A 77-year-old man (American Society of Anesthesiologists grade 3) who underwent microscopic laryngeal surgery for vocal cord tumor and leukoplakia was diagnosed with vocal cord squamous cell carcinoma. In addition, preoperative computed tomography revealed a lung tumor that was suspected to be malignant. After mutual discussion between the thoracic surgeon and the otolaryngologist, they decided to perform a left lower lung lobectomy before administering additional treatment for vocal cord cancer.
The patient had a history of hypertension and diabetes, which were controlled with medication. Two weeks before thoracic surgery, laryngoscopy was performed by an otolaryngologist, which revealed an elevated lesion on the vocal cord and mucosal thickening. After a preoperative conference between the anesthesiologist and thoracic surgeon, one-lung ventilation with a combination of a laryngeal mask airway and bronchial blocker was planned to avoid unexpected vocal cord injury and tumor dislodgment due to the insertion of a large-bore tracheal tube.
A standard anesthetic protocol was implemented, which involved routine noninvasive arterial blood pressure monitoring, electrocardiography, and oxygen saturation measurement on arrival to the operating room; the patient’s vital signs were stable. Before the induction of general anesthesia, a thoracic epidural catheter was inserted into the 6th–7th thoracic interspace. Anesthesia was induced using propofol (2 mg/kg), remifentanil (0.15 μg/kg/min), and rocuronium (0.8 mg/kg) and was maintained using desflurane (4%), remifentanil (0.1–0.15 μg/kg/min), and rocuronium (6 μg/kg/min). Continuous thoracic epidural anesthesia with 0.2% ropivacaine was used for maintaining intra- and postoperative analgesia. Before making a skin incision, cefazolin (1 g) was administered, followed by additional doses every 3 h. After the induction of anesthesia, a 22-G catheter was inserted into the right radial artery for blood sampling and continuous blood pressure monitoring.
After inducing anesthesia and securing the airway with a laryngeal mask airway (ProSeal Laryngeal mask airway #4, Teleflex, Ireland), a 9-Fr bronchial blocker (Phycon TCB bronchial blocker, Fuji Systems, Japan) was connected to the laryngeal mask airway via the multiport adaptor. The laryngeal mask airway cuff was inflated with 10 ml air. The blocker was placed in the left main bronchus under the guidance of a fiberscope 3.4 mm in diameter. The bronchial blocker passed through a position far enough from the vocal cord lesion (Fig. 1). The one-lung ventilation was started immediately after the patient was placed in the right lateral decubitus position. The bronchial blocker balloon was inflated with 6 ml air. During one-lung ventilation, the following ventilator settings were used: pressure control ventilation; inspirated pressure, 20 cm H2O; inspired O2 fraction, 0.6–1.0; and inspiratory fresh gas flow, 2 l/min. The respiratory rate was adjusted to 12–18 breaths/min to maintain an end-tidal carbon dioxide pressure of 35–45 mmHg. The surgery was initiated 25 min post the one-lung ventilation, and the lung collapse caused by the bronchial blocker provided a clear view of the operative field. There was no audible peri-laryngeal leakage during one-lung ventilation.
The surgery was started thoracoscopically and was converted to open thoracotomy midway through the procedure. The operation time was 378 min, and the one-lung ventilation time was 350 min. After the one-lung ventilation was completed, tracheal suctioning was performed using a fiberscope to avoid postoperative atelectasis, but the quantity of sputum was small. After two-lung ventilation, the lung expanded normally. After the surgery was completed and the patient was awake, the laryngeal mask airway was removed. The patient was transferred to the intensive care unit for postoperative care. The patient’s postoperative course was uneventful, and he was discharged without complications.