Double-lumen Endotracheal Intubation Research Articles

PS01.146: THE ANALYSIS OF THE SAFETY OF A MODIFIED LEFT RECURRENT LARYNGEAL LYMPH NODES DISSECTION IN THORACOSCOPIC ESOPHAGEAL CARCINOMA SURGERY

Abstract Background To explore the thoroughness and safety of a modified left recurrent laryngeal lymph nodes dissection in thoracoscopic esophageal carcinoma surgery. Methods Retrospectively analyzed the clinical data of 136 patients with the left recurrent laryngeal lymph nodes dissection from October 2015 to October 2017 in the First Hospital Affiliated to Xiamen University. 67 cases were divided to the traditional dissection group (double lumen endotracheal intubation, 90 ° lateral position) and 69 cases were classified to the modified dissection group (single cavity tracheal intubation, thoracic CO2 positive pressure ventilation, lateral prone position and esophageal suspension technology). Observed and compared the left laryngeal recurrent nerve lymph nodes cleaning and time, intraoperative complications including thoracic duct injury, tracheal injury, hoarseness and pneumonia. Results The cleaning time of the modified dissection group (23 + 8 min) was significantly less than that of the traditional cleaning group (32 plus or minus 5min) (P < 0.01). 5 patients occurred left laryngeal nerve injury in the modified dissection group, with statistically significance (P < 0.01), less than traditional dissection group of 12 patients. The modified dissection method improves the exposure of intraoperative field, the probability of thoracic duct and tracheal injury (1/69, 0/69) were lower than the traditional group (2/67, 1/67), but the difference was not statistically significant (P > 0.05). Moreover, there was no significant difference in lymph nodes metastasis and complications incidence rate (P > 0.05). Conclusion The modified dissection method, including single cavity tracheal intubation, thoracic CO2 positive pressure ventilation, lateral prone position and using esophageal suspension technology, can achieve good operation field exposure, the left recurrent laryngeal lymph nodes ‘the whole block’ cleaning, and the greatest degree protection of laryngeal recurrent nerve, thoracic duct, trachea and other organs damage. It is worthy of clinical popularization and application. Disclosure All authors have declared no conflicts of interest.

Decreasing Time to Place and Teach Double-Lumen Endotracheal Intubation: Engaging Anesthesia in Lean

This report documents our process to standardize and decrease the time to place and teach double-lumen endotracheal tube (DLETT) intubation. A prospective database of patients who underwent lobectomy or segmentectomy by 1 surgeon was reviewed. A systematic approach was instituted starting in 2009. A monitor in the room displayed the bronchoscopic view as anesthesia residents were taught how to drive a bronchoscope. The bronchial side was placed above the carina, a bronchoscope went into the desired side, and the double-lumen tube slid over it. A head towel protected the ears, face, and hair, and the DLETT was anchored so that rebronching after turning was eliminated. All other nonvalued steps were eliminated. There were 2,940 patients. Pulmonary lobectomy was performed in 2,421 patients and segmentectomy in 566. Patients were divided into nine cohorts of 350 consecutive patients, except for the last cohort. Median time for DLETT placement decreased from 13 minutes from January 1997 to February 2001 to a median 45 seconds from June 2016 to May 2017 (p < 0.001). Anesthesia residents, present for 76% of the operations, were able to place the tube independently 80% of the time. There were no airway perforations. DLETT placement can be standardized and taught efficiently. Factors that may lead to this are eliminating nonvalued steps (process of lean), engaging anesthesiologists and surgeons to teach team standardization, improved tracheal-bronchial anatomy and bronchoscopy skills in residents, and displaying the intubation and bronchoscopy on a monitor.

Dose-response relationship of sufentanil blunting responses to double-lumen endotracheal intubation when combined with propofol given by TCI in patients with pulmonary tuberculosis

Objective To determine the dose-response relationship of sufentanil blunting responses to double-lumen endotracheal intubation when combined with propofol given by target-controlled infusion (TCI) in patients with pulmonary tuberculosis. Methods One hundred patients of both sexes with pulmonary tuberculosis, of American Society of Anesthesiologists physical status Ⅰ or Ⅱ, aged 24-58 yr, with body mass index 20% of the baseline value and/or heart rate > 90 bpm within 5 min after intubation.The median effective dose (ED50), ED95 and 95% confidence interval (95% CI) of sufentanil blunting the responses to double-lumen endotracheal intubation were calculated by Probit analysis. Results The ED50 (95% CI) and ED95 (95% CI) of sufentanil blunting the responses to intubation were 0.411 (0.370-0.441) μg/kg and 0.635 (0.556-0.888) μg/kg, respectively, when combined with propofol given by TCI. Conclusion When combined with propofol given by TCI(target plasma concentration 3.5 μg/ml), the ED50 and ED95 of sufentanil blunting the responses to double-lumen endotracheal intubation are 0.411 and 0.635 μg/kg, respectively, in patients with pulmonary tuberculosis. Key words: Propofol; Sufentanil; Dose-response relationship, drug; Tuberculosis, pulmonary; Intubation, intratracheal

Impact of pillow height on double-lumen endotracheal tube intubation with McGRATH MAC: a prospective randomized clinical trial

Study objectiveThis study aimed to compare the impact of pillow height on double-lumen tracheal tube (DLT) intubation with McGRATH MAC (McG) in patients undergoing elective surgery. DesignRandomized clinical trial. SettingOperating room. PatientsFifty adult patients scheduled for elective surgery under 1-lung ventilation with an American Society of Anesthesiologists physical status of 1 to 3. InterventionsDLT intubation with McG was performed with a high pillow (HP group; 25 patients) or low pillow (LP group; 25 patients) by anesthesiologists. MeasurementsIntubation time, number of laryngoscopy, number of tracheal intubation attempts to successful intubation, percentage of glottic opening score, and subjective difficulty of laryngoscopy and tube passage through the glottis were assessed. Main ResultsIntubation time was significantly shorter in the HP group compared with the LP group (HP: 32.1±14.9seconds vs LP: 49.4±11.2seconds, P<.001). The number of laryngoscopy were 1 (HP group, 22 patients; LP group, 17 patients), 2 (HP group, 3 patient; LP group, 7 patients), and 3 (HP group, 0 patient; LP group, 1 patient), with no significant difference between the 2 groups (P=.197). Although the percentage of glottic opening score did not significantly differ between HP and LP groups (HP: 95.6%±6.7% vs LP: 96.0%±12.3%, P=.08), the number of tracheal intubation attempts was significantly lower in the HP group compared with the LP group (P=.009). The visual analog scale score for laryngoscopy did not significantly differ between the 2 groups (P=.54). However, the visual analog scale for tube passage through the glottis was significantly higher in the LP group than in the HP group (P<.001). ConclusionsIntubation with an HP was associated with a better DLT intubation profile than with an LP with McG, possibly due to smoother tracheal tube progression through the glottis.

Video-assisted thoracic surgery experience of calcified lymph nodes for lingular sparing lobectomy.

Video-assisted thoracic surgery (VATS) is commonly used for posterior, superior and lingular segmentectomy. Segmental resections involving the left upper lobe are the following: upper division (S1+2 and S3) (lingular sparing lobectomy), apicoposterior segmentectomy (S1 + S2), and lingulectomy (S4 + S5). Lingular sparing lobectomy is still a challenge for more technical demanding and more anatomic variations, especially when facing calcified lymph nodes. A 73 years old woman was admitted for founding a ground glass opacity (GGO) during the screening test (1.0 cm × 1.0 cm). Her pulmonary function result was forced expiratory volume in 1 second (FEV1): 1.51 L (54.7% predicted). She was a non-smoker, with negative bronchoscopy findings. She received general anesthesia with double-lumen endotracheal intubation and right lung ventilation. Right lateral decubitus position was chosen. The first 1.5-cm incision was selected in the 8th intercostal space in the midaxillary line, and was used for the camera. A 4-cm long incision was made in the 4th intercostal space in the preaxillary line. A third 1.5-cm incision was performed in the 9th intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire left hilum were mobilized. The superior pulmonary vein has usually three major tributaries. The superior branch drains the apicoposterior segments and frequently blocks the access to the apicoposterior arteries. The middle branch drains the anterior segment, and the lowermost branch drains the lingula. The lingular vein must be preserved. The apicoposterior and anterior segment vein was transected with a vascular stapler. Anterior pulmonary artery and anterior bronchus were then divided and stapled. The upper lobe bronchus splits immediately into the lingular bronchus and a common stem. All these segmental bronchi have short course and a calcified lymph node located between the apicoposterior pulmonary artery and apicoposterior bronchus. These situations make the dissection and identification very difficult. Following many failure attempts of trying take the calcified lymph node out. Staple the left apicoposterior pulmonary artery together with the apicoposterior bronchi is completed. And left upper division (S1+2 and S3) was taken out after stapling lung tissue above the level of lingular segment with a 60-mm green linear stapler. Mediastinal lymph nodes of level 9, 7, 4L and 5 were cleared afterwards. Pathology was confirmed with adenocarcinoma (ancinar component dominant). There were no complications and the patient was discharged 6 days postoperatively. Staple the left apicoposterior pulmonary artery together with the apicoposterior bronchi is a safe and feasible way when facing the difficult dissection of the calcified lymph nodes during segmentectomy.

Video-assisted thoracic surgery right upper lobe bronchial sleeve resection.

Video-assisted thoracic surgery (VATS) is a new technology for nearly 30 years in the field of thoracic surgery most watched. However, there are still some controversy concerning the technical difficulties, operation duration, the extent of lymph node dissection and perioperative complications for VATS sleeve bronchial lobectomy when handling the locally advanced central lung cancer (involving the trachea and/or main bronchus). A 66 years old man was admitted for coughing for 2 months. He had smoked for 30 years, 20 packs a day. Chest computed tomography (CT) revealed a 2.5 cm × 4.5 cm mass in the right upper lobe. Bronchoscopy demonstrated the tumor obstructing the right upper lobe bronchus and involved the right main bronchus and bronchus intermedius. Pathology was squamous cell carcinoma. His pulmonary function result was forced expiratory volume in 1 second (FEV1): 1.91 L (64.7% predicted), forced vital capacity (FVC): 4.36 L. He received general anesthesia with double-lumen endotracheal intubation and left lung ventilation. Left lateral decubitus position was chosen. The first 1.5 cm incision was selected in the eighth intercostal space in the midaxillary line, and was used for the camera. A 4 cm long incision was made in the 3rd intercostal space in the preaxillary line. A third 1.5 cm incision was performed in the 9th intercostal space in the postaxillary line for assistant. Pulmonary ligament and the entire right hilum were mobilized. Pulmonary vein is the most forward hilar structure, sometimes immediately prior pulmonary trunk. The right upper lobe vein was transected with a vascular stapler. Truncus and posterior ascending pulmonary artery were then divided and transected with a vascular stapler. Major and minor fissures were stapled by 60 mm green linear stapler. Following clearance of the mediastinal lymph nodes of level 7, 4R and 2R, the bronchial sleeve resection and reconstruction began. The distal right main bronchus and bronchus intermedius were fully mobilized to ensure adequate surgical exposure. Traction sutures were routinely placed on the lateral walls and to reduce tension. Interrupted sutures were chosen for bronchial anastomosis. Bronchial membrane was sutured first, and then circumference end-to-end anastomoses were carried out using 3-0 absorbable sutures. There were no complications and the patient was discharged 8 days postoperatively. The 3rd intercostal space of the anterior axillary line was suggested for right upper lobe bronchial sleeve resection. This incision can reduce the distance and angle between the anastomosis to the incision, providing convenient conditions for easy anastomosis. And avoid the operator fatigue for keeping the posture for a long time. Clearance of the mediastinal lymph nodes before cutting the bronchus was helpful for satisfied explosion of the right main bronchus, the upper lobe bronchus and bronchus intermedius. And this would avoid pulling bronchial anastomosis for mediastinal lymph nodes clearance. Interrupted suture was safe and effective for VATS bronchial anastomosis.

Uniportal video assisted thoracoscopic surgery thymectomy (left approach).

Video assisted thoracoscopic surgery (VATS) thymectomy for the management of myasthenia gravis and thymoma has been described and routinely performed. With the advent of single port surgery, uniportal thymectomy has gained popularity and left side approach is preferred only if the suspecting tumour is situated on the left mediastinum. However, many doubt or dislike the left side VATS approach to anterior mediastinum as the ventricular apex renders maneuverer of instruments difficult. This is certainly not the case as shown in this video and to date, there is no published manuscript on left uniportal thymectomy. Patient positioned semi-supine with left sided propped up and the ipsilateral arm placed naturally and secured by the side and below the chest wall. Cleaned and draped as for sterile procedure. General anaesthesia and lung isolation achieved with a double lumen endotracheal intubation. A 2.5 cm incision was made at 4th intercostal space, anterior axillary line (lateral to nipple line). Extra small size wound protector was used and CO2 insufflation was not needed. Instruments utilised in this case were "not new" and used for laparoscopic surgery 2 decades ago. This video demonstrates the simple technique of left uniportal approach to total thymectomy. Safe en bloc resection of thymus and thymic tumour with surrounding fatty tissue were performed, by combination of careful pleura dissection using diathermy, traction and blunt dissection of thymus. Extra caution when dividing thymic vein branches from innominate vein is prudent in order to prevent intra-operative haemorrhage and subsequent conversion to sternotomy or thoracotomy. In this video, total thymectomy was performed without complication. The specimen was removed through the port and a single chest tube was placed at end of procedure for 1 day. Patient went home uneventfully on day 2. Left uniportal VATS thymectomy is feasible, and preferred for left sided thymoma. This simple approach should be encouraged and performed by all enthusiastic VATS thoracic surgeons.

Study on the effective dose 50 of sufentanil blunting responses to double-lumen endotracheal intubation in elderly patients

Objective To determine the effective dose 50 (ED50) of sufentanil blunting the responses to double-lumen endotracheal intubation under propofol in elderly patients. Methods A retrospective analysis was conducted on patients aged 65-78 years with body mass index 90 bpm within 3 min after tracheal intubation.The ED50(95% confidence interval) of sufentanil blunting the responses to double-lumen endotracheal intubation was calculated. Results The ED50(95%confidence interval) of sufentanil blunting the responses to double-lumen endotracheal intubation in elderly patients was 0.331 μg/kg, and the 95%confidence interval was 0.246-0.409 μg/kg. Conclusions Under propofol to maintain BIS 45-55, the ED50 of sufentanil blunting the responses to double-lumen endotracheal intubation in elderly patients was 0.331 μg/kg. Key words: Sufentanil; Intubation, intratracheal; Dose-response relationship, drug

Prediction of the Size of Double Lumen Endotracheal Intubation by Measuring the Diameter of the Trachea

Objective: To find the faster and easier way than the existing intubating technique for double-lumen tube. We prediction of required double lumen tube size by measure the X-ray trachea diameter size before surgery. Methods: Randomly selected 100 cases of single lung ventilation in patients undergoing thoracic surgery. Measurement of tracheal diameter at the level of clavicle in X-ray. Choose the double-lumen size according to the measurement of tracheal diameter in X-ray. If the tracheal diameter greater than 16 mm, choose a 39 Fr double lumen tube, if the trachea diameter between 15-16 mm, used 37 Fr double lumen tube, with less than 15 mm, used 35 Fr double lumen tube. Record the number of intubation and whether there is difficulty for double lumen tube through the glottis. Results: All patients’ double lumen were selected according for the measurement of the diameter of the trachea, all successful intubation and accurate localization of bronchus. Conclusion: There was no significant difference in the diameter of trachea with age, body weight and height, and the diameter of the female trachea was significantly narrower than that of the male. For vast majority of male Chinese, 39 Fr double lumen tube is suitable, and the height and weight is of small relation, female patients with large differences in the airway diameter, height, weight, gender cannot be the basis for the choice of double lumen tube.

Unidirectionally progressive resection of lower left lung carcinoma under video-associated thoracoscopy.

General anesthesia is adopted through double-lumen endotracheal intubation, one-lung ventilation on the contralateral, and intravenous injection. The patient took a 90 degree decubitus on his contralateral side. The operative incisions: the observation port was made in the mid-axillary line of the 7(th) intercostal section, a second horizontal incision of 4 cm as the main operation port at the 4(th) intercostal space between the anterior axillary line and the midclavicular line, and a 3(rd) incision of 1.5 cm as the secondary operation hole at the 9(th) intercostal space between the axillary line and the bottom scapular line. The surgeons were on the ventral side of the patient, and operated with endoscope apparatus in front of the monitor screen.

Comparison of McGRATH MAC and Macintosh laryngoscopes for double-lumen endotracheal tube intubation by anesthesia residents: a prospective randomized clinical trial

Study ObjectiveThis study aimed to compare the utility of McGRATH MAC (McG) and Macintosh (McL) laryngoscopes for double-lumen endotracheal tube intubation in patients undergoing elective surgery. DesignRandomized clinical trial. SettingOperating room. PatientsFifty adult patients scheduled for elective surgery under 1-lung ventilation with American Society of Anesthesiologists physical status 1 to 3. InterventionsDouble-lumen endotracheal tube intubation was performed with the McG (McG group; 25 patients) or conventional McL (McL group; 25 patients) laryngoscope by anesthesia residents. MeasurementsThe number of attempts to successful intubation, intubation time, percentage of glottis opening score, and subjective difficulty of laryngoscopy and tube passage through the glottis were assessed. Main ResultsThe total numbers of intubation attempts were 1 (McG group, 24 patients; McL group, 16 patients), 2 (McG group, 1 patient; McL group, 8 patients), and 3 (McG group, 0 patient; McL group, 1 patient), with significant differences between the two groups (P = .018). Intubation time was significantly shorter in the McG group compared with the McL group (McG: 17.1 ± 4.6 seconds vs McL: 20.8 ± 5.9 seconds, P = .026). The percentage of glottis opening score was significantly higher in the McG group compared with the McL group (McG: 88.4% ± 13.7% vs McL: 71.4% ± 20.4%, P = .004). ConclusionsThe McG demonstrated a better intubation profile compared with the McL, possibly due to its ease of use for double-lumen endotracheal tube intubation.

Non-intubated video-assisted thoracic surgery in patients aged 80 years and older.

Video-assisted thoracic surgery (VATS) is routinely performed with general anesthesia and double-lumen endotracheal intubation, but this technique may stress an elderly patient's functional reserve. We chose to study the safety and efficacy of non-intubated VATS, utilizing local anesthesia, sedation, and spontaneous ventilation in the elderly. The medical records of all patients aged 80 years and older who underwent VATS under local anesthesia and sedation during the time period 6/1/2002 to 6/1/2010 at Geisinger Health System (Pennsylvania, USA) and 10/1/2011 to 12/31/2014 at Sinai Hospital (Maryland, USA) were retrospectively reviewed. Unsuccessful attempts at this technique were eligible for inclusion but there were none. No patient was excluded based on comorbidity. A total of 96 patients ranging in age from 80 to 104 years underwent 102 non-intubated VATS procedures: pleural biopsy/effusion drainage with or without talc 73, drainage of empyema 17, evacuate hemothorax 4, pericardial window 3, lung biopsy 2, treat chylothorax 2, treat pneumothorax 1. No patient required intubation or conversion to thoracotomy. No patient required a subsequent procedure or biopsy. Complications occurred in three patients (3.1% morbidity): cerebrovascular accident, pulmonary embolism, prolonged air leak. One 94-year-old patient died from overanticoagulation and two 84-year-old patients died of their advanced lung cancers (3.1% morbidity). Non-intubated VATS utilizing local anesthesia and sedation in the elderly is well tolerated and safe for a number of indications.

Technical highlights of robotic-assisted mediastinal tumor resection.

The operation uses general anesthesia, double-lumen endotracheal intubation, contralateral decubitus with slight backward bending, contralateral one-lung ventilation, upper limb buckling and head crossing.

Technical points of the operative procedure for robotic-assisted lung resection and lymph node dissection.

The operation is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in the lateral position on the unaffected side. Singlelung ventilation is performed on the unaffected side. The patient holds a pillow with both upper limbs flexed and is placed in the jackknife position.

Semi-Fowler vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis.

The aim of this study is to compare usefulness of Semi-Fowler position vs. lateral decubitus position for thoracoscopic sympathectomy in treatment of primary focal hyperhidrosis. From January 2009 to January 2010, 263 consecutive patients with palmar and axillar hyperhidrosis underwent thoracoscopic sympathectomy Th2-Th4. Patients were divided into two groups: group A (n=133) underwent thoracoscopic sympathectomy through lateral decubitus using double lumen endotracheal intubation, and group B (n=130) underwent thoracoscopic sympathectomy through Semi-Fowler supine position (semi sitting with arm abducted) using single lumen endotracheal intubation without insufflation of CO2, but with short apnea period. All operations were performed through two 5 mm operating ports, videothoracoscopic camera 0° and endoscopic ultrasound activated harmonic scalpel. There were 107 males and 156 females with median age 30.31±8.35 years. Two groups were comparable in gender, age, severity of sweating. All operations were successfully performed with no complications or perioperative morbidity. For group A average operation time for both sides was 31.2±3.87 min and for group B average time was 14.19±4.98 min. In group B apnea period per one lung lasts 2.86±1.15 min and during that period observed saturation was 92.65%±5.66% without significant cardiorespiratory disturbances. Pleural drains were taken off on operation table after forced manually lung reexpansion. Patients were discharged from hospital for few hours, after the operation and radiologic confirmation of complete lung reexpansion. Based on this data (shorter operating time, lack of incomplete lung collapse, insignificant apnea and better reexpansion of lungs) we concluded that thoracoscopic sympathectomy through Semi-Fowler supine position is highly effective and easy to perform for primary hyperhidrosis.

Unidirectionally progressive resection of left upper pulmonary lobe under video-assisted thoracoscopy.

The case is a nodule in the upper left lobe, and intraoperative frozen section pathological diagnosis on the removed nodule confirmed well differentiated mucinous adenocarcinoma. Unidirectionally progressive resection of the left upper pulmonary lobe under video-assisted thoracoscopy is selected as the surgical method. Right below the operation hole, surgeons gradually advanced in one direction, and dissociated and divided in such order: the upper left pulmonary vein, the upper left lobe bronchus, the upper left pulmonary arterial branches and the fissures. Endoscopic linear cutters and hem-o-lok clip applicator were used to deal with the blood vessels, bronchus, and under-differentiated fissures. At last, the removed upper left lobe was put into a size eight sterile glove and taken out through the main operation hole. General anesthesia with double-lumen endotracheal intubation is used. The patient took a 90 degree decubitus on his contralateral side. The surgeons were on the ventral side of the patient, and operated with endoscope apparatus under the monitor.

Unidirectionally progressive left pneumonectomy & mediastinal lymph node dissection.

The patient has lower left lung tumor and adenocarcinoma at the openings of both upper and lower left lung. Preoperative bronchoscopic biopsy has confirmed the diagnosis. The surgical approach is unidirectionally progressive left pneumonectomy + mediastinal lymph node dissection. The layers of structure are treated one after another until the fissure from a single direction through the working port. Hence, the resecting order should be left superior pulmonary vein-left lower pulmonary vein-left main bronchus-left pulmonary artery. The vessels and bronchi are cut using an endoscopic linear stapler or the Hemolock clips. The resected lobe is placed into a large-size specimen bag and retrieved through the working port to prevent contamination of the chest incision by any tumor tissue. Mediastinal lymph node dissection is performed at the end. The surgery is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in a 90-degree position lying on the unaffected side. Similar to traditional resection of left lung lobes, an approximately 1.5-cm observation port is created in the 7th intercostal space between the middle and anterior axillary lines, an approximately 4-cm working port in the 4th intercostal space between the anterior axillary line and the midclavicular line, and an approximately 1.5-cm auxiliary port in the 9th intercostal space between the posterior axillary line and the subscapular line. The operator stands in front of the patient, manipulating the endoscopic instruments while watching the monitor.

Unidirectionally progressive resection of lower right lung cancer under video-assisted thoracoscopy.

The surgery is performed under general anesthesia with double-lumen endotracheal intubation. The patient is placed in a 90-degree position lying on the unaffected side. An approximately 1.5-cm observation port is created in the 7th intercostal space between the middle and anterior axillary lines, an approximately 4-cm working port in the 4th intercostal space between the anterior axillary line and the midclavicular line, and an approximately 1.5-cm auxiliary port in the 9th intercostal space between the posterior axillary line and the subscapular line. The operator stands in front of the patient, manipulating the endoscopic instruments while watching the monitor. since the patient has right lower lung cancer, a unidirectional procedure is adopted for the surgery, in which the layers of structure are treated one after another until the fissure from a single direction through the working port. Hence, the pulmonary vein, bronchi, pulmonary artery and the poorly developed fissure of the right lower lobe are treated successively during lobectomy. The vessels, bronchi and fissures are cut using an endoscopic linear stapler or the Hemolock clips. The resected lobe is placed into a size 8 sterile glove and retrieved through the working port to prevent contamination of the chest incision by any tumor tissue. Mediastinal lymph node dissection is performed at the end.

The Effect of Prophylactic Dexmedetomidine on Hemodynamic Disturbances to Double-Lumen Endotracheal Intubation: A Prospective, Randomized, Double-Blind, and Placebo-Controlled Trial

The purpose of this study was to determine the effect of dexmedetomidine on hemodynamic responses to DLT intubation compared to placebo and to assess the adverse effects related to dexmedetomidine. Sixty patients were randomly allocated to receive 0.7 μg/kg dexmedetomidine (n = 30) or normal saline (n = 30) 10 minutes before general anesthesia. Systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), and rate pressure product (RPP) between groups were recorded. During intubation and 10 minutes afterward (T1-T10), the mean SBP, DBP, MAP, HR, and RPP in the control group were significantly higher than those in the dexmedetomidine group throughout the study period except at T1. The mean differences of SBP, DBP, MAP, HR, and RPP were significantly higher in the control group, with the value of 15.2 mmHg, 10.5 mmHg, 14 mmHg, 10.5 beats per minute, and 2,462.8 mmHg min−1. Four patients in the dexmedetomidine group and 1 patient in the control group developed hypotension, while 2 patients in the dexmedetomidine group had bradycardia. Prophylactic dexmedetomidine can attenuate the hemodynamic responses to laryngoscopy and DLT intubation with minimal adverse effects. This trial is registered with ClinicalTrials.gov NCT01289769.

Video-Assisted Thymectomy with Contralateral Surveillance Camera a Means to Minimize the Risk of Contralateral Phrenic Nerve Injury

Thymectomy for thymoma has traditionally been performed through midsternotomy that provides excellent exposure for a complete and safe resection. Minimally invasive alternatives have not been extensively evaluated for this disease process because data regarding the long-term oncologic effectiveness of these techniques remain to be established. Furthermore, video-assisted surgery as a unilateral approach may compromise the extension of the resection and could cause irreversible damage to the phrenic nerve of the opposite side. We evaluated the clinical feasibility and safety of a bilateral concomitant video-assisted approach with contralateral surveillance camera in patients undergoing thymectomy for thymoma. Four patients (3 females, 1 male) with thymoma causing myasthenia gravis (MG) were operated thoracoscopically at our institute under general anesthesia with double-lumen endotracheal intubation. The patients were placed in a supine position, and a 5-mm 30-degree lens thoracoscope was introduced into the left pleural space. Two other 10-mm working channels were applied. En bloc thymectomy was then performed, including mediastinal and pericardial fat pads, other tissue, and pleura from the level of the thoracic inlet to the diaphragm. A second 5-mm thoracoscope was inserted into the right hemithorax, and it was kept inside during the entire procedure to allow lateral surveillance of the extension and safety of the resection. Carbon dioxide insufflation and valved ports were used. The duration of the operation was 90 ± 72 minutes. Complete resection was achieved in all patients without any nerve injury. There were no perioperative adverse events. Gradual remission from extremity and ocular weakness was achieved after recovery. The ultimate surgical goal of thymectomy is to completely remove the gland and anterior mediastinal tissue without nerve injury. Bilateral concomitant video-assisted thoracic thymectomy with a contralateral surveillance camera was found feasible and safe. Given the capability of our technique to perform a complete and extensive thymectomy associated with less invasiveness and beneficial effects, there seems to be a role for minimally invasive thymectomy in the treatment of thymoma.