The Hemodynamic Changes Induced by Lung Recruitment Maneuver to Predict Fluid Responsiveness in Children during One Lung Ventilation-A Prospective Observational Study.

BACKGROUND: The prediction of fluid responsiveness in critical patients helps clinicians in decision making to avoid either under- or overloading of fluid. This study was designed to determine whether lung recruitment maneuver (LRM) would have an effect on the predictability of fluid responsiveness by the changes of hemodynamic parameters in pediatric patients who were receiving lung-protective ventilation and one-lung ventilation (OLV). METHODS: A total of 34 children, aged 1-6 years old, scheduled for heart surgeries via right thoracotomy were enrolled. Patients were anesthetized and OLV with lung-protection ventilation settings was established, and then, positioned on left lateral decubitus. LRM and volume expansion (VE) were performed in sequence. Heart rate (HR), systolic arterial pressure (SAP), mean arterial pressure (MAP) diastolic arterial pressure (DAP), stroke volume (SV), stroke volume variation (SVV), and pulse pressure variation (PPV) were recorded via an A-line based monitor system at the following time points: before and after LRM (T1 and T2) and before and after VE (T3 and T4). An increase in stroke volume (SV) or mean arterial pressure (MAP) of ≥10% following fluid loading identified fluid responders. The predictability of fluid responsiveness by the changes of SV (ΔSVLRM) and MAP (ΔMAPLRM) after LRM and VE were statistically evaluated by receiver operating characteristic curves [area under the curves (AUC)]. RESULTS: SVs in all patients were significantly decreased after LRM (p < 0.01) and then, increased and returned to baseline after VE (p < 0.01). In total, 16 out of 34 patients who were fluid responders had significantly lower SV after LRM compared to that in fluid non-responders. The area under the receiver operating characteristic curves for ΔSVLRM was 0.828 (95% confidence interval [CI], 0.660 to 0.935; p < 0.001) and it indicated that ΔSVLRM was able to predict the fluid responsiveness of pediatric patients. MAPs in all patients were also decreased significantly after LRM, and 12 of them fell into the category of fluid responders after VE. Statistically, ΔMAPLRM did not predict fluid responsiveness when LRM was considered as an influential factor (p = 0.07). CONCLUSIONS: ΔSVLRM, but not ΔMAPLRM, showed great reliability in the prediction of the fluid responsiveness following VE in children during one-lung ventilation with lung-protective settings. TRIAL REGISTRATION: ChiCTR2300070690.

Incidental Discovery of a Morgagni Hernia in a 72-Year-Old Woman After COVID-19 Pneumonia: A Case Report.

Morgagni hernia is a rare condition characterized by a congenital retrosternal defect of the diaphragm, leading to the protrusion of abdominal organs into the thoracic cavity. Here, we report the case of a 72-year-old woman with a Morgagni hernia incidentally discovered during evaluation for persistent dyspnea following COVID-19 pneumonia. The diagnosis was made by imaging, including a chest X-ray and a thoracic CT scan, which showed an ascent of the transverse colon and omentum through an anterior retrosternal defect. Surgical exploration via right posterolateral thoracotomy revealed an anterior diaphragmatic hernia with a small defect containing the greater omentum and transverse colon, which was repaired by resecting the hernia sac and closing the diaphragmatic defect by fixing the anterior rim of the diaphragm to the retrosternal fascia with interrupted silk sutures. Postoperative recovery was uneventful, and follow-up examinations revealed no abnormalities on chest X-rays obtained at one, three, and six months. This case highlights the incidental discovery and successful surgical management of a Morgagni hernia in an elderly patient through a thoracic approach.

Improved detection of air-filled lesions using computed tomography in dogs with recurrent spontaneous pneumothorax through reduction of pulmonary atelectasis via positive pressure ventilation.

Introduction: Spontaneous pneumothorax in dogs is predominantly caused by the rupture of air-filled lesions, such as bullae or blebs. The efficacy of Computed Tomography (CT) in detecting these lesions has been deemed limited due to its reportedly low sensitivity. This retrospective, cross-sectional study investigates the utility of CT in eight dogs diagnosed with recurrent pneumothorax, all of which had surgical confirmation of the cause of the pneumothorax. Materials and methods: Thoracic radiographs were obtained before and the day following the CT studies. Initially, a CT study was conducted without positive pressure ventilation (pre-PPV CT). Subsequent CT studies were performed post-evacuation of pneumothorax and with positive pressure ventilation of 15 cmH2O until lung atelectasis was resolved (post-PPV CT). The pre-PPV CT and post-PPV CT images were anonymized and reviewed by two board-certified radiologists. The presence and morphology of air-filled lesions were evaluated on all images. Surgical findings were recorded and compared to the CT findings. Results: Air-filled lesions were detected in 5 out of 8 dogs in the pre-PPV CT studies and in all 8 dogs in the post-PPV CT studies. The CT findings of air-filled lesions were consistent with surgical findings. None of the dogs showed increased severity of pneumothorax in radiographs taken the day following the CT studies. Discussions: The study concludes that the resolution of lung atelectasis by evacuation of pneumothorax and positive pressure ventilation during CT studies is feasible and enhances the detection of air-filled lesions in dogs with recurrent spontaneous pneumothorax. This could potentially aid in improving surgical planning.

Combined coronary artery bypass with descending thoracic aorta to bifemoral bypass grafting using minimal invasive technique.

Coronary artery disease (CAD) and peripheral vascular disease (PVD) often coexist and are prevalent due to population ageing, smoking, diabetes, unhealthy lifestyles, and the epidemic of obesity. In high-risk patients, it is critical to minimize the overall burden of surgery to avoid poor outcomes and morbidity. Here, we present a case of successful coronary artery bypass grafting (CABG) with thoraco-bifemoral bypass surgery for PVD via a left thoracotomy approach. Traditionally, median sternotomy is done for these kinds of surgeries. However, we preferred thoracotomy over sternotomy to avoid morbidity in old age. Our case suggests that combined CABG with thoraco-bifemoral bypass via thoracotomy approach is a reliable surgical option depending on the anatomy of the lesion.

Does lateral approach preserve the right ventricular function after HeartMate 3 insertion?

OBJECTIVES: Lateral thoracotomy (LT) approach may preserve the right ventricular (RV) function after left ventricular assist device (LVAD) implantation. This study evaluated the short- and long-term RV function using echocardiography after LVAD implantation via LT or median sternotomy (sternotomy). METHODS: The patients who underwent HeartMate 3 implantation were retrospectively reviewed. The RV function was assessed before and 1 month and 1 year after LVAD implantation. The primary and secondary outcomes were all-cause mortality and a composite of death or readmission due to RV failure, respectively. RESULTS: Of the 195 patients, 55 (28%) underwent LT and 140 (72%) underwent sternotomy. There were no significant differences in the preoperative RV geometry or function. One month after the LVAD implantation, the LT group had a smaller RV end-diastolic dimension [42 (29-48) vs 47 (42-52) mm; P = 0.003] and RV end-diastolic area [25 (21-28) vs 29 (24-36) cm2; P < 0.001] and a greater RV fractional area change [30 (25-34)% vs 28 (23-31)%; P = 0.04] and peak systolic tissue velocity [8 (7-9) vs 7 (6-8) cm/s; P = 0.01]. Twenty-four patients died and 46 met the composite end point. Kaplan-Meier curve analysis did not reveal significant differences between LT and sternotomy in the 2-year survival (93% vs 83%; log-rank test, P = 0.28) and adverse event rate (76% vs 71%; log-rank test, P = 0.65). CONCLUSIONS: LT approach yielded a better-preserved RV function at 1 month; however, there were no significant differences in the 2-year survival and adverse event rates.

Difficult airway management and low Bispectral Index (BIS) in a patient with left Bochdalek congenital diaphragmatic hernia (CDH).

BACKGROUND: Bochdalek congenital diaphragmatic hernia (CDH) is a developmental defect in the posterolateral diaphragm, allowing herniation of abdominal contents into the thorax causing mechanical compression of the developing lung parenchyma and lung hypoplasia. We describe a case of an adult patient with a Bochdalek hernia who underwent minimally invasive right thoracotomy Perceval bioprosthetic aortic valve replacement (AVR) requiring one-lung ventilation (OLV) on the side of the hernia. This is a complex and challenging case that brings up numerous thought-provoking anesthetic implications. To the best of our knowledge, a Pubmed search did not reveal any publication to date of difficult airway management in an adult patient with CDH. CASE PRESENTATION: The first major problem encountered was patient's crus habitus anatomical condition (exceedingly ventrally displaced trachea) Mallampati Class IV and Cormack-Lehane grade IV extremely difficult endotracheal intubation. Neither glottis nor epiglottis was visible on laryngoscopy; resulting in failed placement of the double-lumen endobronchial tube (DLT) following numerous attempts. The DLT was eventually placed via GlideScope videolaryngoscopy. Whereas the endobroncheal right lung block for left OLV was successfully placed using fiberopticscopy. The crus habitus encroached on OLV tidal volume by the cranially displaced ascending colon and left kidney. Anesthesia was maintained with remifentanil /sevoflurane; adjusted to maintain bispectral index (BIS) at 40-60. Digitally recorded BIS was 38-62 except when BIS precipitously declined to 14-38 (SR, suppression ratio < 10) for 25 min after termination of the cardiopulmonary bypass. CONCLUSIONS: We report a case essentially dealing with an anatomically distorted difficult airway in a patient with left Bochdalek CDH undergoing a complex AVR. We describe anesthetic difficulties and unforeseen issues encountered; such as an extremely difficult DLT placement.

HeartWare to HeartMate 3 left ventricular assist device exchange via a left lateral thoracotomy.

A continuous-flow left ventricular assist device implant is a well-established therapy for patients with end-stage heart failure. Currently, the HeartMate 3 device is the only commercially available durable left ventricular assist device. Therefore, patients on HeartWare HVAD support who require a pump exchange must have a HeartMate 3 implanted.

Successful Repair of a Complete Tracheobronchial Tear Two Months After the Injury.

Tracheobronchial injury (TBI) is a rare but potentially life-threatening tear of the lower airway that can result from iatrogenic or accidental trauma. We present a case of a young male who suffered from acute TBI following blunt trauma to the chest. The patient was managed conservatively with intubation and oxygen support initially. The condition improved and the patient was discharged. However, he developed chest pain two months later and was diagnosed with a complete TBI on the right side. He subsequently underwent open surgical repair of the tear with end-to-end anastomosis, which led to a full recovery.

Less is better? Comparing effects of median sternotomy and thoracotomy surgical approaches for left ventricular assist device implantation on postoperative outcomes and valvulopathy.

OBJECTIVE: Our objective was to compare outcomes after left ventricular assist device implantation performed via median sternotomy or lateral thoracotomy. METHODS: We retrospectively analyzed 222 adult patients with the HeartMate3 (Abbott Lab) left ventricular assist device implanted between November 2014 and November 2021. Outcomes stratified by surgical approach were evaluated in propensity score-matched groups. The primary outcome was 1-year survival. Secondary outcomes included in-hospital morbidity and mortality, readmissions, and significant valvular regurgitation. RESULTS: Our cohort consisted of 60 patients (27%) who underwent lateral thoracotomy and 162 patients (73%) who underwent median sternotomy. Propensity score matching compared 45 patients who underwent lateral thoracotomy with 68 patients who underwent median sternotomy. There were no differences in intensive care unit or hospital stay duration (median, 10 vs 11 days, P = .58; 46 vs 40 days, P = .279), time to extubation (median, 2 days, P = .627), vasoactive-inotropic scores at intensive care unit arrival (18.20 vs 16.60, P = .654), or in-hospital mortality (2 [5%] vs 4 [6.1%] patients, P = 1). One-year survival (95.56% vs 90.61%, P = .48) and all-cause hospital readmission rate (Gray's test: P = .532) were also comparable. Patients who underwent lateral thoracotomy had significantly less early right ventricular failure (24.4% vs 53.7%, P = .004), although they had more follow-up tricuspid regurgitation (17.6% vs 0%, P = .030) and volume overload readmissions (Gray's test: P = .0005). CONCLUSIONS: Our data suggest that lateral thoracotomy is a safe although not necessarily superior alternative to median sternotomy for HeartMate 3 implantation in the perioperative and postoperative periods, because it precludes concomitant tricuspid valve repairs and may be associated with increased risk of late tricuspid regurgitation and volume overload readmissions.

Left ventricular assist device implantation via lateral thoracotomy: A systematic review and meta-analysis.

BACKGROUND: Left ventricular assist device (LVAD) implantation via lateral thoracotomy can offer similar effectiveness to conventional approaches with less perioperative adverse events. We performed a systematic review and meta-analysis to determine the potential benefits of lateral thoracotomy (LT) for LVAD implantation compared to median sternotomy. METHODS: We searched MEDLINE and Embase databases for studies comparing continuous-flow LVAD implantation using LT with conventional sternotomy. Main outcomes were perioperative mortality and complications. RESULTS: Twenty-five observational studies enrolling 3072 patients were included with a median follow-up of 10 months. Perioperative mortality (30 day or in-hospital) was 7% (LT) and 14% (sternotomy); however, mortality differences were no longer statistically significant in matched/adjusted studies (RR:0.86; 95%CI:0.52-1.44; p = 0.58). LT was associated with decreased need for blood product transfusions (mean difference[MD]: -4.7; 95%CI: -7.2 to -2.3 units; p < 0.001), reoperation for bleeding (RR:0.34; 95%CI:0.22-0.54; p < 0.001), postoperative RVAD implantation (RR:0.53; 95%CI:0.36-0.77; p < 0.001), days requiring inotropes (MD: -1.1; 95%CI: -2.1 to -0.03 inotrope days; p = 0.04), ICU (MD: -3.3; 95%CI: -6.0 to -0.7 ICU days; p = 0.01), and hospital length of stay (MD: -5.1; 95%CI: -10.1 to -0.1 hospital days; p = 0.04) in matched/adjusted studies. Overall mortality during follow-up was significantly lower for LT in unmatched/unadjusted studies but not statistically significantly lower in matched/adjusted studies (Hazard Ratio:0.82; 95%CI:0.59-1.14; p = 0.24). CONCLUSION: LVAD implantation via LT was associated with significantly decreased need for blood products, reoperation for bleeding, and postoperative RVAD implantation. Furthermore, days on inotropic support were also lower, likely contributing to the shorter length of stay. These findings support greater use of a LT approach for carefully selected patients.

In search of optimal cardioplegia for minimally invasive valve surgery.

Cardioplegic solutions are used in cardiac surgery to achieve controlled cardiac arrest during operations, making surgery safer. Cardioplegia can either be blood or crystalloid based, with perceived pros and cons of each type. Whilst it is known that cardioplegia causes cardiac arrest, there is debate over which cardioplegic solution provides the highest degree of myocardial protection during arrest. Myocardial damage is measured post-operatively by biomarkers such as serum TnT, TnI or CK-MB. It is known that the outcomes of minimally invasive valve surgery are comparable to full sternotomy valve operations. Despite there being a wide diversity in use of different cardioplegic solutions across the world, this comprehensive literature review found no superiority of one cardioplegic solution over the other for myocardial protection during minimally invasive valve procedures.

Three-dimensional computed tomography-guided excision of an intrathoracic giant thymoma with elongated thymic vessels.

We report the case of an intrathoracic giant thymoma with elongated thymic vessels, which was successfully resected under three-dimensional computed tomography guidance. A large, left-sided intrathoracic mass was incidentally found in a 41-year-old woman during a routine work-up for uterine cancer. Six vessels were noted arising from the tumor, five of which were connected to the anterosuperior mediastinum. The vasculature suggested that the tumor originated from the thymus and grew into the left pleural cavity, which pulled and elongated the associated vessels. Preoperative computed tomography imaging demonstrated that these vessels were located behind the tumor, which increased the risk for catastrophic intraoperative bleeding. We created a detailed surgical plan using our preoperative computed tomography data and successfully excised the tumor using intraoperative three-dimensional computed tomography guidance. Histopathological examination revealed a type AB thymoma without capsular invasion. This case highlighted the role of preoperative planning and intraoperative imaging in resecting an intrathoracic giant thymoma safely. In the video, we demonstrate how we performed the procedure under three-dimensional navigation.

Sex differences in outcomes following less-invasive left ventricular assist device implantation.

BACKGROUND: Worse outcomes in women compared to men undergoing left ventricular assist device (LVAD) implantation remain an underestimated problem in heart failure (HF) patients. With device miniaturization, less-invasive LVAD implantation techniques have gained relevance, but their impact on outcomes in women is unknown. This study investigates sex-related differences in patients undergoing LVAD implantation through less-invasive procedures. METHODS: This retrospective single-center cohort study included patients who underwent isolated LVAD implantation between 2011 and 2018 through less-invasive techniques. Propensity score matching (PSM) was utilized to balance preoperative heterogeneity. Primary endpoint was two-year survival, and secondary endpoints included long-term survival, surgical outcomes and postoperative adverse events. RESULTS: Baseline analysis of 191 patients (females 18.3%) showed differences in terms of age [female (median, 52; IQR, 47-61); male (median, 58.5; IQR, 49-66); P=0.005], underlying diagnosis (P<0.001), INTERMACS profile (P=0.009), history of previous cardiac surgery (P=0.049) and preoperative creatinine values [female (median, 110; IQR, 71-146); male (median, 126; IQR, 9-168); P=0.049]. Over a follow-up of 460.68 patient-years, Kaplan-Meyer analysis showed better survival in females (P=0.027) and a similar probability of cardiac transplantation (P=0.288). After PSM, females showed higher needs for intraoperative fresh frozen plasma (P=0.044) and platelets (P=0.001) but comparable postoperative outcomes. No sex-related differences were noticed regarding two-year outcomes, long-term survival and adverse events. LVAD-related infections remained the most common complication with males experiencing more pump infections than women (P=0.050). CONCLUSIONS: Patients receiving less-invasive LVAD implantation do not show significant sex-related differences in short and long-term outcomes and survival. Prospective studies are needed to evaluate the role of less-invasive techniques in reducing sex-based disparities after LVAD implantation.

Effectiveness of postural lung recruitment on postoperative atelectasis assessed by lung ultrasound in children undergoing lateral thoracotomy cardiac surgery with cardiopulmonary bypass.

OBJECTIVES: To assess the effects of postural lung recruitment maneuvers on the postoperative atelectasis assessed by lung ultrasound (LUS) compared with supine position recruitment maneuvers in children undergoing right lateral thoracotomy cardiac surgery with cardiopulmonary bypass. METHODS: In this randomized and controlled trial, 84 patients aged 3 years or younger, scheduled for right lateral thoracotomy cardiac surgery with cardiopulmonary bypass (CPB) were randomly allocated to postural lung recruitment group or control group. The first LUS exam was performed immediately upon completion of the cardiac surgery (T1), and a repeat ultrasound exam started 1 min after lung recruitment maneuvers (T2). The primary outcome was the incidence of significant atelectasis at T2. RESULTS: The incidence of significant atelectasis at T2 in the postural lung recruitment maneuver group was lower compared with that in the control group (30.2% vs. 58.1%; odds ratio: 0.31; 95% confidence interval: 0.13-0.76; p = .009). The LUS scores for consolidations and B-lines of the left lung were higher than those of the right lung in both groups at T1. More significant reduction of the left LUS scores and sizes of atelectatic areas were found in the postural lung recruitment group than those in the control group. CONCLUSIONS: Postoperative postural recruitment maneuver was more effective to improve reaeration of lung than supine position recruitment maneuver in children undergoing right lateral thoracotomy cardiac surgery with CPB.

A Large Thymoma Resected via Left Antero-lateral Thoracotomy.

Background/Aim: Thymomas are a rare type of mediastinal tumors with a slow growth rate. Because of this, they are well tolerated and patients usually present with large masses, which can extend in either of the thoracic cavities. The surgical approach for such tumors is dictated by the size and localization of the mass. Case Report: We present the case of a patient with a large thymoma, resected through surgery performed by left antero-lateral thoracotomy. The patient presented in our clinic with a persistent cough, dyspnea, chest pain and tightness. Standard thoracic X-ray revealed a bilateral increase in size of the mediastinal shadow, mainly on the left side, with well-defined margins and subcostal intensity. A thoracic computed tomography (CT) scan discovered a tumoral mass within the antero-superior mediastinum, with compression of the mediastinal organs; presentation being suggestive for a thymoma. Surgery was performed, removing a 15/13/10 cm thymoma with a weight of 1126 g. Pathological examination as well as immunohistochemistry confirmed our diagnosis of type AB thymoma, stage I Masaoka-Koga. Conclusion: In conclusion, surgical treatment remains the main therapeutic option in thymomas, but it is often difficult to perform due to tumor size and local invasion. However, even in large thymomas of stages I and II, surgery can be performed using an antero-lateral thoracotomy.

Previous Sternotomy as a Risk Factor in Minimally Invasive Mitral Valve Surgery.

BACKGROUND: Cardiac redo surgery, especially after a full sternotomy, is considered a high-risk procedure. Minimally invasive mitral valve surgery (MIMVS) is a potential therapeutic approach. However, current developments in interventional cardiology necessitate additional discussion regarding the therapy of choice in high-risk patients. In this context, it is necessary to clarify the perioperative and postoperative risks induced by the factor previous sternotomy in the setting of MIMVS. Thus, we present a comparative study analyzing the outcome of MIMVS after previous sternotomy vs. primary operation. METHODS: We identified 19 patients who received isolated or combined mitral valve (MV) surgery via the MIMVS approach after previous full sternotomy (PS group) and compared the results to those of a group of 357 patients who received primary MIMVS (non-PS group). After a propensity score analysis, groups of n = 15 and n = 131, respectively, were subjected to a comparative evaluation. A 1-year follow-up analysis of functional cardiac parameters and clinical symptoms was performed, accompanied by a Kaplan-Meier analysis. RESULTS: Except for the rate of realized MV reconstructions (PS group: 53.8% vs. non-PS group: 85.5%; p = 0.011), no significant differences were to be noted within the intraoperative and early postoperative course. However, patients in the PS group experienced an increased intensive care unit stay length (PS group: 2 days, 95% CI, 1-8 vs. non-PS group: 1 day, 95% CI, 1-2; p = 0.072). The follow-up examinations revealed excellent functional and clinical outcomes for both groups. The Kaplan-Meier analysis displayed no significant difference regarding the postoperative mortality (p = 0.929) related to the patients at risk. CONCLUSION: A previous sternotomy remains a risk factor for MIMVS and demands special attention in the early postoperative period. Nevertheless, the early- and late-term results concerning the functional and clinical outcomes suggest that the MIMVS procedure is satisfactory, even after a full sternotomy.

Modified rib pivot lateral thoracotomy: a case series.

OBJECTIVE: To describe a modified rib pivot thoracotomy and its clinical application in client-owned dogs and cats. STUDY DESIGN: Case series of 24 dogs and 1 cat requiring a thoracotomy. METHODS: A lateral thoracic incision over the required thoracic segment was made. The latissimus dorsi muscle was reflected dorsally. The predetermined rib was identified and the periosteum overlying the rib was elevated circumferentially, avoiding the intercostal neurovascular structures. Holes were pre-placed above and below the proposed osteotomy site. The rib was osteotomised and pivoted cranially. The pleura was incised and the required intrathoracic procedure was then performed. The thoracic cavity was closed by pre-placement of a suture through the pre-placed holes within the osteotomised rib. The pleura and intercostal musculature were closed, avoiding the intercostal neurovascular structures. The rib was re-apposed and the lateral approach was closed. The cases included were reviewed for both the rib pivoted as per the procedure required and postoperative complications. RESULTS: The study group comprised 8 Staffordshire Bull Terriers, 2 Poodles, 2 German Shepherd Dogs, 1 each of Basset Hound, Rhodesian Ridgeback, Golden Retriever, Australian Shepherd, Vizsla, Bull Mastiff, Schnauzer, Jack Russell Terrier, Bulldog, Deerhound, Labrador Retriever and Australian Terrier, and 1 cat. A modified rib pivot thoracotomy was performed for lung lobectomy (n = 11), oesophagectomy (7), subtotal pericardectomy (5), patent ductus arteriosus ligation (1) and thoracic duct ligation (1). Follow-up ranged from 2 to 40 weeks postoperatively. Postoperative complications included seroma formation in two dogs. CONCLUSION: A modified rib pivot thoracotomy should be considered as an alternative lateral thoracic approach with good exposure, minimal complications and low morbidity.

Right lateral mini-thoracotomy for mitral valve surgery.

Since the 1990 s, minimally invasive cardiac surgery has gained wide acceptance due to patient and economic demand. The advantages are less trauma, less bleeding, less wound infections, less pain and faster recovery. Many studies showed that the outcomes are comparable with those of conventional sternotomy. Right lateral mini-thoracotomy evolved into a routine and safe access in specialized centres for minimally invasive mitral valve surgery. The 6-cm incision is performed over the fifth intercostal space in the inframammary groove. With a double-lumen tube, the right lung is deflated before entering the pleural cavity. A soft tissue retractor is used to minimize rib spreading. The stab incisions for the endoscopic camera and the transthoracic clamp are performed in the right anterior and posterior axillary line in the third intercostal space. Surgery on the mitral valve is performed in a standard fashion under a direct vision with video assistance. One chest tube is inserted. The intercostal space is adapted with braided sutures to prevent lung herniation. Ropivacaine is used for local infiltration. The pectoral muscle, subcutaneous tissue and skin are adapted with running sutures. Complications of a right lateral mini-thoracotomy are rare (conversion to sternotomy, rethoracotomy, phrenic nerve palsy, wound infection and thoracic wall hernia) and well manageable.

Anaesthetic management of two different cases of mediastinal mass.

We report the management of two paediatric cases undergoing median sternotomy and right lateral thoracotomy for mediastinal mass. An 8-year-old boy presented with a history of intermittent fever and episodes of respiratory illness since 3 years and a 16-year-old girl presented with dyspnoea, cough, fever and dysphagia for solid foods. Radiological investigation confirmed the diagnoses. Absence of pressure symptoms pointed towards a compressible mass in the boy and indicated a non-compressible mass in the girl. We discuss the anaesthetic management of the younger patient with an uneventful course as opposed to the older patient where airway obstruction ensued soon after induction and led to near-cardiopulmonary arrest necessitating rescue measures. Swift measures at securing airway while simultaneously resuscitating the patient served to successfully revert an otherwise fateful eventuality.