LETTER TO THE EDITOR Year : 2023  |  Volume : 14  |  Issue : 1  |  Page : 63-64

Single-shot segmental thoracic spinal anesthesia for a giant lipoma of the back of the chest

T Kumar Venkatesh, S Parthasarathy
Department of Anesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry, India

Date of Submission12-Nov-2022Date of Decision14-Nov-2022Date of Acceptance17-Nov-2022Date of Web Publication31-Jan-2023

Correspondence Address:
Dr. S Parthasarathy
Department of Anesthesiology, Mahatma Gandhi Medical College and Research Institute, Sri Balaji Vidyapeeth, Puducherry
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_129_22

How to cite this article:
Venkatesh T K, Parthasarathy S. Single-shot segmental thoracic spinal anesthesia for a giant lipoma of the back of the chest. Indian J Med Spec 2023;14:63-4
How to cite this URL:
Venkatesh T K, Parthasarathy S. Single-shot segmental thoracic spinal anesthesia for a giant lipoma of the back of the chest. Indian J Med Spec [serial online] 2023 [cited 2023 Feb 15];14:63-4. Available from: http://www.ijms.in/text.asp?2023/14/1/63/368624

Dear Editor,

Lipomas are among the most widely known mesenchymal neoplasms in humans, occurring more often in mature adults aged between 40 and 60 years. Lipomas can develop in just about any part of the body where normal fat exists. They are common on the back of the neck but are rarely found on the face, scalp, or sternum. Excision of lipomas in the back is almost always a challenge to the attending anesthesiologists due to different associated problems.[1] We present a 40-year-old 120 kg female with a body mass index of 42 who was posted for excision of lipoma of the back. The extension of lipoma was from T2 level to T7 level predominantly on the left side extending from just above the scapula. [Figure 1] was a case of a difficult airway (Mallampati 4 and a mentohyoid distance of around 3 cm) with a normal mouth opening. She did not have any other comorbid illness. Routine investigations including an electrocardiogram (ECG) were normal. The surgeon accepted to operate in the lateral position. Routine monitoring included pulse oximetry, ECG, and noninvasive blood pressure. After, adequate intravenous access, she was administered segmental thoracic anesthesia at the level T6–T7 interspace with 1.2 ml of hyperbaric bupivacaine. The procedure was done on the first attempt without any difficulty or multiple passes. The sensory level was between C8 and L1. The palmar grasp was satisfactory. The surgery proceeded normally with minimal hemodynamic disturbance. The blood loss was <100 ml with a duration of around 30 min. The patient had a normal postoperative course. There was no neurological issue. Obesity poses a definite risk to airway control.[2] In this patient, a difficult airway and obesity prompted us to think about a regional technique. The lumbar spines were difficult to palpate and a need for an ultrasound with adequately experienced personnel may be needed.[3] Large lipomas were being done with tumescent anesthesia[4] but problems with local anesthetic volumes and their adverse consequences remain. General anesthesia with controlled ventilation with a change of position remains the gold standard for this case.[5] In our case, obesity, and a difficult airway made us administer segmental thoracic spinal anesthesia. For emergency airway access, we had planned the insertion of size 3 ProSeal LMA in the lateral position. Even though the authors have done a few cases of such a technique, a basic atraumatic approach is needed. In this case, the nociception was superficial. We used a normal 25 G quincke needle and we did not get any paresthesia. We did not opt for a small gauge needle in favor of increasing the success rate. Usually, the thoracic sympathetic blockade accompanying such blocks may be a nightmare for us; still, this case needed just 3 mg of supplemental ephedrine. The magnetic resonance imaging study of the thoracic spine revealed that the thoracic puncture used to conduct segmental spinal anesthesia is safe and has caused no neurological damage thus far. However, since hyperbaric bupivacaine solution provides a longer sensitive block than isobaric solution, it is more appropriate for segmental spinal anesthesia.[6] Fascial plane blocks like erector spinae plane blocks were not possible due to the position of the swelling. This is just a simple case report which limits major conclusions. We suggest that segmental spinal anesthesia is a feasible option in thoracic wall surgeries.

Patient consent

The patient consent was obtained.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

 

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  [Full text]  3.Ravi PR, Naik S, Joshi MC, Singh S. Real-time ultrasound-guided spinal anaesthesia versus pre procedural ultrasound-guided spinal anaesthesia in obese patients. Indian J Anaesth 2021;65:356-61.  
  [Full text]  4.Morioka D, Sato N, Ohkubo F. Excision of large lipomas using tumescent local anesthesia. J Cutan Med Surg 2016;20:263-5.  
    5.Terzioglu A, Tuncali D, Yuksel A, Bingul F, Aslan G. Giant lipomas: A series of 12 consecutive cases and a giant liposarcoma of the thigh. Dermatol Surg 2004;30:463-7.  
    6.Imbelloni LE, Sakamoto JW, Viana EP, de Araujo AA, Pöttker D, Araujo Pistarino M et al. Segmental spinal anesthesia: A systematic review. J Anesth Clin Res 2020;11:953.  
    
  [Figure 1]