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Minor VATS procedures on spontaneous ventilation anaesthesia: A novel technique
Syed Qadri, Consultant Thoracic Surgeon, Castle Hill Hospital, Hull
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horacic surgery has been evolving progressively over the last decades. There has been continuous improvement in technology and technique from open thoracic surgery to minimal invasive surgery such as video assisted thoracic surgery (VATS) and robotic surgery. The ventilation and anaesthetic management has also evolved over this time. Majority of thoracic surgery is performed with single lung ventilation. However recently thoracic surgery has also been performed with newer anaesthetic management utilising non-tracheal intubation and awake patients. All these development have demonstrated improvement in short- and long term patient outcomes. Thoracoscopic surgery without tracheal intubation is an emerging technique in which patients breath spontaneously during the procedures. Single lung ventilation, double lumen intubation and paralysing agents are not required. Studies have shown rapid recovery, better pain control and lower post op morbidity. Various technique have been described in the literature. We recently adopted this new novel technique using the Laryngeal Mask Airway for Video Assisted Thoracic Surgery (VATS) in procedures such as bullectomy & pleurectomy, pleural biopsy, lung biopsy, drainage of empyema, decortication and wedge excisions. Anaesthetic technique involves intravenous propofol and 100mg of suxamethonium for quick bronchoscopy and the use of a Laryngeal Mask Airway (LMA) (Figure 1) and maintain anaesthesia with inhalation agents. For analgesia paracetamol and titrating dose of
Figure 1
fentanyl is used. Usual monitoring of ECG, non-invasive blood pressure, O2 saturation, end tidal CO2. Surgical technique is the same as in full anaesthesia with one lung ventilation. For surgical exposure surgical pneumothorax is created following port insertion (Figure 2). This allows the lung to collapse to produce adequate surgical exposure (Figure 3). The exposure is identical if not better than single lung ventilation. We have performed more than 40 cases and have not encountered any difficulties in performing the procedures. In fact we find the exposure is improved as compared to single lung ventilation especially in patients with emphysematous lungs. We observed maintenance of oxygen saturation greater than 95% in all patients. End tidal volume was very low during whole procedure. Patients were comfortable and stable during procedures. They recovered from the anaesthesia very quickly after procedure without any anaesthetic or respiratory complication. This is noticeably different from patients with endotracheal intubation who wake up disorientated, drowsy and coughing to expel secretions with increased
pain. We observed that these patients who had surgery on LMA woke up very quickly and were oriented and did not have coughing episodes after surgery, therefore their early post op pain was significantly lower with improved recovery. In conclusion, we found that standard surgical procedures can be performed easily without any Figure 2 difficulty. There was no extra complications in the perioperative period and their post op recovery was unremarkable. To date we have not faced any situation where we had to convert spontaneous ventilation to full anaesthesia. We do not notice any delay in routine discharge or any new post op complication other than what is normally observed. As we do not use double lumen tubes and paralysing agents there is probably a financial benefit of this technique. It also saves on anaesthetic time and it has allowed us to add extra minor procedures on the list. Straight forward VATS procedures can be performed using this technique which is safe and economical with rapid post op recovery. However further evaluation is required. n
Figure 3