| The traditional thoracotomy have longer incision, more postoperative complications, and more severe trauma to the body. With the progress of high-precision optical technology, high-definition camera-imaging system, a high-tech endoscopic surgical instruments and advanced level of anesthesia and guardianship, modern thoracoscopic surgery is provided with the necessary conditions of development. The thoracoscopic surgery rapidly develop and spread worldwide.It becames a surgical technique for the main purpose of treatment from a sole diagnostic technique. Its application is involved in almost all areas of general thoracic surgery. The thoracoscopic surgery turns into a specialized surgical science,which can be used for the diagnosis and treatment of a variety of chest diseases without the limit of surgery time. Due to the small injury, stable intraoperative parameters, less impact on physiological indicators and quick recovery after surgery, thoracoscopy has been widely used in clinical diagnosis and treatment of common lung disease.In thoracoscopic surgery,the double-lumen endotracheal intubation and pulmonary sequestration technology provide unilateral pulmonary ventilation or both sides of pulmonary ventilation respectively, so as to protect the contralateral bronchial and lung from pollution and fully exposed surgical field, so the thoracoscopic minimally invasive surgery is feasible.The complications of OLV include hypoxemia, ventilator-associated lung injury,hypoxia-induced lung injury, mechanical stretch-induced lung injury, ischemia-reperfusion injury, non-dependent lung injury. The anesthetists prevent hypoxemia by increasing the fraction of inspired oxygen and correcting malposition. In additionthe,the use of intravenous anesthetics, continuous positive airway pressure to the non-ventilated lung when surgical pause and the increase of end-expiratory positive pressure in the dependent lung to reduce intrapulmonary shunt fraction can also improve hypoxemia. At the start of one-lung ventilation, lower tidal volume, increased respiratory rate, and pressure control ventilation for dependent lung to reduce inspiratory peak pressure rise, or shortening the time of one-lung ventilation can prevent ventilator-associated lung injury.But the other complications of unilateral lung ventilation,such as ischemia-reperfusion injury, non-dependent lung injury,is still difficult to prevent. In recent years, in order to avoid the risk of intubation, some foreign scholars reported experience in the awake thoracic surgery under epidural anesthesia. They confirmed that some small thoracoscopic surgery can be carried out in spontaneous breathing under non-single-lung ventilation anesthesia. Thoracoscopic lobectomy implemented by Taiwan scholar through epidural anesthesia with intrathoracic vagus nerve block achieved good results. However, the technical requirements of non-endotracheal intubation anesthesia have high demand and close cooperation between anesthesiologists and surgeons. Ambrogi, an Italian scholar, reported8sets of successful thoracoscopic surgery for spontaneous pneumothorax with laryngeal mask airway and lateral position, but the feasibility and safety of this method is not yet entirely clear, nor control study with intubation anesthesia.Purpose and SignificanceReference to the experience of the existing non-tracheal intubation assisted thoracoscopic surgery, we conducted the randomized controlled clinical studies to assess the safety and feasibility of thoracoscopic surgery for chest disease, get experimental data, and accumulate experience in order to carry out the thoracoscopic surgery assisted by laryngeal mask anesthesia for complex thoracic diseases.Research methodsApril2012to December2012, the test group included33patients with chest diseases (bullae14, pectus excavatum5, hyperhidrosis10, peripheral lung nodules4), accepted thoracoscopic surgery under low tidal volume and high-frequency lung ventilation through laryngeal mask. The control group included33patients with chest diseases(bullae15, pectus excavatum6, hyperhidrosis8, peripheral lung nodules3) accepted thoracoscopic surgery under single-lung ventilation through double-lumen endotracheal intubation.1. Anesthesia Methods1.1The Anesthesia Methods of Laryngeal Mask GroupAll patients were taken to30°semi-recumbent position.Before anesthesia, fiberoptic bronchoscopy, intubation equipment and bronchial blockage must be prepared to carry out endotracheal intubation immediately if necessary. The ECG, pulse oximetry, respiratory rate, blood pressure and body temperature were conventional continuous monitored. Anesthesia was induced with the pumped0.3μg/kg dexmedetomidine.10minutes later,propofol (target plasma concentration2.5μg/ml) and remifentanil (target plasma concentration3ng/ml) were pumped,0.15mg/kg cisatracurium was intravenously injected.Maintenance of Anesthesia:Monitoring bispectral index (BIS) was maintained at40to60. Intravenous infusion of propofol (target plasma concentration of1.5-3μg/ml), remifentanil (target plasma concentration of4.5ng/ml), additional0.15μg/kg sufentanil before skin incision. Additional0.05mg/kg cisatracurium according to surgery requires. During surgery, maintain SpO2≥90%.1.5cm incision was observation hole,which cause iatrogenic pneumothorax to make the ipsilateral lung collapse gradually.If necessary, instrumental extrusion tolobe can be carried out. Before Suturing chest wall,additional0.1μg/kg sufentanil was needed, then the pumped infusion stopped. Awake time is the time of calling open eyes. The timing of unplugging the laryngeal mask shall be decided by the anesthetist.After unplugging the laryngeal mask in the recovery room,patients were sent back to the ICU.1.2The Anesthesia Methods of Intubation Anesthesia GroupAll patients were taken to the contralateral decubitus. The anesthesia monitor was the same as laryngeal mask group’s. Anesthesia was induced with the pumped0.6μg/kg dexmedetomidine.10minutes later,propofol (target plasma concentration3～3.5μg/ml) and remifentanil (target plasma concentration4-6ng/ml) were pumped,0.12mg/kg cisatracurium was intravenously injected. The tidal volume of the ventilator is set to8-10ml/kg, a respiratory rate is15/min, inspiratory to expiratory ratio is1:2and the oxygen concentration is50%, to maintain PetCO228-35mmHg, At the start of surgery, single-lung ventilation began.Maintenance of Anesthesia:BIS was maintained at40to60. Intravenous infusion of propofol (target plasma concentration of2～4μg/ml), remifentanil (target plasma concentration of4-6ng/ml), additional0.15～2μg/kg sufentanil before skin incision. Additional0.05mg/kg cisatracurium according to surgery requires. Before Suturing chest wall,additional0.1μg/kg sufentanil was needed, then the pumped infusion stopped. During surgery, maintain SpO2>90%.Awake time is the time of calling open eyes. The timing of unplugging the intubation shall be decided by the anesthetist.After unplugging the intubation in the recovery room,patients were sent back to the ICU. 2.Thoracoscopic SurgeryThe Patients of LMA group were30°semi-recumbent to make the collapsed lung fallen, which can increase the angle and space instrumentation. According to specific surgery, the appropriate intercostal was selected as observation hole. A trocar was placed through1.5cm skin incision.A30°0.5cm thin endoscopy or operational explored. A0.5cm incision made in other appropriate intercostal was used in the placement of small trocar under the surveillance of the thoracoscope. The small thoracoscope can be moved to the incision to observe thoracic cavity.If necessary, the second operation hole can be set. Good horizons and operating space was established under the surveillance of the thoracoscope. Two or three trocars can be alternately used as observation holes or operating hole. We can use oval clamps to gently press the lung with slightly collapse, to determine the lesion, and choose the best hole. When the surgery is over, the chest was flushed and lung was swelled with laryngeal mask. Depending on the specific circumstances, the drainage tube was placed depending.Intubation patients took contralateral supine and set armpit pads to widen intercostal space of surgery side. According to specific surgery, the appropriate intercostal was selected as observation hole.A trocar was placed through1.5cm skin incision.A30°endoscopy or operational explored. A0.5cm incision made in other appropriate intercostal was used in the placement of small trocar under the surveillance of the thoracoscope. If necessary, the second operation hole can be set. Good horizons and operating space was established under the surveillance of the thoracoscope. Two or three trocars can be alternately used as observation holes or operating hole. We can use oval clamps to gently press the lung with slightly collapse, to determine the lesion, and choose the best hole. When the surgery is over, the chest was flushed and lung was swelled with intubation. Depending on the specific circumstances, the drainage tube was placed depending.Research Content and Process1.Research Content1.1Intraoperative PortionHorizons exposed score,anesthetic effect score,surgical time, anesthesia time of every surgery were recorded. Sedation dose, analgesia dose,muscle relaxants dose,intraoperative minimum SpO2, intraoperative highest PetCO2and blood loss were counted.. The above areas were compared between the test group and control group.1.2Postoperative PortionPostoperative oral intake time, postoperative activity time, postoperative hospital stay. WBC changes,NEU%changes before and after surgery, gastrointestinal symptoms, sore throat and hoarseness of all patients were recorded. The above areas were compared between the test group and control group.2.The Research Process2.1The Inclusion CriteriaThe test group and control group must meet the same entry criteria. Inclusion criteria included10-65years old, no history of respiratory disease, such as tuberculosis,COPD, respiratory sleep syndrome,no disease of the circulatory system coronary heart disease, such as congenital heart disease, rheumatic heart disease, and complexity bullae diagnosed by clinic, no the pleural adhesions and no clinical signs of active infectious diseases on the ipsilateral chest radiograph. Exclusion criteria included mental illness,no good cooperation, hypovolemia, blood diseases or clotting mechanism of blood patients, ASA score≥3, lung function FEV1.0<60%,pulmonary nodule diameter>6cm,trachea anatomical abnormality or lesions involving with bronchia, BMI≥30. This study was reviewed and approved by the Research Ethics Committee of Nanfang Hospital of Southern Medical University, all participate signed informed consents.2.2Grouped and SurgeryGrouping was conducted randomizedly by Excel Software. Test group accepted thoracoscopic surgery under high-frequency small tidal volume lung ventilation through laryngeal mask and general anesthesia, and the control group accepted thoracoscopic surgery under single lung ventilation through the double-lumen endotracheal intubation. The intraoperative evaluation indicators and postoperative recovery were recorded.2.3Data AnalysisMeasurement data,such as age and weight,was calculated by X±S. Groups were compared using the t-test Categorical variables such as gender, smoking status, were expressed as percentage and analyzed by the X2test. SPSS13.0processes all data, P<0.05was statistically significant.The Main Conclusions1. Thoracic surgery assisted by laryngeal mask anesthesia is safe and feasible and can avoid intubation and thoracic epidural anesthesia-related risks.2. Postoperative recovery of LMA group was significantly better than Intubation group. |
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