloan H. Complications
of pulmonary resection. Annals of Thoracic Surgery 1975; 20:
215–36.
Okada M, Tsubota N, Yoshimura M, Miyamoto Y, Yamagishi H, Satake S.
Surgical treatment for chronic pleural empyema. Surgery Today
2000; 30: 506–10.
Ponn RB, Silverman HJ, Dederico JA. Outpatient chest tube
management. Annals of Thoracic Surgery 1997; 64: 1437–40.
Schfers SJ, Dresler CM. Update on talc, bleomycin, and the tetracyclines
in the treatment of malignant pleural effusions. Pharmacotherapy
1995; 15: 228–35.
Weissberg D, Refaely Y. Pleural empyema: 24-year experience. Annals of
Thoracic Surgery 1996; 62: 1026–9.
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13
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Tracheostomy
RANDAL S. WEBER, MD, FACS
Hubert L. and Oliver Stringer Distinguished Professor of Cancer Research, Chairman Department of Head and Neck Surgery, University of Texas
MD Anderson Cancer Center, Houston, Texas, USA
ARA A. CHALIAN, MD, FACS
Specialist Associate Professor, Director Head and Neck Reconstructive Surgery Service, Department of Otorhinolaryngology–Head and Neck
Surgery, University of Pennsylvania Health System, Philadelphia, PA, USA
SARAH H. KAGAN, PHD, RN
Associate Professor of Gerontological Nursing; School of Nursing, Gerontology Clinical Nurse Specialist, Hospital of the University of
Pennsylvania; Secondary Faculty, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia, PA,
USA
HISTORY
The creation of an opening into the trachea for establishment
or maintenance of the airway dates back to antiquity. In the
early 1800s the procedure was performed by a few pioneering
surgeons for patients in danger of asphyxiation. In the latter
half of the nineteenth century and the early portion of the
twentieth century, tracheostomy has evolved into a lifesaving
procedure safely performed for patients with airway obstruction.
PRINCIPLES AND JUSTIFICATION
Elective tracheostomy is performed for various indications
but most commonly for respiratory failure and ventilator
dependency. Other indications include acute airway obstruction, congenital or acquired stenosis of the larynx, subglottis
or trachea, and the presence of copious secretions that cannot
be cleared by the patient. Surgical procedures on the upper
aerodigestive tract, which have the potential to produce
swelling of the base of tongue, larynx, or pharynx, are managed by elective tracheostomy.
PREOPERATIVE ASSESSMENT AND
PREPARATION
For elective tracheostomy under general anesthesia, the airway is first controlled by endotracheal intubation. When the
patient has some degree of airway obstruction and endotracheal intubation is considered hazardous, the tracheostomy is
performed with the patient awake and breathing spontaneously while monitored by the anesthesiologist.
OPERATION
The patient is supine, a transverse roll is placed beneath the
shoulders, and the neck is extended. This position hyperextends the neck, elevates the cricoid, and allows identification
of the laryngeal skeleton. The anesthesiologist has access to
the patient’s airway and remains in control of the endotracheal tube during the course of the tracheostomy. Among
patients with airway distress who are unable to lie flat on the
operating table, the procedure is performed in the semiFowler position with the head elevated. Hyperextension of
the neck, which may result in further airway embarrassment,
should be avoided. Administration of intravenous sedation
is avoided in this setting to prevent suppression of respiratory drive, which could produce apnea, and loss of the airway.
The two key surgical principles necessary to perform a
rapid, efficient, and safe tracheostomy are: (1) maintaining
orientation in the midline without deviation to the side of the
trachea and (2) meticulous hemostasis. The patient’s neck
and upper chest are prepped with an antiseptic solution, and
sterile drapes are placed appropriately for adequate exposure
of the surgical field.
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