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ABTS - Thoracic Surgery Notecards > Anatomy and Surgical Approaches to the Mediastinum > Flashcards

Anatomy and Surgical Approaches to the Mediastinum Flashcards

1
Q

Boundaries of mediastinum

A
  • Sternum (anterior)
  • Spine (posterior)
  • Thoracic inlet (superior)
  • Diaphragm (inferior)
  • Pleurae (laterally)
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2
Q

Boundaries and structures of Anterior compartment

A
  • Sternum (anterior)
  • Great vessels and percardium (posterior)
  • Contents:
    • Thymus
    • Internal mammary arteries
    • Adipose tissue
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3
Q

Boundaries and structures of Middle Compartment

A
  • Great vessels and pericardium (anterior)
  • Anterior surface of thoracic spine (posterior)
  • Contents:
    • Great vessels
    • Pericardium
    • Heart
    • Trachea
    • Proximal main stem bronchi
    • Vagus and phrenic nerves
    • Esophagus
    • Thoracic Duct
    • Descending Aorta
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4
Q

Boundaries and stuctures of the Posterior Compartment

A
  • Mostly a potential space that lies laterally along spine
  • Contents:
    • Sympathetic chain + ganglia
    • Intercostal neurovascular bundles
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5
Q

Definition of Medistinal LN levels

A

Levels 1-9

(contained in mediastinal pleura)

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6
Q

Surgical options for mediastinal access

A
  • Cervical mediastinosopy
  • Anterior mediastinoscopy (Left side = Chamberlain procedure)
  • Median sternotomy
  • Transcervical approach
  • Bilateral thoracosternotomy (Clamshell)
  • Unilateral thoracosternotomy (Hemi-clamshell)
  • VATS
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7
Q

MC indication for MLN biopsy

A

Assess for N2 nodal involvement in stage I-III NSCLC

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8
Q

Rationale for pursuing MLN sampling for NSCLC

A

5% false-negative rate to detect MLN mets with PET/CT

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9
Q

Other indications for MLN biopsy

A
  • Tissue diagnosis in setting of mediastinal lymphadenopathy (sarcoid, lymphoma)
  • Biopsy mediastinal masses
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10
Q

Relative contraindications to cervical mediastinoscopy

A
  • Severe kyphosis of c-spine
  • tracheostomy
  • Large thyroid goiter
  • Aortic arch or innominate artery aneurysm
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11
Q

Cervical mediastinoscopy should not be performed in the presence of what conditions

A

SVC syndrome (high risk of bleeding)

Significant innominate artery calcifications (high risk of embolic stroke)

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12
Q

MLN levels accessible during cervical mediastinoscopy

A

Levels 2,4,7

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13
Q

MC complications of cervical mediastinoscopy

A
  • Major bleeding (0.1-0.6%)
  • RLN injury (0.5%)
  • Pneumothorax
  • Airway injury
  • Esophageal perforation
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14
Q

MC biopsy site associated with major hemorrhage during cervical mediastinoscpy

A

Station 4R

(injury to azygous or SVC)

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15
Q

2nd MC biopsy site associated with major bleeding during cervical mediastinoscopy

A

Station 7

(RPA and bronchial artery bleeding)

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16
Q

MC biopsy site associated with RLN injury during cervical mediastinoscopy

A

Station 4L

(minimize use of electrocautery along left boarder of trachea)

17
Q

MLN levels accessible during EBUS/TBNA

A

Stations 1,2,3,4,7

(Can also access 10 and 11)

18
Q

Left anterior mediastinoscopy (Chamberlain procedure) can access which MLN levels

A

Levels 2,4,5,6,7

(Anterior medistinoscopy can be used to biopsy left or right mediastinal masses)

19
Q

Surgical access for anterior mediastinoscopy

A
  • Small transverse incision just lateral to sternal boarder in 2nd or 3rd ICS
    • Resection of costal cartilage will enhance exposure
    • Avoid injury to IMA and phrenic nerve
20
Q

Median sternotomy most frequently used for what mediastinal condition

A

Thymectomy

21
Q

Transcervical approach to anterior mediastinum utilized for what procedures:

A
  • Thymectomy
    • Non-invasive
    • < 4 cm
  • Biopsy or resection of anterior mediastinal tumors (e.g parathyroid adenoma)
22
Q

Surgical technique for transcervical approach to anterior mediastinum

A
  • 4-5 cm collar incision just above sternal notch
  • Cooper thymectomy retractor placed to lift sternum
23
Q

Bilateral thoracosternotomy (Clamshell) exposure utilized for what mediastinal conditions

A

Large anterior mediastinal tumors

24
Q

Surgical technique for bilateral thoracosteronotomy

A
  • Incision in inframammary crease bilaterally
  • Subcutaneous flaps (anterior to pectoralis fascia) superiorly to 3rd-4th ICS
  • Division of pectoralis muscle fibers
  • Bilateral anterior thoracotomies
  • Sternum division

(IMA ligated and divided)

25
Q

Unilateral thoracosternotomy usefult to access

A
  • Anterior Pancoast’s tumors
  • Large thyomomas with lateral extension
  • Neurogentic tumors arising from proximal brachial plexus
26
Q

Surgical technique for unilateral thoracosternotomy (hemi-clamshell)

A

Partial upper sternal split + Anterior thoracotomy (4th ICS)

27
Q

VATS used for access to what conditions

A
  • Anterior, middle, posterior mediastinal masses
  • Thymectomy
    • Non-invasive tumors
28
Q

MC use of VATS for mediastinal tumors

A

Resction of posterior mediastinal tumors (e.g. neurogenic)

ABTS - Thoracic Surgery Notecards (48 decks)

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