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Operative Role Reference

Staged breakdown of anaesthetic and surgical responsibilities across major procedures

Coronary Artery Bypass Grafting (CABG)

On-pump CABG via median sternotomy. Cardiopulmonary bypass used for the anastomotic phase. Typically LIMA to LAD ± saphenous vein grafts to other vessels. Duration 3–5 hours.

Anaesthetist
Cardiac Surgeon
01 Pre-operative Assessment & Setup
PRE-OP
▶
Anaesthetist
  • Review echo, cath report, EF, LV function, valve pathology, coronary anatomy
  • Identify high-risk features: poor LV function, recent MI, LMS disease, renal/respiratory comorbidity
  • Discuss plan with surgeon: likely CPB duration, expected ischaemic time, anticipated haemodynamic challenges
  • Arterial line (radial — confirm Allen's test), large-bore IV access ×2, consider introducer/PAC in poor LV
  • TOE probe if planned (routine in most centres for CABG); baseline TOE pre-induction or post-intubation
  • Preoxygenate; prepare vasopressors (metaraminol, vasopressin), inotropes (adrenaline, milrinone), heparin drawn
  • Cell saver circuit primed and ready with perfusionist
Cardiac Surgeon
  • Mark LIMA harvest site; confirm bilateral IMA or single LIMA plan with patient and team
  • Confirm conduit strategy: LIMA, radial artery, long saphenous vein (LSV)
  • Discuss target vessels with perfusionist: CPB setup, cardioplegia strategy (antegrade, retrograde, del Nido vs blood)
  • Briefing to scrub nurse: suture types, clips, stabiliser if OPCAB option being considered
  • Confirm sterile field prep; patient positioned supine, chest rolls may be placed
02 Induction & Intubation
INDUCTIONCRITICAL
▶
⚠ High-risk momentIn poor LV function, induction is the highest-risk phase for haemodynamic collapse. Vasopressors must be immediately available; consider low-dose noradrenaline infusion running prior to induction in EF <30%.
Anaesthetist
  • Cardiac induction: high-dose opioid technique (fentanyl 5–10 mcg/kg or sufentanil) to blunt sympathetic response; low-dose propofol or etomidate to avoid hypotension
  • Rocuronium for neuromuscular blockade; ketamine sometimes used as adjunct in low EF
  • Controlled, smooth laryngoscopy — avoid tachycardia and hypotension; grade haemodynamics as much as airway
  • Confirm ETCO2, SpO2, bilateral air entry; set ventilator for cardiac parameters (avoid high PEEP if compromised RV)
  • Insert TOE: baseline LV/RV function, RWMA, valves, check for aortic pathology before cannulation
  • Insert CVC (IJV or subclavian): CVP, infusion ports; consider PA catheter if EF <25% or complex haemodynamics
  • Initiate infusions: propofol or volatile agent (usually sevoflurane via the CPB machine gas port), remifentanil, NMB infusion
  • Target: MAP 65–75, HR 55–75, avoid tachycardia (increases O2 demand), normothermia until CPB
Cardiac Surgeon
  • Not scrubbed yet — available if emergency is declared (e.g., arrest requiring emergency sternotomy)
  • Confirms consent signed, imaging available, perfusionist is primed and ready
  • In many centres, a second team begins leg or radial harvest simultaneously with induction
03 Sternotomy & LIMA Harvest
▶
Anaesthetist
  • Deepen anaesthesia prior to skin incision; anticipate haemodynamic response to sternotomy
  • During sternotomy: brief apnoea often requested (deflate lungs for saw pass) — communicate clearly with surgeon
  • Monitor for pneumothorax, haemorrhage; adjust ventilation during sternal retraction
  • During LIMA harvest: right lung ventilation usually maintained; may need to reduce tidal volume if visualisation is poor
  • Heparin administered (typically 300–400 IU/kg) prior to cannulation — confirm with surgeon; verify ACT >480 seconds before CPB
  • Ensure vasopressors titrated: sternal retraction causes vagal response; MAP dips are common
  • Papaverine or topical vasodilators may be requested for LIMA — prepare on request
Cardiac Surgeon
  • Midline sternotomy with oscillating or gigli saw; retractor placed (Finochietto or sternal retractor)
  • Open pericardium; inspect heart: identify LV function, wall motion, coronary anatomy landmarks
  • LIMA takedown: skeletonised or pedicled harvest from left chest wall, IMA retractor used; care with pleural entry
  • Assess LIMA quality, flow, pulsatility — clip side branches; papaverine-soaked gauze applied
  • Vein harvesting (endoscopic or open LSV) proceeds simultaneously by second surgeon or assistant
  • Pericardial stay sutures placed; inspect aorta for calcification (cannulation site assessment)
04 Cannulation & Initiation of CPB
ON CPBCRITICAL
▶
⚠ Critical transitionGoing on bypass involves significant haemodynamic shift — MAP usually drops at initiation. RV and LV both unload rapidly. Anaesthetist must be vigilant for air entrainment, ventricular distension, aortic dissection.
Anaesthetist
  • Confirm ACT prior to cannulation (must be >480 sec); re-check after heparin dosing
  • Communicate with perfusionist: flow targets (2.4 L/min/m²), MAP target on bypass (50–70 mmHg), temperature plan
  • Cease mechanical ventilation once full CPB flow established (lungs are bypassed); leave lungs partially inflated
  • Maintain anaesthesia via vapour delivery through CPB circuit (volatile via oxygenator) or TIVA via pump
  • Monitor: MAP via arterial line (now reflecting CPB circuit pressure), TOE for LV/RV distension and venting adequacy
  • If LV becomes distended on TOE → alert surgeon immediately (LV vent required)
  • Temperature monitoring: nasopharyngeal and bladder — target mild/moderate hypothermia (32–34°C) or normothermia depending on case plan
Cardiac Surgeon
  • Aortic cannulation: purse-string sutures, Seldinger or direct cannulation of ascending aorta; confirm position with perfusionist
  • Venous cannulation: single two-stage cannula (RA/IVC) or bicaval cannulation; snares applied
  • Signal perfusionist to go on bypass — gradual flow increase to full support; confirm venous drainage, de-air circuit
  • Cross-clamp the aorta (Satinsky or DeBakey); signal perfusionist to deliver cardioplegia
  • Cardioplegia delivery: antegrade via aortic root or directly into coronary ostia; retrograde via coronary sinus catheter if needed
  • Confirm cardiac arrest — confirm flatline on ECG; temperature of heart should drop to ~15–20°C with cold cardioplegia
  • Place LV vent (via RSPV or aortic root) to decompress and maintain clear operative field
05 Distal Anastomoses (Arrested Heart)
ON CPB
▶
Anaesthetist
  • Vigilant monitoring of CPB circuit: MAP, flows, gases, ACT — dose additional heparin if ACT drifts below target
  • Repeat cardioplegia deliveries coordinated with surgeon (typically every 15–20 mins, or when surgeon requests)
  • Monitor temperature: ensure adequate cooling maintained; begin rewarming per surgeon plan
  • Blood gases from perfusionist circuit — correct pH, electrolytes (especially K⁺ — cardioplegia loads potassium), glucose
  • Haematocrit management: maintain Hct >21% on CPB; transfuse PRBCs or use ultrafiltration if diluted excessively
  • TOE: monitor LV vent function; ensure no air accumulation in cardiac chambers
  • Minimal intervention otherwise — heart is arrested; anaesthetist primarily monitors and maintains bypass conditions
Cardiac Surgeon
  • Identify target coronary vessel (LAD, diagonal, OM, RCA, PDA) — correlate with pre-op cath findings
  • Arteriotomy on target vessel: longitudinal incision ~5mm; vessel dilator used; avoid damaging intima
  • LIMA-to-LAD anastomosis: end-to-side with running 7-0 or 8-0 prolene; loupe magnification ×3.5 or microscope
  • Vein graft distal anastomoses to remaining targets: same technique, 7-0 prolene, precise placement avoiding tension
  • Graft flushed and clamped; assess quality under magnification — no kinks, no significant suture line defects
  • Request repeat cardioplegia before moving to next anastomosis if ischaemic time is extending
06 Proximal Anastomoses & Weaning from CPB
CPB WEANCRITICAL
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⚠ Critical transitionWeaning from bypass is the second highest-risk period. LV function must be reassessed with TOE. Inotropes and vasopressors must be ready; RV failure is common and can be sudden.
Anaesthetist
  • Confirm rewarming complete: nasopharyngeal temp >36.5°C, bladder >35°C before wean attempted
  • Recommence mechanical ventilation prior to wean; confirm bilateral air entry, adequate tidal volumes
  • De-air protocol with surgeon: ensure no air in LV or aortic root on TOE (critical for neurological outcomes)
  • Pre-wean checklist: rhythm (defibrillation if VF/AF), pacing available, electrolytes corrected, Hct adequate
  • Commence inotropes if poor LV function anticipated: adrenaline 0.01–0.1 mcg/kg/min ± milrinone for RV dysfunction
  • Wean CPB gradually — perfusionist reduces flow in stepwise fashion; anaesthetist monitors MAP, CVP, TOE continuously
  • Post-wean TOE: confirm new RWMA in grafted territories (should improve vs pre-bypass); assess LV/RV function, valves
  • Protamine reversal of heparin (1 mg per 100 IU heparin given) — administer slowly; watch for anaphylaxis, pulmonary hypertension
Cardiac Surgeon
  • Proximal anastomoses to ascending aorta: partial side-biting clamp (Satinsky); aortotomy with punch device; vein grafts anastomosed end-to-side with 6-0 prolene
  • Cross-clamp removed — heart reperfuses; may fibrillate (expect and prepare for internal defibrillation if needed)
  • Assess graft function: Doppler flow probe on each graft; confirm pulsatile high flow through each conduit
  • Transit-time flow measurement (TTFM) on all grafts — values documented; inadequate flow requires investigation
  • De-air ascending aorta via aortic root vent before coming off bypass
  • Once off CPB: assess haemostasis from anastomotic sites, cannulation sites, LIMA bed
07 Decannulation, Haemostasis & Closure
▶
Anaesthetist
  • Monitor coagulation: TEG/ROTEM or conventional (PT, APTT, fibrinogen, platelets); treat coagulopathy guided by results
  • Transfuse: PRBCs if Hct <24, FFP if coagulopathy, cryoprecipitate if fibrinogen <1.5, platelets if <80 or dysfunctional (post-bypass)
  • Antifibrinolytic administration if not given pre-bypass (TXA — usually given pre-CPB; re-dose if significant bleeding)
  • Maintain MAP 65–75 with vasopressors; avoid hypertension (suture line tension) and hypotension
  • Chest drain monitoring: >200 mL/hr for 2+ consecutive hours = surgical re-exploration threshold
  • Analgesia planning: intrathecal morphine if given pre-op, epidural if placed, systemic opioid + paracetamol + NSAID if applicable
  • Prepare for transfer: ICU notification with handover details including bypass time, cross-clamp time, graft function, current infusions
Cardiac Surgeon
  • Remove venous cannula; close RA purse-strings; decannulate aorta; close aortic purse-strings
  • Temporary pacing wires placed (epicardial, atrial ± ventricular) in all patients — sutured to myocardium
  • Mediastinal and pleural drains placed (28–32 Fr); positioned to drain pericardium and left pleura if entered
  • Meticulous haemostasis: cautery, prolene sutures to bleeding points, topical haemostatic agents (Surgicel, Floseal)
  • Sternal closure: stainless steel wires (typically 6–8) through or around sternum; figure-of-eight or single loop technique
  • Layered soft tissue closure: sternal fascia, subcutaneous, skin (staples or subcuticular suture)
Key Anaesthetic Pharmacology — CABG
Heparin
300–400 IU/kg IV before cannulation; ACT target >480 sec on CPB; reversed with protamine post-CPB
Tranexamic Acid
1g IV loading dose + 1g infusion; reduces fibrinolysis and transfusion requirement; give before incision
Cardioplegia
High K⁺ solution (St Thomas', del Nido, Custodiol) to arrest heart; cold or tepid; antegrade ± retrograde
Milrinone
PDE3 inhibitor; inodilator — improves RV function, reduces pulmonary vascular resistance; 0.375–0.75 mcg/kg/min
Adrenaline
First-line inotrope post-CPB; 0.01–0.1 mcg/kg/min; titrated to CO and MAP
Vasopressin
0.03–0.04 units/min; vasopressor of choice when systemic vasodilation is prominent (post-CPB vasoplegia)
Bentall Procedure

Composite replacement of the aortic valve, aortic root, and ascending aorta using a valved conduit graft, with reimplantation of coronary ostia. Indicated for aortic root aneurysm ± aortic regurgitation. Duration 4–7 hours. Significantly higher complexity than isolated CABG.

Anaesthetist
Cardiac Surgeon
Clinical ContextThe Bentall is typically performed for: Marfan syndrome root aneurysm, bicuspid aortic valve with root dilatation, aortic dissection involving the root (Type A), or isolated root aneurysm with or without AR. The haemodynamic and technical challenges substantially exceed an isolated CABG.
01 Pre-operative Assessment & Preparation
PRE-OP
▶
Anaesthetist
  • Review CT aorta (root diameter, extent of aneurysm, coronary ostia heights, arch involvement) and echo (AR severity, LV function, aortic stenosis if bicuspid)
  • Identify AR-related physiology: dilated LV, eccentric LV hypertrophy, preserved or depressed EF — adapt haemodynamic targets accordingly
  • In severe chronic AR: LV is volume-loaded and often dilated; may handle hypotension poorly; avoid bradycardia (increases regurgitant fraction)
  • In acute Type A dissection: dramatically higher haemodynamic instability; may have tamponade, coronary malperfusion — true emergency
  • Bilateral radial arterial lines (left arm and right arm): required if the aneurysm or dissection may compromise the innominate artery; radial pressures may diverge
  • Right femoral arterial line as backup in complex dissections; femoral venous access if bilateral upper limb compromised
  • Advanced neuromonitoring if circulatory arrest planned: cerebral NIRS (bilateral), EEG, consider retrograde or antegrade cerebral perfusion plan
  • Deep hypothermic circulatory arrest (DHCA) may be needed if arch is involved — discuss with surgeon; temps target 15–20°C; neuroprotection: steroids, mannitol, ice packs to head, thiopentone
  • Large bore access (8Fr introducer), consider femoral venous for CPB venous drainage if emergency
Cardiac Surgeon
  • Detailed review of CT: root diameter, sinotubular junction, coronary ostia position, extent of dilation (need for hemiarch or arch replacement?)
  • Select conduit: mechanical valved conduit (St Jude, ATS), bioprosthetic conduit (Freestyle, Hancock), or valve-sparing root replacement (David or Yacoub) if AR is functional with preserved leaflets
  • Plan coronary reimplantation strategy: standard button technique (Cabrol reserved for low ostia or redo)
  • Discuss CPB and circulatory arrest plan with perfusionist: cannulation strategy, cooling targets, cerebral protection method
  • In Type A dissection: urgent — consent on table, may bypass imaging; plan for femoral or axillary cannulation if ascending aorta unsafe
  • Ensure hybrid room or have availability of aortic stent grafts if arch involvement is suspected
02 Induction & Intubation
INDUCTIONCRITICAL
▶
⚠ Extreme haemodynamic sensitivityIn significant AR, diastolic blood pressure is already low. MAP drops during induction can precipitate coronary ischaemia (coronary filling occurs in diastole — already compromised). In aneurysm patients, avoid hypertension and tachycardia which increase wall stress (law of Laplace).
Anaesthetist
  • Maintain HR 80–90 in severe AR (faster HR reduces diastolic time and regurgitant fraction) — contrast with CABG where slow HR is preferred
  • Vasodilator infusion running: SNP or GTN to offload LV if hypertensive; avoid afterload increases
  • Induction: high-dose opioid (fentanyl 10–15 mcg/kg), etomidate (haemodynamically stable) or careful ketamine — avoid propofol boluses in severely dilated LV
  • Intraaortic balloon pump (IABP) contraindicated in significant AR — augments diastole and worsens regurgitation
  • TOE immediately post-intubation: quantify AR, measure root, assess LV size and function, confirm no new RWMA, look for dissection flap extension
  • Target MAP: 65–80 mmHg; avoid hypertension (>100 MAP) prior to aortic clamping — risks propagation of dissection or rupture
  • Bilateral NIRS probes confirmed and baseline recorded
  • In dissection: femoral arterial line pressure may reflect true lumen vs false lumen — correlate bilateral readings
Cardiac Surgeon
  • Present and immediately available — any arrest requires emergent sternotomy; in dissection, patient may deteriorate rapidly
  • Confirms imaging on screen, conduit selected, perfusionist primed
  • In acute dissection: team may scrub during induction to save time
03 Sternotomy & Pericardiotomy
CRITICAL
▶
⚠ Dissection-specific riskIn Type A dissection, opening the pericardium may release tamponade suddenly — blood floods out, cardiac output may temporarily improve then collapse. Have perfusionist ready to go immediately on CPB upon pericardial entry. Volume bolus ready.
Anaesthetist
  • Brief apnoea for sternal saw; vigilant at sternotomy for haemopericardium in dissection cases
  • In haemopericardium/tamponade: prepare for immediate haemodynamic decompensation and rapid CPB institution
  • Vasopressors running; blood products immediately available if dissection patient
  • Maintain communication with surgeon regarding aortic size and fragility — manipulations can precipitate rupture
  • Cell saver circuit active — expect significant blood loss
Cardiac Surgeon
  • Sternotomy with particular caution: aneurysm may be adherent to the sternum — oscillating saw used carefully; hand on sternum for vibration feedback
  • In redo: even higher risk of cardiac adherence; consider femoral cannulation before sternotomy
  • Pericardium opened carefully: assess for haemopericardium, size of aneurysm, degree of root involvement
  • Identify and protect phrenic nerves (both sides); note RV anatomy and adhesions
  • Assess aortic anatomy under direct vision: confirm extent of repair needed, whether arch is involved
  • Decision: if hemiarch replacement needed → plan for DHCA and circulatory arrest
04 Cannulation & CPB — Cooling for DHCA if Required
ON CPBCRITICAL
▶
Anaesthetist
  • Confirm ACT >480 before cannulation; repeat heparin dosing as needed
  • Cannulation strategy (with surgeon): arterial may be femoral (if ascending unsafe), right axillary (preferred in dissection — provides true lumen perfusion and antegrade cerebral perfusion potential), or distal ascending if safe
  • Cease ventilation once full CPB flow; communicate with perfusionist regarding flow targets
  • If DHCA planned: begin active cooling to 15–18°C nasopharyngeal; minimum 20–30 min cooling before arrest
  • Neuroprotection protocol for circulatory arrest: methylprednisolone 500mg–1g IV, mannitol 0.5 g/kg, ice packs to head, thiopentone 3–5 mg/kg (burst suppression on EEG)
  • NIRS monitoring: bilateral NIRS must remain >50% and not drop >20% from baseline; if falls, alert surgeon — adjust cannula, consider antegrade cerebral perfusion (ACP)
  • Cerebral oximetry and EEG correlate reasonably well; burst suppression confirms adequate barbiturate loading before circulatory arrest
  • Coordinate temperature targets precisely with perfusionist: gradients between nasopharyngeal and bladder must equilibrate before arrest
Cardiac Surgeon
  • Arterial cannulation: femoral or axillary (purse-strings, Seldinger, confirm position with TEE in false/true lumen) or distal ascending aorta
  • Venous cannulation: bicaval or single two-stage RA cannula
  • Full CPB initiated; confirm adequate decompression of heart
  • Aortic cross-clamp: placed as distal as possible on ascending aorta proximal to aneurysm; some cases the cross-clamp is applied at the arch
  • Cardioplegia: cold blood or del Nido delivered directly into coronary ostia (aortic root cannot be used for antegrade cardioplegia as it will be excised); retrograde via coronary sinus is standard
  • Cooling phase used to mobilise structures, identify coronary buttons (especially left coronary which can be in awkward position in root aneurysm)
05 Aortic Root Excision & Coronary Button Mobilisation
ON CPB
▶
Anaesthetist
  • Maintain cardiac arrest conditions; coordinate cardioplegia delivery every 15–20 min (into coronary ostia directly once root is open)
  • Monitor and maintain MAP 50–65 on CPB; adjust vasodilators/vasopressors with perfusionist
  • Ongoing blood gas and ACT monitoring; haematological support as needed
  • Minimal direct intervention during root work; main role is maintaining stable bypass conditions and vigilance for circuit issues
  • Ensure TOE probe is not impeding surgical access — may temporarily retract to neutral
Cardiac Surgeon
  • Aortotomy: transverse incision at or just above the sinotubular junction; opened circumferentially to expose valve and sinuses of Valsalva
  • Aortic valve excised: leaflets removed; annulus sized with valve sizer
  • Coronary ostia mobilised as "buttons": careful full-thickness circular buttons of aortic wall taken around each coronary ostium (left and right), maintaining 5–10mm of surrounding tissue; meticulous technique to avoid injury to the LCA or RCA
  • Root excision: aneurysmal sinuses of Valsalva excised, leaving only coronary buttons and the aortic annulus; care with left coronary which is immediately adjacent to the pulmonary artery
  • Annulus inspected and cleared; haemostatic sutures placed if needed around annulus for bleeding points
  • Measure distance from annulus to coronary ostia — critical for conduit sizing and positioning
06 Conduit Implantation & Coronary Reimplantation
ON CPBCRITICAL
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⚠ Most technically demanding phaseCoronary button reimplantation is the most technically exacting part of the Bentall. Tension, kinking, or torsion of a coronary button = perioperative MI. The right coronary button is particularly at risk given the geometry required.
Anaesthetist
  • Maintain cardiac arrest; coordinate cardioplegia delivery into coronary buttons as instructed by surgeon
  • After button reimplantation, surgeon will test each coronary for haemostasis — prepare for protracted cross-clamp time; communicate with perfusionist regarding time and temperature
  • Anticipate higher transfusion requirements: large anastomotic surface area, coagulopathy from prolonged CPB
  • TEG/ROTEM drawn before coming off bypass — get ahead of coagulopathy
  • Begin preparation for coming off bypass: inotropes drawn (adrenaline, milrinone), vasopressors, pacing discussed with surgeon
Cardiac Surgeon
  • Conduit seated at aortic annulus: horizontal mattress sutures (braided 2-0 Ethibond ± pledgets) circumferentially through annulus and into sewing ring of conduit; tied sequentially
  • Conduit oriented correctly: mechanical valve orientation must allow for leaflet opening without coronary ostial obstruction
  • Left coronary button anastomosis: hole punched in conduit at appropriate level and position; end-to-side anastomosis with continuous 5-0 prolene; tension-free, no rotation
  • Right coronary button: more technically challenging due to distance and geometry; may require creative positioning; extension using saphenous vein segment occasionally needed (Cabrol-like modification)
  • Inspect both coronary anastomoses under magnification: confirm no narrowing, no tension, no twist
  • Distal aortic anastomosis: conduit sutured to distal ascending aorta (or arch if hemiarch replacement performed) with running 4-0 prolene; Teflon felt reinforcement of aortic wall if fragile (dissection, Marfan)
  • If DHCA required for arch: circulatory arrest declared at this point — co-ordinate with anaesthetist and perfusionist
07 Deep Hypothermic Circulatory Arrest (if hemiarch/arch)
DHCA
▶
⚠ Maximum risk periodDHCA >30 minutes dramatically increases stroke, cognitive dysfunction, and multi-organ failure risk. Every minute counts. Safe DHCA window at 18°C nasopharyngeal is approximately 30 mins. ACP extends this to 40–60 mins.
Anaesthetist
  • Confirm all neuroprotection agents administered (thiopentone burst suppression confirmed on EEG, steroids given, mannitol given, ice to head)
  • Confirm nasopharyngeal ≤18°C and temperature equilibration between nasopharyngeal and bladder probes
  • Communicate arrest time to perfusionist and surgeon; start the clock
  • During DHCA: no ventilation, no CPB flow; monitor NIRS continuously — values should remain stable or improve (circulatory demand is near zero at this temperature)
  • Antegrade cerebral perfusion (ACP) if planned: 10 mL/kg/min via axillary artery or direct cannulation of innominate + left carotid; NIRS must remain >50%
  • Time updates to surgeon every 5 minutes from start of arrest
  • Resume CPB immediately when surgeon signals — confirm flow, re-commence cooling or rewarming as appropriate
Cardiac Surgeon
  • Venous drainage cannula removed from RA; head of table slightly elevated to reduce cerebral venous engorgement
  • Opened aortic arch: transverse arch opened; identify arch vessels (innominate, left carotid, left subclavian) from inside
  • Hemiarch or total arch repair: felt-reinforced anastomosis of conduit or graft to arch/hemiarch using continuous prolene; island or branched graft technique for total arch
  • Speed is paramount: every minute in arrest is brain ischaemia (even with ACP, deep hypothermia is a limited resource)
  • De-air aortic arch before reperfusion — pack with CO₂ (heavier, displaces air from open aorta), direct suction of air through vent
  • Signal to resume CPB when arch repair completed
08 Rewarming, Weaning from CPB & De-airing
CPB WEANCRITICAL
▶
Anaesthetist
  • Active rewarming from perfusionist: slow rewarming (avoid rapid rewarming — neurological injury from temperature gradients); no more than 10°C gradient between perfusate and nasopharyngeal
  • Rewarming from DHCA requires longer time than elective CABG — 30–60 min to reach normothermia
  • Recommence ventilation once heart begins to move; confirm bilateral air entry
  • Aggressive de-airing on TOE: visualise all cardiac chambers; air in ascending aorta, LV apex, pulmonary veins — alert surgeon to de-air accordingly (vents, needle venting of aorta)
  • Inotropes: likely need higher doses than CABG; adrenaline ± milrinone; consider vasopressin for vasoplegia (common after prolonged CPB/DHCA)
  • Post-CPB TOE: carefully assess valve function (mechanical valve: confirm leaflet opening, no perivalvular leak, LVOT obstruction); coronary button flows (new RWMA in LAD or RCA territory = coronary compromise); RV function (often impaired after DHCA)
  • Protamine administration: same dosing; extra caution — watch for pulmonary hypertension (common after prolonged CPB)
Cardiac Surgeon
  • Cross-clamp removal: heart reperfuses through reimplanted coronary buttons — this is the test of button integrity
  • Observe: ECG for ST changes (coronary compromise), heart rhythm (VF expected and acceptable transiently), LV wall motion on TOE
  • Internal defibrillation if required: 20J internal paddles directly on ventricles
  • Inspect all anastomotic suture lines for haemostasis while on CPB (identifies problems before protamine)
  • Aortic root filled with blood — de-air via needle venting of distal aorta and conduit; coordinate with anaesthetist
  • Temporary epicardial pacing wires (atrial and ventricular): essential post-Bentall as AV node is at risk from root work and oedema
  • Heart rate management: pacing backup essential; complete heart block can occur after root replacement
09 Decannulation, Haemostasis & Closure
▶
⚠ Coagulopathy riskAfter prolonged CPB ± DHCA, coagulopathy is almost universal. The anastomotic surface of a Bentall is extensive. Expect surgical re-exploration rates of 5–10%. ROTEM/TEG-guided product replacement is mandatory.
Anaesthetist
  • ROTEM/TEG-guided transfusion: treat each defect specifically — FFP for clotting factor deficiency (EXTEM CT prolonged), cryoprecipitate for fibrinogen <1.5 (FIBTEM A10 <8mm), platelets for thrombocytopenia (<80) or dysfunction (ROTEM amplitude low)
  • PCC (prothrombin complex concentrate) if massive coagulopathy and FFP inadequate; factor VIIa as last resort
  • Protamine: given slowly; especially careful after DHCA — pulmonary vasoreactivity is high; have vasodilator (GTN) and vasopressor (vasopressin) ready
  • Mechanical valve: confirm anticoagulation plan; heparin infusion commenced in ICU within hours of surgery; target INR 2.5–3.5 with warfarin long term
  • TOE final sweep: valve function, no perivalvular leak, LV/RV function, no pericardial effusion
  • ICU handover: CPB/DHCA total time, cross-clamp time, coronary button reimplantation, valve type and size, current haemodynamic support, anticoagulation plan, pacing requirements, neurological monitoring baseline
Cardiac Surgeon
  • Systematic haemostasis: all suture lines inspected — conduit-to-annulus, coronary buttons (right then left), distal anastomosis, felt reinforcement lines
  • Haemostatic agents liberally applied: Floseal at root, Surgicel at felt margins, BioGlue occasionally at felt-reinforced suture lines in dissection
  • Pericardial wrap of conduit: some surgeons wrap the conduit with pericardium to reduce pseudoaneurysm risk at coronary button sites; others leave open
  • Generous drain placement: mediastinal drains ×2, bilateral pleural if opened; atrial and ventricular pacing leads
  • Sternal closure: standard wire technique; extra care in Marfan (sternal quality may be poor) — may use Robicsek technique (figure-of-eight cross-wires) for added security
  • Layered wound closure; subcutaneous drain if desired
Key Bentall-Specific Considerations
Neuroprotection (DHCA)
Thiopentone (burst suppression), methylprednisolone, mannitol 0.5g/kg, ice packs to head, NIRS monitoring, ACP if available
DHCA Temperature
Target nasopharyngeal 15–18°C; bladder equilibration; safe window ~30 mins without ACP, ~60 mins with selective ACP
Coronary Button Risk
New RWMA on TOE post-wean = coronary compromise; RCA button most vulnerable; requires immediate return on CPB and revision
Complete Heart Block
Root work may injure AV node; pacing wires essential; temporary transvenous pacing via introducer as backup; permanent PPM if persistent post-op
Anticoagulation (Mechanical)
Commence heparin infusion 4–6h post-op; bridge to warfarin (INR 2.5–3.5); aspirin 100mg ongoing; high-risk of valve thrombosis if anticoagulation delayed
Vasoplegic Syndrome
Common after prolonged CPB; vasopressin 0.03–0.04 u/min + methylene blue 1.5mg/kg IV if refractory; noradrenaline adjunct; consider hydrocortisone
Isolated Aortic Valve Replacement (AVR)

Replacement of the aortic valve via median sternotomy using a prosthetic (mechanical or bioprosthetic) valve. Indicated for severe aortic stenosis or aortic regurgitation. Duration 2–4 hours. More straightforward than Bentall but de-airing is critical and conduction system is at risk.

Anaesthetist
Cardiac Surgeon
01 Pre-operative Assessment & Setup
PRE-OP
▶
Anaesthetist
  • Review echo: valve area (severe AS <1.0 cm²), mean gradient (>40 mmHg severe), AR severity, LV function (EF, hypertrophy, LVEDP)
  • AS physiology: fixed outflow obstruction, LV hypertrophy, diastolic dysfunction — induction is high risk; maintain sinus rhythm, avoid hypotension and tachycardia
  • AR physiology: volume-loaded, dilated LV; avoid bradycardia (increases regurgitant fraction); afterload reduction if on infusions
  • Arterial line (radial) pre-induction; large-bore IV ×2; consider CVC if complex or poor LV
  • TOE planned post-intubation: quantify valve pathology, LV function, RWMA, degree of calcification
  • Prepare vasopressors (metaraminol, phenylephrine for AS — maintain afterload); in AR, prefer noradrenaline over vasopressin
Cardiac Surgeon
  • Confirm valve selection with patient: mechanical (requires lifelong anticoagulation) vs bioprosthetic (avoids anticoagulation, limited durability ~15–20 years)
  • TAVI (transcatheter AVR) discussion: if patient high surgical risk, heart team may prefer TAVI — confirm operative plan pre-theatre
  • Review CT or echo for aortic annulus size (valve sizing), degree of calcification of root and valve
  • Discuss CPB plan with perfusionist: standard ascending aortic/right atrial cannulation; cardioplegia strategy (antegrade aortic root ± retrograde in severe AR)
02 Induction & Intubation
INDUCTIONCRITICAL
▶
⚠ AS induction riskIn severe AS, the LV cannot increase output against sudden afterload drops. Hypotension at induction can precipitate irreversible subendocardial ischaemia. Run phenylephrine or metaraminol infusion before induction. Avoid tachycardia — the hypertrophied LV needs time to fill.
Anaesthetist
  • Vasopressor infusion (phenylephrine 50–100 mcg/min or metaraminol) running before induction to maintain SVR
  • High-dose opioid induction: fentanyl 5–10 mcg/kg + etomidate (preferred in severe AS) or low-dose propofol; avoid bolus vasodilation
  • Target: HR 60–80 (avoid tachycardia), MAP >65 maintained throughout; sinus rhythm critical in AS (loss of atrial kick = haemodynamic collapse)
  • Immediate defibrillator availability; pads on patient before induction in severe AS
  • TOE immediately post-intubation: confirm valve anatomy, LVOT, LV function; look for any surprises (additional pathology)
  • In AR: slightly higher HR target (75–90) acceptable to reduce diastolic regurgitant time
Cardiac Surgeon
  • Not scrubbed — available for emergency sternotomy if cardiac arrest
  • Confirms prosthesis is available and correct size based on pre-op echo; backup sizes on standby
03 Sternotomy, Cannulation & CPB Initiation
ON CPB
▶
Anaesthetist
  • Standard cardiac anaesthesia: deepen for incision, brief apnoea for saw pass
  • Heparin 300–400 IU/kg IV before cannulation; confirm ACT >480 sec with perfusionist
  • In severe AR: antegrade cardioplegia via aortic root may not work well (regurgitant valve dilutes/bypasses coronaries) — surgeon may prefer direct coronary ostial delivery or retrograde; coordinate with surgeon
  • Cease ventilation on full CPB; maintain anaesthesia via circuit volatile or TIVA
  • TOE: watch for LV distension during CPB initiation (LV vent may be needed in AR)
Cardiac Surgeon
  • Median sternotomy, pericardiotomy, stay sutures; inspect aorta for cannulation site (avoid calcified areas)
  • Ascending aortic cannulation and single two-stage venous cannula (or bicaval if needed)
  • CPB initiated; aortic cross-clamp applied; cardioplegia delivered
  • In severe AR: cross-clamp causes immediate LV distension as regurgitant flow persists — LV vent via RSPV is standard; cardioplegia directly into coronary ostia
04 Aortotomy, Valve Excision & Prosthesis Implantation
ON CPB
▶
Anaesthetist
  • Maintain stable CPB conditions; ACT checks; temperature management
  • Blood gas monitoring: K⁺ (cardioplegia loads potassium), glucose, Hct
  • Repeat cardioplegia every 15–20 min or per surgeon request
  • Minimal intervention during valve work — this is the surgeon's phase
  • Pre-wean preparation: draw inotropes (adrenaline), have vasopressors ready; pacing plan (pacemaker common post-AVR)
Cardiac Surgeon
  • Transverse or oblique aortotomy above sinotubular junction; retracted to expose valve
  • Valve excision: leaflets excised; annulus decalcified with rongeurs — careful not to disrupt the annulus or AV node (3 o'clock position, adjacent to right coronary sinus)
  • Annulus sized with valve sizer; prosthesis selected
  • Interrupted or continuous suture technique: pledgeted mattress sutures circumferentially through annulus and into sewing ring; prosthesis seated and tied
  • Mechanical valve: confirm leaflet opening/closing is unobstructed; correct orientation (avoid coronary ostial impingement)
  • Aortotomy closure: continuous 4-0 prolene with felt reinforcement if aortic wall fragile
05 De-airing, CPB Wean & Post-wean Assessment
CPB WEANCRITICAL
▶
⚠ De-airing is critical in AVRThe aortic valve is the outflow tract — air trapped in the LV or aortic root travels directly into the coronary ostia (RCA most vulnerable, as it sits anteriorly). Meticulous de-airing is mandatory. Complete heart block is common post-AVR — pacing wires are always placed.
Anaesthetist
  • Recommence ventilation before cross-clamp removal; Trendelenburg position to move air to RV rather than LV
  • Aggressive TOE de-airing protocol: watch LV apex, LVOT, ascending aorta — alert surgeon to any air collections
  • Cross-clamp removal → reperfusion; expect VF (normal), internal defibrillation if needed
  • Heart block: extremely common after AVR (AV node proximity to non-coronary sinus) — surgeon will place atrial and ventricular pacing wires; pace at 80 if junctional or slow rhythm post-wean
  • Post-wean TOE: assess prosthetic valve function (mechanical: listen for clicks, look for normal leaflet motion; bioprosthesis: normal leaflet mobility, no stenosis or regurgitation); assess for perivalvular leak (colour Doppler); LV/RV function
  • Protamine reversal; watch for protamine reaction
Cardiac Surgeon
  • Systematic de-airing: root vent, needle aspiration of aortic root, manual cardiac massage to displace air
  • Cross-clamp removal; observe coronary reperfusion — RCA air embolism manifests as inferior ST elevation and RV dysfunction
  • Epicardial pacing wires: atrial and ventricular leads — standard in all AVR; AV conduction may be impaired for 24–48h post-op
  • Decannulation and haemostasis; sternal closure
Key AVR Considerations
AS Induction Rule
Maintain SVR, maintain sinus rhythm, avoid tachycardia. The hypertrophied LV cannot compensate for hypotension. Vasopressor infusion before induction is standard.
AR Induction Rule
HR 75–90 (reduce diastolic regurgitation), afterload reduction, LV vent mandatory on CPB. IABP contraindicated in significant AR.
Pacing Post-AVR
Complete heart block in ~5%; junctional rhythm common. Always pace at 80–90 bpm if slow. Permanent PPM if CHB persists >5–7 days post-op.
Mechanical Valve Anticoagulation
Heparin infusion 4–6h post-op; warfarin target INR 2.0–3.0 (aortic position); aspirin 100mg ongoing. Never delay anticoagulation.
Patient-Prosthesis Mismatch
Small annulus → small prosthesis → residual gradient. Confirm post-implant gradient acceptable on TOE. Annular enlargement or supra-annular bioprosthesis if mismatch predicted.
RCA Air Embolism
Inferior ST elevation + RV dysfunction after cross-clamp removal = RCA air. Return to CPB if haemodynamically significant; temporary RV support; resolves with reperfusion.
Mitral Valve Repair / Replacement (MVR)

Correction of mitral valve pathology via median sternotomy and left atriotomy. Repair is preferred when feasible (lower mortality, no anticoagulation, better LV preservation). Replacement used when repair is not durable. Bicaval cannulation is standard. Duration 3–5 hours.

Anaesthetist
Cardiac Surgeon
Pathology ContextMR causes: degenerative (myxomatous, Barlow's disease), rheumatic, ischaemic (papillary muscle dysfunction), infective endocarditis, functional (dilated cardiomyopathy). MS causes: rheumatic predominates. Repair options depend on leaflet, chordal, and annular anatomy — pre-op TOE and surgical team discussion essential.
01 Pre-operative Assessment
PRE-OP
▶
Anaesthetist
  • Review echo: MR mechanism (Carpentier classification I–III), severity, annular size, leaflet anatomy (posterior leaflet prolapse most repairable), LV size and function, pulmonary pressures
  • Severe chronic MR: LV is volume-loaded and may appear to have normal EF — EF <60% in severe MR represents significant dysfunction; afterload dependence post-repair
  • Pulmonary hypertension: common in chronic MR/MS; anticipate RV failure post-CPB; milrinone/iloprost may be needed
  • AF: very common in mitral disease; confirm anticoagulation status pre-op; discuss rate/rhythm plan with surgeon (concomitant MAZE procedure planned?)
  • Arterial line, CVC ± PA catheter if pulmonary pressures severely elevated; large-bore IV ×2
  • Baseline TOE: quantify MR/MS, identify mechanism and anatomy, assess LV/RV, pulmonary vein flow reversal
Cardiac Surgeon
  • Detailed review of echo and TOE: identify repair feasibility — posterior leaflet prolapse has ~95% repair rate; anterior leaflet, bileaflet, and rheumatic disease are more complex
  • Repair strategy: ring annuloplasty ± leaflet resection (quadrangular/triangular), chordal transfer, artificial neochordae (PTFE sutures), commissuroplasty
  • Replacement strategy: if repair not feasible — bioprosthetic (no anticoagulation) vs mechanical; discuss with patient; chordal-sparing technique to preserve LV geometry
  • Concomitant procedures: MAZE (AF ablation), tricuspid repair, PFO closure — confirm operative plan
  • Bicaval cannulation required for all MVR — allows full right heart decompression and left atriotomy access
02 Induction, Sternotomy & Cannulation
INDUCTIONON CPB
▶
Anaesthetist
  • MR induction: afterload reduction desirable (promotes forward flow); avoid bradycardia (worsens MR by increasing LVEDV); maintain HR 80–95
  • MS induction: similar caution to AS — avoid tachycardia (reduces diastolic filling time across tight valve); avoid hypotension; maintain sinus rhythm
  • Standard cardiac induction: high-dose opioid + etomidate or low-dose propofol; vasopressors available
  • TOE post-intubation: confirm anatomy; establish baseline LV/RV function; check pulmonary artery pressure estimate
  • Heparin 300–400 IU/kg; ACT >480 sec before CPB
  • Bicaval cannulation changes haemodynamics more than single two-stage: expect modest MAP drop when IVC and SVC snared — vasopressors ready
Cardiac Surgeon
  • Median sternotomy; pericardiotomy; bicaval cannulation: aortic cannula + separate SVC and IVC cannulae (allows full cardiac decompression and dry field for LA work)
  • CPB initiated; SVC and IVC snares tightened to prevent venous return diluting operative field
  • Aortic cross-clamp; cardioplegia antegrade (may supplement with retrograde via coronary sinus)
  • Left atriotomy: incision behind the interatrial groove (Waterson's groove) or trans-septal approach; retractor placed to expose mitral valve
03 Valve Repair or Replacement
ON CPB
▶
Anaesthetist
  • Maintain stable CPB; cardioplegia every 15–20 min; blood gas and ACT monitoring
  • This is the surgically intensive phase — anaesthetist primarily supports bypass conditions
  • Anticipate longer cross-clamp time than AVR (more complex reconstruction possible); communicate CPB time with perfusionist
  • Draw inotropes ahead of wean: milrinone (PDE3 inhibitor, reduces PVR — particularly useful in elevated pulmonary pressures), adrenaline; vasopressors available
  • Note: after repair or replacement of MR, the LV suddenly faces increased afterload (competent valve eliminates low-resistance LA pop-off) — LV dysfunction common post-repair; inotropes often needed
Cardiac Surgeon
  • Repair: Assess leaflets, chordae, papillary muscles; identify prolapsing or flail segments
  • Posterior leaflet resection: quadrangular/triangular resection of prolapsing segment; leaflet edges approximated with 4-0 prolene running suture
  • Neochordae: PTFE (Gore-Tex) sutures from papillary muscle head to leaflet edge — correct length is critical (determined intraoperatively)
  • Ring annuloplasty: sizing and implantation of rigid, semi-rigid or flexible ring (Edwards, Medtronic, Carpentier-Edwards) with interrupted pledgeted sutures; reduces annular dilation and supports repair
  • Saline test: inject saline into LV under pressure to confirm coaptation — no central jet, no residual prolapse visible
  • Replacement: Native valve excised; papillary muscle attachment preserved (chordal-sparing technique protects LV geometry); prosthesis sized and sutured; confirm leaflet clearance
04 LA Closure, De-airing & CPB Wean
CPB WEANCRITICAL
▶
⚠ LV dysfunction after MR correctionPost-repair, the LV loses its low-impedance pop-off into the LA. True LV function may be worse than pre-op EF suggested. Inotropic support is frequently needed. RV failure from elevated PVR is also common — milrinone is first-line.
Anaesthetist
  • De-airing is critical: left heart is opened (LA, mitral valve) — air enters LV directly; fill carefully on TOE; watch LV apex, LVOT, and mitral prosthesis/repair area
  • Recommence ventilation before cross-clamp removal; Trendelenburg position helps move air anteriorly to be aspirated via aortic root vent
  • TOE post-wean — the most important assessment in MVR/repair:
    • Repair: residual MR? (trace/mild acceptable; moderate or above → return to bypass for revision); SAM (systolic anterior motion of anterior leaflet causing LVOTO — emergency, needs revision or medical management with fluids, phenylephrine, beta-blockade)
    • Replacement: prosthesis function, perivalvular leak, leaflet mobility (ensure chordae not caught in prosthesis)
  • LV function: often needs milrinone 0.375–0.5 mcg/kg/min + adrenaline; avoid high doses of noradrenaline (increases PVR)
  • Pulmonary hypertension: if PAP elevated, inhaled iloprost or NO if available; milrinone; avoid hypoxia and hypercarbia
  • Pacing: AV block less common than AVR but possible; atrial lead important if patient needs rate support
Cardiac Surgeon
  • LA closure: running 3-0 or 4-0 prolene; de-air via vent in closure suture line before final knot
  • Cross-clamp removal with aggressive de-airing of aortic root; cardiac massage to expel air from coronaries
  • Epicardial pacing wires: atrial lead (important for rate control in AF patients) + ventricular lead
  • If SAM detected on TOE: stop inotropes, give volume, consider phenylephrine; surgical revision (re-do repair or replacement) if haemodynamically significant SAM persists
  • If residual MR >mild on TOE: assess repair — revision or conversion to replacement; do not accept significant residual MR
  • Decannulation; protamine; haemostasis; sternal closure
Key MVR/Repair Considerations
SAM (Systolic Anterior Motion)
LVOTO caused by anterior mitral leaflet being drawn into LVOT in systole — after repair with redundant anterior leaflet or undersized ring. Treat: stop inotropes, give volume, phenylephrine. Surgical revision if refractory.
Post-MR LV Dysfunction
After correcting chronic severe MR, true LV contractile function is unmasked. EF may fall from 'preserved' to low normal. Milrinone + adrenaline infusions frequently required post-CPB.
Pulmonary Hypertension
Common in chronic MR/MS. Milrinone reduces PVR and supports RV. Inhaled iloprost or NO if PAP crisis. Avoid hypoxia, hypercarbia, acidosis. Vasopressin preferred vasopressor to avoid worsening PVR.
Bicaval Cannulation
Mandatory for mitral work — allows full right heart decompression. SVC and IVC snares prevent blood from flooding the operative field. More access than single two-stage venous cannula.
Mitral Replacement Anticoag
Mechanical mitral: INR 2.5–3.5 (higher than aortic position — mitral has lower flow velocity). Bioprosthetic: aspirin ± 3 months warfarin while endothelialisation occurs; then aspirin alone.
Repair vs Replacement
Repair: lower 30-day mortality, no anticoagulation, better LV preservation, ~1% per year failure rate. Replacement: more durable for complex/rheumatic disease, but requires lifelong follow-up and anticoagulation (mechanical).
Orthotopic Liver Transplant (OLT)

Replacement of native diseased liver with donor allograft via orthotopic implantation. Piggyback or conventional technique. Duration 6–12 hours.

Anaesthetist
Surgeon
01 Pre-op Assessment & Setup
PRE-OP
▶
Anaesthetist
  • Review MELD score, aetiology of liver failure (alcoholic, viral, NASH, acute fulminant), prior encephalopathy grade
  • Assess coagulation: INR, fibrinogen, platelet count, TEG/ROTEM if available — expect baseline coagulopathy
  • Review renal function: hepatorenal syndrome (HRS) type, creatinine trend, urine output, need for CRRT
  • Check electrolytes — hyponatraemia common; correct Na slowly (target ≥130 mmol/L pre-op, avoid rapid correction)
  • Pulmonary assessment: hepatopulmonary syndrome, portopulmonary hypertension, pleural effusions
  • Confirm large-bore access plan: bilateral large-bore IVs, rapid infusion catheter (RIC/Level 1), arterial line, large-bore CVC
  • Ensure blood bank alert: massive transfusion protocol activated, FFP, cryo, platelets, pRBCs cross-matched (min 10 units pRBC)
  • Confirm cell salvage, ROTEM, and point-of-care testing available in theatre
Surgeon
  • Confirm donor organ logistics: cold ischaemia time, organ quality (DCD vs DBD), back-table preparation timeline
  • Review recipient anatomy: prior abdominal surgery, portal vein thrombosis (PVT) grade, hepatic artery anatomy
  • Plan technique: conventional (IVC clamping + venovenous bypass) vs piggyback (PVVB preservation)
  • If significant PVT: plan thrombectomy or alternative inflow (jump graft, renoportal anastomosis)
  • Brief team: perfusionist if VVBP planned, scrub nurse, haematology liaison
  • Confirm back-table bench surgery: flush, inspect allograft, trim hepatic artery and bile duct
02 Induction & Vascular Access
INDUCTION
▶
Anaesthetist
  • RSI in most patients (ascites, gastroparesis, raised aspiration risk) — ketamine or etomidate preferred to avoid hypotension
  • Avoid succinylcholine if severe hyperkalaemia; rocuronium acceptable with sugammadex reversal available
  • Insert arterial line (radial) pre-induction; aim MAP ≥65 mmHg throughout
  • Large-bore CVC (right internal jugular preferred, 8.5Fr introducer) — avoid subclavian (coagulopathy risk)
  • Consider PA catheter or TOE for haemodynamic monitoring — hyperdynamic circulation typical (high CO, low SVR)
  • Insert urinary catheter with temperature probe; oesophageal temperature probe
  • Active warming: forced air blanket, fluid warmer (Level 1 or Belmont) — hypothermia greatly worsens coagulopathy
  • Baseline ROTEM (EXTEM, INTEM, FIBTEM, APTEM) to guide product use throughout
Surgeon
  • Position supine, arms abducted; ensure bilateral subcostal access
  • If VVBP planned: insert axillary and femoral cannulae prior to skin incision
  • Prep and drape widely: bilateral subcostal to xiphisternum (Mercedes or bilateral subcostal incision)
  • Insert self-retaining retractor system (Thompson or Bookwalter) once abdomen open
03 Native Hepatectomy (Dissection Phase)
CRITICAL
▶
Anaesthetist
  • Expect significant haemorrhage, especially with portal hypertension and varices — maintain MAP ≥65, transfuse to Hb ≥80 g/L
  • ROTEM-guided coagulation: FIBTEM <10 mm → cryoprecipitate; EXTEM CT prolonged → FFP; platelet count <50 → pool
  • Avoid aggressive fluid resuscitation — crystalloid worsens coagulopathy and congests future graft
  • Vasopressors (noradrenaline) to maintain MAP without volume overload; target CVP 5–10
  • Monitor for compression of IVC during dissection — may cause acute haemodynamic instability; communicate with surgeon
  • Maintain normothermia aggressively — hypothermia potentiates coagulopathy exponentially
  • Blood gas every 30–60 min: track pH, lactate, Ca2+, K+, glucose
Surgeon
  • Divide falciform and triangular ligaments; free hepatic flexure of colon if adherent
  • Dissect hepatoduodenal ligament: isolate and divide hepatic artery, portal vein (preserve length for anastomosis)
  • Skeletonise common bile duct; divide at appropriate level for duct-to-duct reconstruction
  • Mobilise retrohepatic IVC — conventional: circumferential dissection; piggyback: preserve IVC, develop hepatic venous cuff
  • If significant PVT: perform thrombectomy of portal vein; notify anaesthetist of anticipated blood loss
  • Control short hepatic veins meticulously before IVC clamping; haemostatic clips or suture ties
  • Notify anaesthetist 5 minutes before portal clamp: "Approaching anhepatic phase"
04 Anhepatic Phase & Vascular Anastomoses
CRITICAL
▶
Anaesthetist
  • Portal + IVC clamping → dramatic reduction in venous return; anticipate 30–50% drop in CO
  • If no VVBP: pre-load with 500–1000 mL; increase vasopressors (noradrenaline ± vasopressin); accept MAP 50–55 transiently
  • If VVBP running: ensure adequate flows (≥1 L/min); monitor for VVBP-related complications (air embolism, thrombosis, limb ischaemia)
  • Anhepatic phase = no hepatic metabolism: avoid drugs heavily liver-metabolised; succinylcholine contraindicated; citrate accumulation with blood products → calcium gluconate boluses PRN
  • Hyperkalaemia often worsens: K+ every 15–20 min; treat if >5.5 mmol/L (insulin-dextrose, calcium, consider CVVH)
  • Metabolic acidosis expected — limit bicarbonate; allow permissive pH 7.20–7.25 until reperfusion
  • Prepare vasopressin infusion for reperfusion; draw up methylprednisolone (500 mg) per protocol
  • Ensure defibrillator immediately available, atropine drawn up, adrenaline at hand
Surgeon
  • Clamp portal vein, hepatic artery, supra- and infra-hepatic IVC (conventional) or hepatic veins (piggyback)
  • Remove native liver; achieve haemostasis of retroperitoneal bed
  • Piggyback: construct triangular venous cuff from hepatic veins; anastomose to donor suprahepatic IVC (side-to-side or end-to-side)
  • Conventional: end-to-end supra-hepatic and infra-hepatic IVC anastomoses with 3-0 or 4-0 prolene
  • Portal vein anastomosis (end-to-end, 5-0 prolene); leave growth factor if size discrepancy
  • Flush graft via portal vein with albumin solution prior to reperfusion to clear preservation fluid
  • Alert anaesthetist: "Reperfusion in 2 minutes — portal clamp coming off"
05 Reperfusion
CRITICAL
▶
⚠ Post-Reperfusion Syndrome (PRS) Defined as >30% drop in MAP for >1 min within 5 min of reperfusion. Incidence ~30%. Driven by cold, acidotic, hyperkalaemic preservation fluid entering systemic circulation + ischaemia-reperfusion mediator release. May cause severe bradycardia, asystole, or VF.
Anaesthetist
  • At portal clamp release: simultaneously give vasopressin 0.5–1 unit IV bolus (± infusion 0.03–0.04 units/min)
  • Bolus adrenaline 50–100 mcg IV if severe PRS; escalate to chest compressions if asystole
  • Methylprednisolone 500 mg IV at reperfusion per immunosuppression protocol
  • Treat hyperkalaemia aggressively: calcium gluconate 10 mL of 10% IV stat, insulin-dextrose; repeat K+ at 2 minutes post-reperfusion
  • Correct acidosis: sodium bicarbonate 50–100 mmol if pH <7.15; monitor response with serial gas
  • Active warming: raise room temperature, warm all IV fluids, warm irrigation — target core temp ≥36°C
  • ROTEM immediately post-reperfusion: expect fibrinolysis (APTEM vs EXTEM); if LI30 <85%: tranexamic acid 1 g IV
  • Monitor for return of bile production (amber bile in cholangiocath) as early indicator of graft function
Surgeon
  • Release portal clamp first (lower K+ load than arterial); observe graft colour and turgor
  • Immediately assess for anastomotic bleeding; place haemostatic sutures while anaesthetist manages haemodynamics
  • Construct hepatic artery anastomosis (6-0 or 7-0 prolene, end-to-end, with operative loupes or microscope)
  • Confirm hepatic artery Doppler flow post-anastomosis before proceeding
  • Release arterial clamp; observe graft for arterialisation (pinking, pulsatile bile)
  • Achieve meticulous haemostasis of all raw surfaces; argon beam coagulation, topical agents PRN
06 Biliary Reconstruction & Haemostasis
POST-REPERFUSION
▶
Anaesthetist
  • Continue ROTEM-guided product administration; target fibrinogen ≥2 g/L, INR <2, platelets >50
  • Reassess renal function: urine output, creatinine — HRS may persist despite reperfusion
  • Begin weaning vasopressors as haemodynamics stabilise; avoid excessive noradrenaline (hepatic arterial vasoconstriction)
  • Titrate immunosuppression per protocol: tacrolimus target levels, mycophenolate, steroid taper plan documented
  • Monitor for primary non-function (PNF): no bile, persistent coagulopathy, worsening acidosis, transaminases >5000 — escalate urgently
  • Ensure warm, stable, and haemostatic before considering ICU transfer
Surgeon
  • Duct-to-duct biliary anastomosis (6-0 PDS): end-to-end choledochocholedochostomy; T-tube optional (usually avoided)
  • If duct-to-duct not feasible (PSC, size mismatch, diseased recipient duct): Roux-en-Y hepaticojejunostomy
  • Intraoperative cholangiogram or fluoroscopy to confirm biliary continuity and absence of leak
  • Systematic haemostasis: liver bed, ligamentum teres stump, drain sites, abdominal wall
  • Place surgical drains: Blake drain near bile duct anastomosis and subhepatic space
  • Inspect bowel viability if prolonged anhepatic phase with splanchnic congestion
07 Closure & ICU Handover
EMERGENCE
▶
Anaesthetist
  • Most patients intubated to ICU; extubation only if: minimal transfusion, warm, haemostatic, haemodynamically stable, GCS adequate, encephalopathy resolved
  • Final blood gas, electrolytes, lactate, ROTEM before departure — document trajectory
  • Ensure vasopressor requirements documented and ICU infusions prepared for transfer
  • Handover includes: cold ischaemia time, total blood product use, intraoperative events (PRS, arrhythmias), current immunosuppression, renal status, drain output
  • ICU targets communicated: MAP ≥65, urine output ≥0.5 mL/kg/hr, normoglycaemia (BGL 6–10), normothermia
  • Early tacrolimus levels, LFTs, coag, and Doppler USS of hepatic vasculature within 2 hours of ICU arrival
Surgeon
  • Mass closure of fascia (looped PDS #1); skin clips or subcuticular suture
  • If abdominal compartment syndrome risk (oedematous bowel, high closure tension): consider temporary abdominal closure (VAC/Bogota bag)
  • Document drain positions; secure drain to skin
  • Handover: anastomotic details, Doppler flow findings, bile output, any intraoperative technical concerns
  • Post-op imaging plan: Doppler USS hepatic vasculature at 2–4 hrs; CT angiography if Doppler inadequate
Decompressive Craniectomy

Surgical removal of a large bone flap to allow brain expansion in refractory raised intracranial pressure. Indicated for severe TBI, malignant MCA infarction, or refractory intracranial hypertension. Duration 1.5–3 hours.

Anaesthetist
Surgeon
01 Pre-op Assessment & ICP Optimisation
PRE-OP
▶
Anaesthetist
  • Review CT imaging: midline shift, herniation (uncal, central, transtentorial), contusion burden, oedema pattern
  • Review ICP monitor data if inserted: current ICP, CPP (target ≥60 mmHg), waveform morphology, plateau waves
  • Assess GCS trajectory; note pupillary changes (unilateral dilation = uncal herniation — emergency)
  • Tier 1–2 ICP management already in progress: HOB 30°, head midline, sedation (propofol/midazolam + fentanyl), normoventilation (PaCO2 35–40)
  • If acute herniation in progress: hyperventilate to PaCO2 32–35 mmHg temporarily as bridge to theatre; mannitol 0.5–1 g/kg IV or hypertonic saline (3% NaCl 250 mL or 23.4% NaCl 30 mL)
  • Confirm serum Na — avoid hyponatraemia (<135 mmol/L worsens cerebral oedema); target 140–150 for ICP management
  • Normoglycaemia: target BGL 6–10 mmol/L; hypoglycaemia and hyperglycaemia both worsen neurological outcome
  • Confirm arterial line in situ or insert pre-induction; establish reliable IV access × 2
Surgeon
  • Review imaging: determine side (dominant vs non-dominant hemisphere; malignant MCA → ipsilateral to infarct; TBI → side of greater mass effect)
  • Plan craniectomy size: minimum 12 × 15 cm decompression recommended (smaller = ineffective and risks cortical herniation over edge)
  • Discuss bone flap preservation: cryopreservation (−80°C, available if facility supports) vs subcutaneous abdominal pocket
  • Confirm consent (if obtainable): risks include contralateral deterioration, paradoxical herniation (sinking skin flap syndrome), infection, CSF leak
  • Brief team for positioning: head fixation (Mayfield pins vs horseshoe), lateral vs supine positioning
02 Positioning & Induction
INDUCTION
▶
⚠ Induction Risk Loss of sympathetic drive and positive-pressure ventilation at induction can precipitously lower CPP. Have vasopressors immediately available. Target MAP 80–100 throughout — permissive hypertension to maintain CPP ≥60 with ICP likely elevated.
Anaesthetist
  • Pre-oxygenate thoroughly; RSI if GCS ≤8 or aspiration risk (most TBI patients)
  • Induction agents: ketamine (1–1.5 mg/kg) acceptable — evidence no longer supports avoidance in raised ICP; thiopentone (3–5 mg/kg) if available for ICP-lowering effect; avoid propofol bolus if haemodynamically unstable
  • Rocuronium (1.2 mg/kg) for RSI; maintain neuromuscular blockade throughout (coughing raises ICP acutely)
  • Maintain MAP 80–100 from induction: phenylephrine or noradrenaline infusion pre-emptively commenced
  • Intubate and confirm ETCO2; target PaCO2 35–40 (unless acute herniation, then 32–35 temporarily)
  • Isoflurane or sevoflurane <1 MAC (all volatiles cause cerebral vasodilation and raise ICP at higher doses); TIVA with propofol/remifentanil preferred by many centres
  • Insert IDC (urinary catheter) — monitor output for mannitol diuresis; monitor for diabetes insipidus (TBI)
  • Head of bed 20–30° throughout; ensure venous drainage not impeded by neck position or collar
Surgeon
  • Position: supine (frontal/fronto-temporal) or lateral decubitus (temporal/temporoparietal); head fixed in Mayfield clamp or horseshoe
  • Mayfield pins: infiltrate with LA; coordinate application with anaesthetist (causes acute MAP surge — deepen anaesthesia 60 sec prior)
  • Contralateral shoulder roll if lateral; ensure all pressure points padded (case may run 2+ hours)
  • Mark surgical landmarks: temporal fossa, pterion, coronal suture, sagittal suture, ear
  • Wide prep and drape; mark question-mark (trauma) or reverse question-mark incision depending on pathology
03 Craniotomy & Bone Flap Removal
CRITICAL
▶
Anaesthetist
  • Maintain MAP 80–100 during scalp incision (LA with 1:200,000 adrenaline infiltrated by surgeon reduces bleeding)
  • Before dural opening: position optimised, mannitol given if not already, ETCO2 dialled to target, adequate depth of anaesthesia confirmed
  • Prepare for acute haemorrhage if contusion or extradural haematoma decompresses rapidly on dural opening
  • Monitor for Cushing's response during dissection (hypertension + bradycardia + irregular respiration) — indicates critical ICP elevation
  • Continue neuromuscular blockade monitoring (TOF); ensure full block maintained
  • Anticipate blood loss from temporalis muscle and diploic veins; ensure adequate IV access
Surgeon
  • Question-mark or trauma flap incision through scalp to periosteum; Raney clips for haemostasis
  • Elevate temporalis muscle and periosteum; retract with fishhooks or self-retaining retractor
  • Burr holes × 4–6 (standard positions: keyhole, temporal squama, posterior temporal, parietal); connect with craniotome
  • Ensure temporal extension to the floor of the middle fossa (≤1 cm above zygomatic arch) — inadequate temporal decompression is a common technical error
  • Bone flap size minimum 12 × 15 cm; larger is generally safer
  • Epidural haematoma if present: evacuate before dural opening
  • Preserve bone flap: label, wrap in saline gauze for cryopreservation or prepare abdominal pocket
04 Dural Opening & Brain Decompression
CRITICAL
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⚠ Dural Opening Acute decompression may cause rapid brain herniation through dural opening, tearing bridging veins, or catastrophic haemorrhage from contused cortex. Have bipolar, saline irrigation, and haemostatic agents immediately available. Surgeon must be prepared for swollen brain to prolapse.
Anaesthetist
  • At surgeon's warning of dural opening: ensure MAP at higher end (90–100 mmHg) to maintain CPP as ICP drops precipitously
  • If brain tense and bulging despite mannitol and hyperventilation: consider additional 20% mannitol 100 mL, or furosemide 20–40 mg IV
  • TIVA agents can reduce cerebral metabolic rate: propofol infusion increase; thiopentone burst suppression if extreme ICP
  • Maintain normothermia — therapeutic hypothermia not recommended for routine TBI but avoid hyperthermia (>37.5°C worsens outcome)
  • Continue blood gas monitoring; correct any hypercarbia immediately
  • Document and communicate ICP trend if external monitor still in situ
Surgeon
  • Open dura in stellate or cruciate fashion — maximise decompression; hitch dura to pericranium to prevent epidural haematoma
  • If MCA infarct: no surgical evacuation needed; aim is simply decompressive expansion space
  • If TBI with intracerebral haematoma: evacuate accessible contusions under direct vision or with gentle suction/irrigation; avoid blind deep evacuation
  • Bipolar diathermy of all cortical bleeding vessels; avoid manipulation of eloquent cortex
  • Duraplasty: patch dura with pericranium, fascia lata, or synthetic dural substitute — large patch to accommodate expected further swelling
  • Watertight dural closure of patch with 4-0 Nurolon or prolene; tack-up sutures to reduce epidural dead space
05 Bone Flap Preservation & Closure
CLOSURE
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Anaesthetist
  • Assess post-decompression haemodynamics: MAP may fall as ICP-mediated Cushing's response resolves — titrate vasopressors accordingly
  • Final arterial blood gas: confirm PaCO2 35–40, pH >7.35, normoglycaemia, normothermia
  • Anti-epileptic prophylaxis if indicated (levetiracetam 1 g IV for TBI patients)
  • Plan for post-op destination: neurosurgical ICU; patient remains intubated and sedated
  • Dexamethasone: indicated for malignant MCA infarct (vasogenic oedema component); not recommended for TBI (no benefit, may worsen outcome)
  • Document: estimated blood loss, fluids in/out, vasoactive agents, ICP values, any intraoperative events
Surgeon
  • Bone flap — option A (cryopreservation): wrap in saline-soaked gauze, double-bag labelled specimen, store at −80°C for delayed cranioplasty (6–12 weeks)
  • Bone flap — option B (subcutaneous abdominal pocket): create subcutaneous pocket in left lower quadrant, insert bone, close with absorbable suture — avoids cold chain but adds abdominal wound
  • Replace temporalis muscle anatomically with absorbable sutures; reduces temporal hollowing at cranioplasty
  • Scalp closure in layers: galea with 0 Vicryl, skin with staples
  • Subgaleal drain if significant ooze; remove within 24–48 hours
  • Head dressing; document bone flap location clearly in operation note and alert system
06 ICU Transfer & Neuroprotective Management
ICU HANDOVER
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Anaesthetist
  • Transfer intubated and sedated; portable monitoring including ETCO2 and arterial line transduced throughout transfer
  • Handover to ICU team: indication, bone flap storage location, intraoperative ICP values, current vasoactive medications, blood gas results, anti-epileptic drugs given
  • ICU targets: MAP 80–100, CPP ≥60 (if ICP monitor in situ), PaCO2 35–40, PaO2 >80, normoglycaemia, core temp 36–37°C
  • Head of bed 30°; midline head position; avoid tight ET tube ties compressing jugular veins
  • Plan: repeat CT head within 2–4 hours post-op to assess decompression adequacy and exclude new haemorrhage
  • Sedation protocol: propofol ± fentanyl infusion; daily sedation hold when ICP controlled to assess neurology
Surgeon
  • Dictate operative note immediately: incision type, bone flap dimensions, dural opening technique, duraplasty material, bone flap storage method and location
  • Alert bone bank or abdominal ward (if subcutaneous) of flap storage
  • Plan cranioplasty timing: typically 6–12 weeks post-craniectomy when swelling resolved, infection excluded, nutritional status optimised
  • Family communication: explain procedure, expected course, cranioplasty plan, importance of helmet for scalp protection
Ivor Lewis Oesophagectomy

Two-phase resection of the oesophagus for cancer or high-grade dysplasia: abdominal phase (laparoscopic or open gastric mobilisation and conduit formation) followed by right thoracotomy (oesophageal resection, lymphadenectomy, and intrathoracic anastomosis). Duration 4–7 hours.

Anaesthetist
Surgeon
01 Pre-op Assessment & Optimisation
PRE-OP
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Anaesthetist
  • Cardiopulmonary risk stratification: spirometry (FEV1, FVC, DLCO), CPET (VO2max <15 mL/kg/min = high risk), echocardiogram if indicated
  • Assess aspiration risk: dysphagia grade, weight loss (>10% significant malnutrition), pre-op nasojejunal feeding or TPN if severely malnourished
  • Chemotherapy effects: bleomycin (pulmonary toxicity — limit FiO2 intraop; target SpO2 94–96% with FiO2 as low as safe), cisplatin (nephrotoxicity, hypomagnesaemia, peripheral neuropathy)
  • Plan airway management: double-lumen ETT (DLT) or single-lumen + bronchial blocker (BB); right DLT or left DLT — know the anatomy and plan
  • Thoracic epidural catheter (TEA): gold standard analgesia — insert T5–T8 interspace pre-operatively; test with 3 mL 2% lignocaine + adrenaline; confirm dermatomal level
  • Arterial line pre-induction; large-bore IV access × 2; CVC (right IJ or subclavian)
  • Confirm cross-match, cell salvage availability; FFP and platelets available but major haemorrhage less common than in liver/cardiac surgery
  • Mark epidural before positioning; document sensory level and epidural infusion rate plan
Surgeon
  • Review staging: CT chest/abdomen/pelvis, PET, endoscopic ultrasound (EUS) for T and N stage
  • Confirm resectability: no involvement of aorta, trachea, or vertebral bodies; no distant metastases
  • Review prior neoadjuvant therapy (FLOT or CROSS protocol); assess nutritional status and co-morbidities
  • Plan abdominal approach: laparoscopic (MIS) vs open midline/upper midline
  • Plan conduit: gastric tube (preferred — single vascular pedicle on right gastroepiploic artery); colon interposition if prior gastrectomy
  • Brief team: position changes required (supine → left lateral), confirm thoracic scrub set available, stapler sizes, anastomotic technique (circular stapler vs hand-sewn)
02 Induction & Double-Lumen Tube Placement
INDUCTION
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Anaesthetist
  • RSI mandatory: oesophageal obstruction = high aspiration risk; use cricoid pressure
  • DLT selection: left DLT (37–41 Fr depending on patient size) most commonly used; right DLT only if left mainstem pathology; confirm DLT size using height-based formula or CT airway measurement
  • Insert DLT; confirm bilateral ventilation with auscultation and capnography; advance to feel slight resistance then inflate bronchial cuff
  • Fibreoptic bronchoscope (FOB) confirmation mandatory: visualise carina, confirm bronchial lumen in left mainstem, cuff just below carina without herniating
  • FOB of right lumen: confirm clear view of right upper lobe bronchus take-off not obscured by cuff
  • Document DLT position at teeth; re-confirm with FOB after any position change
  • Commence thoracic epidural infusion: 0.1–0.125% bupivacaine + fentanyl 2 mcg/mL at 6–10 mL/hr; confirm haemodynamic stability
  • TIVA or balanced volatile anaesthesia; avoid high FiO2 if prior bleomycin (target SpO2 94–96%)
Surgeon
  • Position supine for abdominal phase; arms abducted; ensure access for bilateral subcostal ports if laparoscopic
  • For laparoscopic approach: confirm table position (reverse Trendelenburg for upper abdominal access), monitor CO2 insufflation pressure (ETCO2 will rise — communicate with anaesthetist)
  • Confirm DLT position will not be disturbed by abdominal phase positioning before draping
03 Abdominal Phase — Gastric Mobilisation & Conduit Formation
ABDOMINAL
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Anaesthetist
  • Laparoscopic insufflation: anticipate ETCO2 rise (increase MV by 10–20%); monitor for CO2 embolism (sudden ETCO2 drop, haemodynamic collapse)
  • Haemodynamic effects of pneumoperitoneum: increased SVR, reduced venous return — vasopressor (phenylephrine) often required
  • Fluid restriction strategy: target zero balance to slightly negative; avoid oedematous anastomosis and interstitial lung fluid — restrict to 5–6 mL/kg/hr crystalloid max; vasopressors to maintain MAP rather than volume loading
  • Monitor urine output: accept 0.3–0.5 mL/kg/hr during abdominal phase with fluid restriction; not an indication to bolus fluids unless oliguric and hypovolaemic
  • Epidural top-up not typically required during abdominal phase if GETA maintained; will be crucial post-op
  • Communicate ETCO2 and respiratory compliance trends to surgical team for pneumoperitoneum pressure adjustments
Surgeon
  • Laparoscopic ports: camera umbilical, working ports bilateral upper quadrant; liver retractor port
  • Divide greater omentum preserving right gastroepiploic artery (RGEA); ligate and divide short gastric vessels with LigaSure or ultrasonic shears
  • Divide lesser omentum; define and preserve right gastric artery; ligate left gastric artery and vein at origin (lymphadenectomy nodes 7, 8, 9)
  • Kocher manoeuvre to mobilise duodenum and allow stomach to reach chest
  • Pyloromyotomy or pyloroplasty (or botox injection) — gastric drainage procedure to prevent post-vagotomy gastroparesis
  • Form gastric conduit: linear stapler along lesser curve, creating tube 4–5 cm diameter based on RGEA; preserve conduit length and vascularity
  • Feeding jejunostomy insertion for post-op enteral nutrition (standard of care)
  • Pass conduit through oesophageal hiatus (posterior mediastinal route); attach with stay suture to oesophageal specimen for thoracic retrieval
04 Position Change & One-Lung Ventilation Initiation
CRITICAL
▶
⚠ DLT Position Change Re-confirm DLT position with FOB after every position change. Left lateral decubitus causes cephalad shift of the mediastinum and can displace the DLT. Failure to reconfirm is a leading cause of intraoperative hypoxaemia during OLV.
ℹ One-Lung Ventilation Strategy Use lung-protective OLV: TV 4–6 mL/kg IBW, PEEP 5 cmH2O to dependent lung, FiO2 titrated to SpO2 ≥94%, Pplat <30 cmH2O. Permit permissive hypercapnia (PaCO2 50–55) if needed to maintain plateau pressure. Hypoxic pulmonary vasoconstriction (HPV) is the primary mechanism maintaining oxygenation — avoid vasodilators (nitric oxide, GTN) which blunt HPV unless treating refractory hypoxaemia.
Anaesthetist
  • Co-ordinate position change: supine to left lateral decubitus with surgeon and scrub; protect arms, head, and pressure points
  • FOB re-confirmation of DLT immediately post-positioning; adjust if displaced
  • Initiate OLV: clamp and open right lumen (non-dependent lung); confirm adequate left lung ventilation
  • OLV settings: TV 4–5 mL/kg IBW, RR 14–18, PEEP 5, FiO2 starting at 0.8 then titrate down; Pplat target <28 cmH2O
  • Anticipate SpO2 fall in first 10–20 min of OLV (HPV takes 10–15 min to fully establish); intervene if SpO2 <90%
  • If refractory hypoxaemia: apply CPAP 5 cmH2O to non-dependent (operative) lung; recruitment manoeuvres to dependent lung; increase FiO2; notify surgeon to request intermittent two-lung ventilation if critical
  • Arterial blood gas at 15–20 min of OLV; document PaO2/FiO2 ratio
  • Ensure epidural working well; analgesic synergy important for post-op respiratory function
Surgeon
  • Left lateral decubitus positioning: right arm on arm board, axillary roll, bean bag or hip bolsters
  • Flex table slightly at waist to open right thorax; ensure hip and shoulder stable
  • Mark and prep right posterolateral thoracotomy; prep to midline anteriorly and scapular tip posteriorly
  • Allow 10–15 minutes for anaesthetist to confirm OLV before incision
05 Thoracic Phase — Oesophageal Resection & Lymphadenectomy
CRITICAL
▶
Anaesthetist
  • Continuous SpO2 monitoring; act promptly on desaturation — communicate timing with surgeon for brief two-lung ventilation if SpO2 <88%
  • Haemodynamic monitoring during thoracic dissection: aortic manipulation, mediastinal retraction, and atrial compression can cause arrhythmias and hypotension
  • Maintain MAP ≥65; vasopressor titration (noradrenaline preferred); caution with large fluid boluses (lung protective strategy)
  • Fluid balance: strict fluid restriction continues — goal-directed therapy (arterial waveform variation, oesophageal Doppler) preferred over fixed rate crystalloid
  • Monitor for thoracic duct injury (chylothorax): assess drain fluid post-op; inform surgeon if unexpected clear high-volume drain output
  • Temperature management: open thorax causes heat loss; maintain warming blanket to dependent side, warm IV fluids
  • Arterial blood gas hourly during OLV; document PaCO2, pH, lactate, K+
Surgeon
  • Posterolateral thoracotomy: 5th or 6th intercostal space; divide latissimus dorsi and serratus anterior; rib spreader
  • Incise inferior pulmonary ligament; retract right lung anteriorly to expose posterior mediastinum
  • Incise mediastinal pleura over oesophagus; encircle with tape at mid-oesophagus
  • En bloc resection: oesophagus with perioesophageal tissue, subcarinal nodes (station 7), right and left paratracheal nodes, para-oesophageal nodes (stations 8 and 9)
  • Identify and protect right recurrent laryngeal nerve (courses around right subclavian artery) and left RLN (around aortic arch); injury causes hoarseness and aspiration
  • Thoracic duct: ligate at diaphragmatic hiatus to prevent chylothorax (mass ligation of tissue between aorta and azygos vein)
  • Divide azygos vein with stapler if required for exposure
  • Pass gastric conduit into thorax; deliver specimen and attached conduit; divide oesophagus at target level
06 Intrathoracic Anastomosis
CRITICAL
▶
ℹ Anastomotic Leak Risk Anastomotic leak (5–15% incidence) is the most feared complication — associated with 30–50% mortality. Risk factors: conduit ischaemia (tension, poor vascularisation), technical error, malnutrition, prior radiotherapy, contaminated field. Ensure conduit lies without tension or torsion.
Anaesthetist
  • Maintain MAP ≥65 during anastomosis — conduit perfusion pressure is critical to anastomotic healing
  • Avoid vasoconstrictors that significantly reduce splanchnic flow (high-dose phenylephrine); noradrenaline preferred
  • Ensure adequate FiO2 and SpO2 ≥95% during anastomosis: tissue oxygenation supports healing
  • Nasogastric tube (NGT): surgeon will request NGT advanced through anastomosis into conduit; advance gently under guidance — do NOT force blindly
  • Monitor for aspiration at anastomosis: keep circuit maintained, suction available
  • Document time of anastomosis completion (relevant for early post-op anastomotic leak surveillance)
Surgeon
  • Assess conduit perfusion: colour, mesenteric pulse, Doppler signal of right gastroepiploic pedicle at tip of conduit; ischaemic tip must be resected
  • Circular stapled anastomosis (most common): anvil in oesophageal end, stapler via conduit apex; fire at appropriate diameter (25–28 mm); inspect donuts for completeness
  • Hand-sewn anastomosis (alternative): single-layer end-to-side or end-to-end with absorbable suture (PDS 3-0); interrupted or continuous
  • Check anastomosis for tension: conduit must sit without redundancy or stretching; ensure no torsion of conduit pedicle
  • Leak test: air insufflation via NGT with anastomosis submerged in saline — bubbles indicate leak requiring reinforcement
  • Wrap anastomosis with intercostal muscle flap or omentum if available (vascularised reinforcement)
  • Position NGT 40–45 cm at teeth (tip in conduit, not across anastomosis); confirm radiologically post-op
07 Closure & Extubation Planning
EMERGENCE
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Anaesthetist
  • Resume two-lung ventilation after chest closure; recruitment manoeuvre (sustained inflation 30 cmH2O × 30 sec) to re-expand atelectatic right lung
  • Extubation criteria: warm, haemostatic, SpO2 ≥95% on FiO2 0.4, adequate reversal of neuromuscular blockade (TOF ratio ≥0.9), cooperative (if not sedated), pain controlled via epidural
  • Thoracic epidural: confirm working bilaterally before extubation — inadequate analgesia is a primary cause of post-op respiratory failure; NRS pain score ≤3 on coughing
  • Change DLT to single-lumen ETT if remaining intubated (e.g. ICU post-op); DLTs are not designed for prolonged ventilation
  • If bleomycin history: maintain lowest FiO2 consistent with SpO2 ≥94% post-op; document O2 exposure duration
  • Post-op plan: HDU or ICU; chest drain management (water seal, not suction immediately); NGT on free drainage; jejunostomy feeds commenced at 6–12 hours
  • Anti-emetic prophylaxis: ondansetron + dexamethasone + droperidol (PONV risks post-oesophagectomy are high; vomiting risks anastomotic strain)
  • Document: total fluids in/out, estimated blood loss, drain outputs, epidural level and infusion rate, NGT position
Surgeon
  • Intercostal drains × 2 (apical and basal) via separate stab incisions; ensure not compressing conduit pedicle
  • Thoracotomy closure: pericostal sutures (0 Vicryl), intercostal muscle, fascial layers (0 PDS), subcutaneous (2-0 Vicryl), skin (3-0 monocryl or staples)
  • Confirm chest drains swinging and draining before dressing
  • Post-op imaging: CXR in recovery (lung re-expansion, drain positions, NGT position)
  • Feeding protocol: jejunostomy free water at 6 hours; jejunostomy feeds at 12–24 hours; contrast swallow day 5–7 to assess anastomotic integrity before oral intake
  • Dictate operative note: anastomotic technique, stapler size, conduit perfusion assessment, drain positions, NGT depth
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