Open Thoracotomy Lobectomy
Patient phenotype
Lung cancer not amenable to VATS (large tumor, central, prior surgery, expected LN dissection complexity). Same comorbidity profile as VATS.
Procedure
Posterolateral thoracotomy (most common), lateral decubitus, rib spreader. More painful + invasive than VATS. ~3-5 hours. Higher pulmonary complication rate.
Anesthetic plan
Same as VATS but THORACIC EPIDURAL is gold standard for postop analgesia (cuts pulmonary complications by half). Paravertebral acceptable alternative. ESP increasingly used.
Setup
- ·Same as VATS
- ·Thoracic epidural pre-induction (T4-T7)
- ·Test dose verified
Biggest concerns by phase
Thoracic epidural — strongly favored
Cuts pulmonary complications, length of stay, post-thoracotomy pain syndrome incidence. Ropivacaine 0.1% + fentanyl 2 mcg/mL infusion 4-8 mL/h. Continue 3-4 days postop. PVB or ESP if epidural contraindicated.
Same OLV management as VATS
Lung-protective TV 4-6 mL/kg IBW, PEEP 5-10, FiO₂ titrated. Recruitment after re-expansion. Permissive hypercapnia.
Hypotension from thoracic epidural
Sympathectomy from epidural → drop in SVR + BP. Phenylephrine or norepinephrine to maintain MAP. Don't bolus crystalloid (pulmonary edema).
Extubation in OR + chest tube management
Extubate in OR if hemodynamically stable + good pain control. Chest tubes (1-2) on water seal. Cough strength important — adequate analgesia from epidural.
Post-thoracotomy pain syndrome prevention
Multimodal + epidural reduces incidence (chronic neuropathic pain in 30-50% otherwise). Ketamine intraop, gabapentin postop also help.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
65-yo M, FEV1 60%, LUL central NSCLC, LUL lobectomy via posterolateral thoracotomy. Plan for analgesia?
What an examiner probes for
- ▹Thoracic epidural strongly preferred
- ▹Test dose + post-induction confirmation
- ▹OLV + lung-protective ventilation
- ▹Hemodynamic management with epidural
- ▹Postop epidural management
Sources
- Miller's Ch 68
- Slinger Thoracic 2e
- PROSPECT Thoracic Surgery 2017
Anatomy reference
Sourced reference images. 4 matches for "lung pulmonary thoracic".
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