VATS Lobectomy
Patient phenotype
60s-70s, smoker or former smoker, NSCLC stage I-II most common. Often COPD + CAD + reduced FEV1. PFTs reviewed: predicted postop FEV1 + DLCO matters. Some have completed neoadjuvant chemo.
Procedure
3-4 small thoracotomy ports, video-assisted resection of single lobe + mediastinal LN sampling/dissection. Lateral decubitus. One-lung ventilation (OLV) required. 2-4 hours. Less invasive than open thoracotomy = better postop pain + faster recovery.
Anesthetic plan
GETA with double-lumen tube (DLT) or bronchial blocker for OLV. Thoracic epidural OR paravertebral block OR erector spinae block (ESB) — all options for postop analgesia (open thoracotomy mandates one; VATS often does well with ESB or surgeon-placed catheters). A-line + 2× PIV.
Setup
- ·A-line
- ·2× PIV (16-18g)
- ·Forced air warmer
- ·Fiberoptic bronchoscope (DLT confirmation)
- ·Type & screen
- ·Bronchial blocker as backup if DLT fails
- ·Foley if case > 3h expected
Biggest concerns by phase
Predicted postop pulmonary function
ppoFEV1 = preop FEV1% × (1 - segments removed/19). > 40% generally tolerated; < 30% high risk. Lower-lobe + RUL each ~3 segments; LUL ~5; RML ~2. DLCO ppo < 40% increases risk. VO2max < 15 mL/kg/min = high mortality risk.
Smoking + cardiac comorbidity
Smoking cessation > 8 weeks ideal. CAD common — ECG, echo if symptoms. Beta-blocker continued, statin continued. Hold ACE/ARB morning. Pulmonary HTN screening (echo).
DLT placement + position confirmation
Left-sided DLT default (right has variable RUL takeoff). Direct laryngoscopy or video. Auscultation + fiberoptic confirmation MANDATORY (carina visible, blue cuff in left mainstem just below carina). Reconfirm position after lateral decubitus turn.
One-lung ventilation strategy
Lung-protective: TV 4-6 mL/kg IBW (dependent lung), PEEP 5-10, RR for ETCO₂ < 50, FiO₂ titrated to SpO₂ ≥ 92%. CPAP to nondependent lung if hypoxia. Permissive hypercapnia OK. Avoid N₂O. Recruitment after re-expansion.
Hypoxia during OLV
Hypoxic pulmonary vasoconstriction shunts blood to ventilated lung — preserved by avoiding high-dose volatile (> 1 MAC blunts HPV). Stepwise hypoxia rescue: increase FiO₂ → recheck DLT position → CPAP 5 to nondependent lung → PEEP to dependent lung → 2-lung ventilation if surgeon allows → clamp pulmonary artery if all else fails.
Fluid restriction — pulmonary edema in dependent lung
Re-expansion pulmonary edema in dependent lung is a recognized post-thoracic complication. Limit crystalloid to 1-2 mL/kg/h. Use vasopressors for hypotension, not bolus.
DLT exchange or extubation strategy
Most extubate in OR after VATS. If high risk, exchange DLT for single-lumen via tube exchanger before transport to ICU. Pain control critical for chest physiotherapy + cough.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
70-year-old F, FEV1 1.2L (45% predicted), DLCO 50%, planned RUL VATS lobectomy. 30 min into OLV, SpO2 drops from 95 to 84 on FiO2 1.0. Walk through your rescue.
What an examiner probes for
- ▹Calls for help, alerts surgeon
- ▹Stepwise: confirm DLT position with fiberoptic, suction, CPAP to nondependent
- ▹PEEP to dependent lung, recruitment
- ▹Increase MAP if HPV blunted
- ▹Pulmonary artery clamp if all else fails
Sources
- Miller's Ch 68
- Slinger Thoracic Anesthesia 2e
- ACCP Pulmonary Risk Stratification 2013
Anatomy reference
Sourced reference images. 4 matches for "lung pulmonary thoracic respiratory".
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