Mediastinal Mass Resection
Updated On: July 23, 2026
Anesthetic Approaches
Loss of muscle tone - spontaneous ventilation and chest wall tone splint the airway and keep the cardiac chambers filling. Induction and paralysis remove both, and the collapse that follows sits below the tube, so intubation does not rescue it.
Position-dependent symptoms - ask what happens lying flat. Orthopnea, a dry cough or syncope that is worse supine is the best single predictor of collapse, and the position the patient refuses to adopt is the one that will kill them in the operating room.
Induction in the tolerated position - sit them up or leave them semi-recumbent if that is where they breathe, and have enough hands in the room to turn them lateral or prone at once. A simple change of position is the first maneuver that relieves collapse.
Airway anatomy on CT - read it yourself. Measure the narrowest tracheal diameter and look for carinal or bronchial involvement, pulmonary artery and SVC compression, and pericardial invasion. Losing half the tracheal lumen marks the high-risk patient.
Echo before induction - the mass can compress the right heart, the pulmonary artery or the SVC, and pericardial involvement can tamponade. That is a cardiovascular collapse you cannot ventilate your way out of, and you want to know beforehand.
Rescue plan before induction - a rigid bronchoscope open on the trolley, a surgeon in the room who can pass it, and reinforced tubes long enough to push past the obstruction into a mainstem bronchus. None of it can be sent for after the fact.
Elective bypass standby - in the worst masses, cannulate the femoral vessels and have bypass or ECMO primed before induction. Started as salvage after arrest it almost never works, because the circulation has already gone.
Superior vena cava obstruction - a plethoric face, distended neck and chest wall veins mean a drug given in an arm may never arrive. Site large-bore access in a lower limb before induction, and take central and pressure lines from the femoral vein.
The relaxant decision - with a symptomatic anterior mass a relaxant is effectively contraindicated until the airway is secured and proven. Keep the patient breathing through induction; a posterior lesion with a clear airway can be relaxed normally.
Switch to positive pressure - the drug is not the only hazard. Moving from spontaneous to controlled ventilation reverses the gradient that holds the airway open, so ventilate by hand and stop if compliance suddenly falls away.
Sedated biopsy sitting up - when tissue is all that is needed, a core needle or anterior mediastinotomy under local with light sedation and the patient upright avoids the whole problem. Marrow or pleural fluid may give the diagnosis with no anesthetic.
Bleomycin in the history - germ cell tumors are often given cisplatin, etoposide and bleomycin before resection, and bleomycin lung injury is driven by oxygen. Drop the FiO2 to 0.4 or below once the airway is secure and saturation allows.
The uncooperative child - a small child will not perform upright and supine spirometry, so imaging and the parents' account of how the child sleeps carry the assessment. Inhalational induction with the child breathing is the usual route in.
Risk repeated at emergence - obstruction can appear for the first time on waking, so extubate in the operating room, fully awake, with the surgeon and the bronchoscope still in the room. Check for a leak around a deflated cuff before the tube comes out.
Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it's going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient's arms.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape. Unhook anesthesia circuit while turning lateral and be especially careful to keep patient's head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient's head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn't being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.
High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.
Arterial line (general considerations): Preoperatively check pulses to gauge the best side to attempt the A-line. Perform an Allen test to ensure adequate blood flow. Have the A-line equipment set up and ready in the room.
High Blood Loss RISK (general considerations): Though most of these cases don't result in a high blood loss, there is a high blood loss RISK. Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra IV push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Bispectral Index Scale (BIS) monitor (general considerations): The recommended values under general anesthesia are 40-65. Values of 65-85 are recommended for sedation.
The mediastinum is divided by its relationship to the heart, and the compartment the mass sits in predicts the problem. Anterior lesions - lymphoma, thymoma, teratoma, germ cell tumor, substernal goitre - lie directly on the trachea, the main bronchi, the superior vena cava and the right heart, and are held off those structures by nothing more than chest wall tone and the negative intrathoracic pressure of spontaneous breathing. Middle and posterior lesions such as bronchogenic and duplication cysts and neurogenic tumors rarely threaten the airway. The awake patient compensates by posture, so someone with critical compression can look entirely well sitting upright in clinic and arrest minutes after induction.
Approach - anterior masses are removed through a median sternotomy; middle and posterior lesions through a posterolateral thoracotomy or thoracoscopically.
Diagnostic access - an anterior mediastinotomy through the third costal cartilage, the Chamberlain procedure, reaches the aortopulmonary window and the anterior mediastinum for tissue.
Resection - a well encapsulated tumor lifts out cleanly, while an invasive one takes pericardium, lung or a phrenic nerve with it.
Great vessel involvement - invasion of the aorta or the arch vessels turns the case into a vascular operation, and blood has to already be in the room.
Closure - a chest drain is left to re-expand the lung and drain the pleural space.
Hand over the airway story and not just the numbers - what happened at induction, whether the obstruction was positional, and the position the patient tolerates. If SVC obstruction was present, upper body edema can worsen after extubation, so head-up positioning and the lower-limb access both stay.