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16. Usually because of inadequate anesthetic to vocal cords and tracheobronchial tree.
17. Sepsis (usually after BAL)
18. Do not perform in patients with bilateral vocal cord paralysis
19. Can lead to edema resulting in life-threatening airway obstruction
Template Dictation
Preoperative Diagnosis: [INDICATIO N – e.g. severe/change in cough, hemoptysis, diffuse lung disease, bacteriologic
sampling, lung abscess, aspiration)
Postoperative Diagnosis: Same
Procedure(s) Performed: Flexible bronchoscopy (with associated procedures)
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT –e.g. worsening
cough and unresolving pneumonia]. Chest xray and sputum culture reveals [FINDINGS – collapse of lobe with gram stain with
gram negative rods.].
Description of Procedure: The flexible bronchoscopy tower and bronchoscope was brought to the patient’s room on [DATE].
The patient’s identity and planned procedure were verified, and a time out was performed. Monitors and supplemental oxygen
were applied. We proceeded to anesthetize the patient topically. The flexible bronchoscope was inserted
[TRANSORALLY/TRANSNASALLY]. The vocal cords were visualized and bilateral movement was noted [or abnormal
movement on the (left/right) side was noted]. 1% lidocaine was injected through the bronchoscopy port anesthetizing the
larynx. The tracheobronchial tree remote from the area of interest was assessed first. All lobes and segments were clearly
visualized. Pathologic findings included [FINDINGS, e.g. bronchial irritation, edema, etc). The bronchoscope was then
moved to the area of concern. Findings of (e.g. large purulent mucous with edema) was identified in (area of
tracheobronchial tree)]. (Further diagnostic procedures performed as indicated and described). Specimens removed
included [X, e.g bronchoalveolar lavage]. The bronchoscope was successfully removed without complication. Patient’s
hemodynamics continued to be [X, e.g. stable] at the end of procedure. The patient remained in a monitored bed post
procedure.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
2. Rigid Bronchoscopy
Cameron T. Stock, MD and Douglas J. Mathisen, MD
Massachusetts General Hospital, Boston, MA
Essential Operative Steps
1. Induction of anesthesia is initiated when all equipment and team members are present
2. The patient’s neck is extended and a teeth guard is placed on the upper incisors
3. The bronchoscope is used to lift the epiglottis revealing the vocal cords
4. The bronchoscope is rotated 90 degrees while passing through the cords to minimize trauma
5. The bronchoscope is connected to the ventilator
6. The bronchoscope is advanced under direct vision to the area of interest
7. Serial dilations should proceed with gentle pressure and small incremental increases in the diameter of the
bronchoscope. A gentle corkscrew action under direct vision is best.
Potential Complications and Pitfalls
1. Failure to clearly visualize the epiglottis and vocal cords by being posterior and under the larynx
2. Creation of a mucosal flap with the tip of the bronchoscope by advancing forcefully or without clearly visualizing the
tracheal lumen
3. Perforation of the tracheal lumen by using excessive force or by not being in the axis of trachea when dilating a
stenotic segment
4. Inadequate ventilation leading to CO2 retention, acidosis and potential for arrhythmias
Template Dictation
Preoperative Diagnosis: Tracheal stenosis, tracheal malignancy
Postoperative Diagnosis: Same
Procedure(s) Performed: Rigid bronchoscopy, dilation of tracheal stenosis, dilation of endobronchial tumor
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with known [tracheal tumor, tracheal stenosis, newly diagnosed
asthma] who presented with increasing dyspnea and audible stridor. The patient was noted to be hypoxic with an increased
work of breathing. Humidified facemask oxygen was administered, and the patient’s symptoms stabilized. The patient was
observed in the ICU while waiting for the operating room to open. The patient was brought expeditiously to the operating room
for evaluation.
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient was identified with two
unique identifiers and the correct procedure was confirmed. The patient was placed supine on the operating table. After all
necessary equipment and all members of the surgical team were confirmed present, general anesthesia was administered. Rigid
bronchoscopes of sizes ranging from 3.5 mm to 9 mm and Jackson-Pilling esophageal bougies were available in the operating
room. After the patient was preoxygenated with mask ventilation, the #7 rigid bronchoscope was passed into the patient’s
mouth and the glottis was clearly visualized. Care was taken not to lever the scope off the patient’s incisors. The epiglottis was
retracted anteriorly using the tip of the bronchoscope revealing the vocal cords. Both cords were noted to be moving
symmetrically and no glottic edema was noted. The bronchoscope was passed through the cords by rotating the scope 90
degrees to enter the trachea parallel to the cords. The scope was cleared of secretions. The visualized tracheal mucosa was
noted to be free from inflammation. We discussed with the anesthesiologist paralyzing the patient or using deep inhalation
anesthesia. It was decided to proceed with our preferred method of spontaneous ventilation under deep inhalation anesthesia as
the patient was adequately ventilating.
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[Choose One:]
If obstructing tumor: We observed a near obstructing endobronchial tumor at the takeoff of the right mainstem
bronchus. The #7 rigid bronchoscope was able to pass distal to the lesion along the membranous wall revealing a normal
appearing bronchus intermedius that was not involved with tumor. The lesion was initially biopsied with a cupped biopsy
forceps to check for consistency and avascularity. Next, using the beveled tip of the bronchoscope and advancing slowly with a
constant rotary motion, the center of the tumor was cored out. After several passes with the bronchoscope in this manner, we
were left with a patent bronchial lumen. Bleeding was controlled with direct pressure applied by the bronchoscope, and tumor
fragments were removed with the suction catheter. At the conclusion of the procedure the bronchoscope was able to easily
pass through the right main bronchus into the bronchus intermedius.
If benign stenosis: At 3 cm distal to the vocal cords, we observed a tight tracheal stenosis consistent with the patient’s
known post-intubation stenosis. The tracheal lumen appeared to narrow to a diameter of 2-3mm, and the surrounding tracheal
mucosa appeared injected and inflamed. Secretions were cleared with a long suction catheter. Serial dilations of the stricture
were initiated using the Jackson-Pilling esophageal bougies beginning with the smallest and progressively increasing their size.
Next the #7 bronchoscope was withdrawn, and the 3.5 mm bronchoscope was advanced to the lesion. Using firm but gentle
pressure and slight rotation of the bronchoscope, the scope was advanced past the stenotic segment. Care was taken not to exert
excessive force so as to avoid perforating the membranous trachea proximal to the lesion. The bronchoscope was immediately
connected to the ventilator and the patient was bag ventilated to facilitate clearance of CO2. The 4 mm bronchoscope was next
used to traverse the lesion. We incrementally increased the size of the bronchoscope until the 8 mm bronchoscope was able to
pass easily through the area of previous stenosis. Small tissue fragments were carefully removed using the biopsy forceps and
suctioning. Areas of bleeding were tamponaded using the bronchoscope and topical dilute epinephrine was also used to control
oozing from the tracheal lumen. At this point no further dilations were thought to be necessary. At the conclusion of the
procedure, the patient was well oxygenated and hemodynamically stable. All instrument, sponge, and needle counts were
confirmed to be correct. The bronchoscope was withdrawn. The patient was awoken from anesthesia and brought to the
recovery room in stable condition. In anticipation of some swelling following our dilation, Decadron 10 mg IV then 4 mg IV
every 6 hours for 24 hours was ordered for the patient. A chest x-ray was ordered.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
3. Esophagogastroduodonoscopy
Timothy J Pirolli, MD and Ahmad Y. Sheikh, MD
Stanford University Hospital and Clinics, Stanford, California
Essential Operative Steps
1. Lines and Monitoring
2. General endotracheal anesthesia with single-lumen endotracheal tube or monitored anesthesia care
3. Checking all equipment to ensure the video monitor, insufflation and saline infusion ports are working adequately.
4. Insert gastroscope into esophageal inlet (direct laryngosopy may be used to facilitate insertion of scope)
5. Advance gastroscope with insufflation and examine the esophagus. Assess for mucosal changes. Document location
of z-line (gastroesophageal junction) and diaphragmatic pinch to assess for a hiatal hernia.
6. Advance gastroscope with insufflation and examine the gastric mucosa
7. Retroflex gastroscope to examine the cardia. Endoscopically grade (i.e., Hill classification) of the gastroesophageal
valve.
8. Advanced gastroscope with insufflation to examine the pylorus and duodenum.
9. Take biopsies as needed
10. Retract gastroscope with desufflation under direct vision
11. Extubate patient and transfer to PACU
Potential Complications and Pitfalls
1. Oropharyngeal trauma
2. Difficulty positioning gastroscope down the esophagus due to anatomical anomalies or strictures. A pediatric
gastroscope and or gentle dilatation may be helpful
3. Bleeding
4. Esophageal or gastric perforation
5. Failure to desufflate the gastrointestinal lumen
Template Dictation
Preoperative Diagnosis: [INDICATION - e.g. Dysphagia, GERD]
Postoperative Diagnosis: Same
Procedure(s) Performed: Esophagogastroduodenoscopy.
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [COMPLAINT – e.g. increasing
dysphagia and reflux]. After the risks and benefits were describe to the patient, he/she signed informed consent and proceeded
to the operating room for an esophagogastroduodenoscopy
Description of Procedure: The patient was taken to the operating room on [DATE]. The patient’s identity and planned
procedure verified with a surgical timeout, and the patient was placed on the operating room table in the supine position.
General anesthesia with a single-lumen endotracheal tube was obtained. The flexible adult gastroscope was inserted into the
posterior oropharynx and posterior to the left arytenoid, into the esophageal inlet. Insufflation was gently used to expand the
lumen. The cricopharyngeus was located at [DISTANCE] from the incisors. The cervical and thoracic esophagus were
inspected and normal mucosa was observed. There were no strictures, esophagitis, erosions, ulcers, petechiae, or other
abnormalities. The gastroesophageal junction was located at [DISTANCE] from the incisors. There was no evidence of
Barrett’s esophagus, hiatal hernia or other abnormalities. [Insert abnormal findings] We then entered the stomach. The
gastroscope was retroflexed to examine the cardia, which was normal. A Hill class [X] valve was noted. The remainder of
the stomach was examined and appeared normal. The gastroscope was then advanced to the pylorus, which was widely
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patent. The scope was inserted through the pylorus without difficulty, and the first, second and third portions of the duodenum
were inspected and found to be normal, without evidence of ulcer disease. The duodenum and stomach were evacuated free of
air and debris and the scope withdrawn into the distal esophagus. There was no evidence of perforation or mucosal
irregularity. We then removed the gastroscope without difficulty.
All instrument, sponge and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
extubated and subsequently transferred to the post-anesthesia care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
4. Mediastinoscopy
Nicholas Baker, MD and Ryan Levy, MD
University of Pittsburgh Medical Center, Pittsburgh, PA.
Essential Operative Steps:
1. Right radial arterial line
2. General endotracheal anesthesia
3. Prep and drape entire neck and chest in the event an emergent median sternotomy is required
4. Transverse skin incision one fingerbreadth above sternal notch
5. Divide platysma transversely and strap muscles longitudinally in midline
6. Palpate for high innominate artery
7. Incise pretracheal fascia and enter with mediastinoscope
8. Blunt finger dissection to develop the pretreacheal plane to the level of the carina, staying on the trachea during the
dissection
9. Insert mediastinoscope with tip angled toward airway
10. Identify carina and level 7 lymph nodes
11. Identify left tracheobronchial angle and level 4L nodes
12. Identify right tracheobronchial angle and level 4R nodes
13. Biopsy superficially with care not to injure deep structures.
14. Check for hemostasis
15. Approximate strap muscles, platysma, and skin
Potential Complications and Pitfalls:
1. Review preoperative CT for calcified lymph node targets, high innominate artery and aberrant anatomy
2. Place patient with head at top of bed with full neck extension
3. Eye protection for the patient
4. Monitor arterial line to identify excess pressure on innominate artery
5. Palpate for high innominate artery.
6. Mediastinoscope must be under pretracheal fascia
7. Keep tip of mediastinoscope angled toward airway when advancing in to chest
8. Stay on the trache and mainstem bronchi
9. Biopsy superficially only visible nodes
10. Structures at risk for injury when biopsying level 7 nodes: esophagus, deep main pulmonary artery, anterior
pericardium, left atrium
11. Structures at risk for injury when biopsying level 4L nodes: lateral aorta and left recurrent laryngeal nerve (NO
CAUTERY due to the risk of nerve injury)
12. Structures at risk for injury when biopsying level 4R nodes: lateral azygos , pleura, right pulmonary artery
13. Control bleeding with pressure the pretracheal space (DO NOT REMOVE MEDIASTINOSCOPE WHEN YOU
ENCOUNTER BLEEDING). Pack the pretracheal plane, keep calm, assess the situation and assure you have
adequate IV access and help. A Sternal saw should be kept in the room at all times during this operation so that it
may be immediately available in an emergency.
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. Lung cancer, lung nodule, mediastinal lymphadenopathy]
Postoperative Diagnosis: Same
Procedure(s) Performed: Video assisted mediastinoscopy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
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Anesthesia: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [DURATION] history of [Complaint – e.g. lung mass,
nodule, or mediastinal lymphadenopathy].
Description of Procedure: The patient was taken to the operative suite on [DATE]. The patient’s identity and planned
procedure verified and the patient was placed supine of the operating table. Following an uneventful induction of general
anesthesia, the patient was intubated with a single lumen endotracheal tube without incident. A right radial arterial line was
placed. The patient’s arms were tucked, a shoulder roll was placed, and the neck was extended as much as safely possible.
Eye protection goggles were placed on the patient. The patient’s neck and entire chest was prepped and draped in a sterile
standard fashion.
The skin was marked one finger breadth above the sternal notch. A transverse two centimeter skin incision was made and
electrocautery was used to incise the platysma in a transverse fashion. The strap muscles were divided in the midline in a
longitudinal fashion. The trachea was identified, pretracheal fascia was sharply incised with Metzenbaum scissors and the
pretracheal space was developed using blunt finger dissection.
Next the mediastinoscope was placed into the pretracheal space just above the trachea and advanced into the mediastinum.
Blunt dissect with a mediastinoscope sucker with intermittent touch cautery was, used to dissect along the anterior trachea
down to the level of the carina. The right and left main stem bronchus were identified. Blunt dissection with suction and touch
electrocautery was used to identify level 7 lymph nodes. Cup biopsy forceps were used to superficially biopsy visible level 7
nodes. Next, the left tracheobronchial angle was identified. Blunt dissection without using electrocautery was used to dissect
level 4L lymph nodes. Cup biopsy forceps were used to superficially biopsy visible level 4L nodes. Next, right
tracheobronchial angle was identified. Blunt dissection with suction and touch electrocautery was used to dissect level 4R
lymph nodes. Cup biopsy forceps were used to superficially biopsy visible level 4R nodes.
Hemostasis was obtained with careful electrocautery and pressure from packing a sponge into the wound. The sponge was
removed and hemostasis was acceptable. The mediastinoscope was removed. The strap muscles were approximated with #2-0
absorbable stitch, the platysma was approximated with a #2-0 absorbable stitch, and the skin was approximated with a #4-0
absorbable stitch. Benzoin, steri-strips, and dry sterile dressing were applied.
All instrument, sponge, and needle counts were confirmed to be correct x 2 at the end of the operation. The patient was
extubated in the operating room and subsequently transferred to the post anesthesia care unit in stable condition.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
5. Chamberlain Procedure
Geoffrey T. Lam, MD, and Jessica S. Donington, MD
NYU School of Medicine, New York, NY
Essential Operative Steps
1. Lines and monitoring
2. General endotracheal anesthesia: double-lumen tube preferable but not essential
3. Bronchoscopy: to confirm double-lumen tube placement
4. Transverse mediastinotomy in second left intercostal space
5. Preservation of internal mammary artery
6. Biopsy
7. Evacuation of pleural air if pleural space entered
8. Closure of incision
Potential Complications and Pitfalls
1. Injury to internal mammary artery or vein
2. Injury to aorta or pulmonary artery
3. Pneumothorax
4. Injury to phrenic nerve
5. Injury to recurrent laryngeal nerve
Template Dictation
Preoperative Diagnosis: [INDICATION – e.g. mediastinal lymphadenopathy, anterior mediastinal mass]
Postoperative Diagnosis: Same
Procedure(s) Performed: Chamberlain procedure with biopsy, fiberoptic bronchoscopy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Fluids: [BLANK]
EBL: [BLANK]
Specimens: [BLANK]
Drains: [BLANK]
Indication(s) for Procedure: [AGE] year old [GENDER] with [MEDIASTINAL LYMPHADENOPATHY]. Preoperative
imaging revealed [FINDINGS].
Description of Procedure: Informed consent for surgery was obtained from the patient, including a discussion of risks,
benefits and alternatives, and the form was documented in the chart. The patient was taken to the operating room on [DATE]
and placed on the operating room table in the supine position. Anesthesia inserted appropriate intravascular access and
hemodynamic monitoring lines. Preoperative IV antibiotics were administered. A time out was observed to identify the
correct patient, procedure and anatomic location. General endotracheal anesthesia through a double-lumen tube was then
induced. Bronchoscopy was performed, which confirmed proper placement of the endotracheal tube. The patient was left in
the supine position with the neck extended and the arms tucked. A Bair Hugger was applied and all pressure points were
padded. The left lung was isolated [IF SINGLE LUNG VENTILATION USED]. The neck and chest were prepped and
draped in sterile fashion.
A 3 cm transverse incision was made in the second intercostal space to the left of the sternum. The pectoralis muscle was
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divided in the direction of its fibers, thereby exposing the chest wall. The intercostal fibers were divided from the superior
aspect of the third rib, taking care not to injury the internal mammary artery. The mediastinal space was entered. Exposure
was obtained by retracting the internal mammary artery medially, and by dissecting the mediastinal pleural free from the
posterior sternum and retracting it laterally. The aortopulmonary window was digitally palpated and examined for enlarged
lymph nodes. Lymph nodes were sampled from station 5 and 6 [DIRECTLY/USING THE MEDIASTINOSCOPE] and
were passed off the field. The vagus and phrenic nerves were seen along the aortic arch and preserved. Hemostasis was
achieved by direct pressure. Because the pleural space was entered, a small red rubber catheter was placed into left pleural
space. The incision was closed in layers. The pectoralis fascia was closed using a running 0 Vicryl suture. The patient’s
back was then raised, and the left lung was re-inflated with the end of the red rubber catheter submerged under saline. When
the bubbling ceased, the catheter was removed. The subcutaneous layer was closed using 2-0 Vicryl, and the skin was closed
using a running 3-0 Monocryl subcuticular stitch. Sterile dry dressings were applied.
The patient tolerated the procedure well. The patient was extubated in the operating room and transferred in stable condition
to the recovery room. At the end of the case, the sponge, needle and instrument counts were correct x2.
Dr. [BLANK] was present and scrubbed for [BLANK] elements of this procedure.
6. Diagnositic Thoracoscopy
Nicholas Engstrom, MD and Brandon Tieu, MD
Oregon Health and Sciences Center, Portland, Oregon
Essential Operative Steps
1. Lines and Monitoring
2. Single lumen endotracheal intubation
3. Flexible Bronchoscopy
4. Dual lumen endotracheal exchange
5. Positioning (lateral decubitus)
1. Axillary roll
2. Bean bag
3. Elevated arm support
4. Bed Flexion
6. Camera port 7
th
intercostal space, mid-axillary line
7. Working port in 5
th
intercostal space, anterior axillary line
8. Parietal pleural visualization
9. Mediastinal pleural visualization
1. Anterior
2. Posterior
10. Diaphragm visualization
11. Inspection of the fissures
12. Palpation of the Lung
13. Biopsy
14. Assess hemostasis
15. Intercostal nerve blocks
16. Chest tube placement
17. Assess lung re-inflation
Potential Complications and Pitfalls
1. Chest entrance injuries
1. Lung
2. Diaphragm
3. Heart (left sided approach)
2. Biopsy site bleeding
3. Post op air-leak
4. Insufficient visualization
Template Dictation
Preoperative Diagnosis:
Postoperative Diagnosis:
Procedure(s) Performed: Diagnostic Thoracoscopy
Attending Surgeon: [BLANK]
Secondary Surgeon: [BLANK]
Assistants: [BLANK]
Anesthesia: [BLANK]
Indication(s) for Procedure: Patient is a (AGE) year old (GENDER) with (DURATION) history of (COMPLAINTS).
He/she was evaluated with (TESTS) and found to have (FINDINGS). A formal discussion regarding diagnostic thoracoscopy
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