LAUSR

A 19-year-old, 50 kg male, presenting with a non-obstructive adenoid cystic carcinoma of the posterior tracheal wall, was planned tracheal resection with end-to-end anastomosis. In the operation theatre, invasive arterial monitoring was instituted in addition to standard anaesthesia monitors. Anaesthesia was induced with propofol, fentanyl and controlled ventilation using oxygen-air-isoflurane through a small-sized endotracheal tube (ET). LASER guided delineation of posterior mucosal cuts was performed using a micro-laryngoscope. Following the frozen section report, surgeons proceeded to resect the trachea. The ET was replaced with a size 4 ProSeal laryngeal mask airway (PLMA). Bronchoscopy through PLMA confirmed an unobstructed view of vocal cords. Controlled ventilation was continued through PLMA till 30 min before the expected time of tracheal cut. Then, an infusion of propofol (at 100 μg/kg/min) replaced the inhalational anaesthetics. Boluses of neuromuscular blockers were avoided. When the trachea was incised, the patient had resumed spontaneous breathing. Two millilitres of 4% lignocaine were instilled on the tracheal mucosa. Oxygen was delivered through the PLMA at 5 litres/ minute till the time the two cut ends of the trachea were in approximation. Later, the patient breathed room air through the cut lumen of the distal trachea at 16-20 breaths per minute. Oxygen saturation was maintained between 98 and 100%, and the partial pressure of carbon dioxide in the blood remained between 50 and 55 mmHg. The surgeons applied intermittent suction to prevent aspiration of blood clots into the distal airways. Three tracheal rings along with the right lobe of the thyroid were resected. Avoiding muscle relaxants enabled the surgeons to perform nerve monitoring, for which electrodes were inserted into the thyroid cartilage. End to end anastomosis of tracheal ends was performed without any interruption [Figure 1]. The total duration of the procedure was 4 hours. At the end of the surgery, no neuromuscular reversal was required, PLMA was removed and the further recovery was uneventful.