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International Society For Minimally Invasive Cardiothoracic Surgery

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Non Intubated Subxiphoid Pneumonectomy
Royal Papworth Hospital, Cambridge, United Kingdom.

BACKGROUND:Surgical approaches to major pulmonary resections have evolved from thoracotomy to multiportal Video-Assisted Thoracoscopy(VATS) and subsequently uniportal VATS. The efficacy of this progress has been demonstrating reductions in complications, patient perception of pain and postoperative length of stay.Subxiphoid extrathoracic access and nonintubated opioid-free anaesthesia have demonstrated promising results with respect to safety, technical feasibility and enhanced recovery.
METHODS:The authors report the case of a patient undergoing pneumonectomy. Both subxiphoid and nonintubated,opioid free techniques were utilised. Following preoxygenation for three minutes, anaesthesia was induced utilising a combination of intravenous propofol (1.5 mg/kg), clonidine 1mcg/kg and lidocaine 1mg/kg. A supraglottic airway device (iGel size 4) was inserted. Spontaneous ventilation anaesthesia was maintained with sevoflurane through a circle breathing circuit. The patient was placed in the left lateral decubitus position with posterior angulation to enhance subxiphoid exposure. The operating surgeon was positioned in front of the patient with the first assistant caudal to him. A 3-5 cm vertical incision was made in the sternocostal angle and the linea alba dissected. Blunt digital dissection is used to enter the pleural cavity followed by insertion of a ten mm thirty degree camera through an Alexis. Operative progression was as follows: infiltration of right phrenic and vagus nerves with 0.25% levobupivacaine, dissection of mediastinal pleural, ligation of the inferior pulmonary ligament/vein,superior pulmonary vein,the main pulmonary artery and finally ligation of the right main bronchus.Systematic mediastinal staging was undertaken.
RESULTS:The patient was extubated in theater. Patient Controlled Analgesia was utilised overnight and discontinued on the first day. Pain relief was maintained using paracetamol and oramorph.The patient began to decline oramorph on the third day. Rehabilitation began on day one following transfer to the ward. Physiotherapy discharged the patient on day three concluding he had returned to baseline function and the patient left the hospital on day 4 following CXR.
CONCLUSIONS: Our successful experience in this patient extends the indication of nonintubated subxiphoid VATS advanced pulmonary resection for patients requiring pneumonectomy. The result suggests that nonintubated subxiphoid VATS pneumonectomy is technically feasible, although further studies are required to validate the indications, safety, and efficacy of this innovative procedure.

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