What is the anesthetic management for excision of a breast lesion and Latissimus Dorsi (LD) flap with Internal Mammary Artery Perforator (LICAP)?

From the Guidelines

Anesthetic management for breast lesion excision with Latissimus Dorsi flap and LICAP typically involves general anesthesia with careful attention to positioning, pain management, and hemodynamic stability, as recommended by recent guidelines 1. The procedure begins with standard monitoring (ECG, pulse oximetry, non-invasive blood pressure) and induction using propofol (1.5-2.5 mg/kg), fentanyl (1-2 mcg/kg), and a muscle relaxant such as rocuronium (0.6 mg/kg). Airway management requires endotracheal intubation as the surgery involves lateral positioning. Anesthesia is maintained with sevoflurane or desflurane (0.8-1.2 MAC) and remifentanil infusion (0.05-0.2 mcg/kg/min). Some key points to consider in the anesthetic management include:

• Positioning requires special attention as the patient needs lateral access for the LD harvest, with careful padding of pressure points and protection of the brachial plexus.
• Multimodal analgesia is essential, including preoperative acetaminophen (1g IV), dexamethasone (4-8mg IV), and intraoperative regional techniques such as pectoralis and serratus plane blocks with ropivacaine 0.25-0.5% (20-30ml total) 1.
• Temperature management is crucial as flap perfusion depends on adequate peripheral circulation, so active warming with forced-air devices should be used.
• Fluid management should be judicious, typically with crystalloids at 3-5 ml/kg/hr, maintaining normotension to ensure flap perfusion.
• Postoperative pain control includes continuation of multimodal analgesia with scheduled acetaminophen, NSAIDs if not contraindicated, and opioids as needed, as supported by the guidelines 1. This comprehensive approach optimizes surgical conditions while ensuring patient comfort and flap viability through stable hemodynamics and adequate tissue perfusion. Some of the key recommendations from the guidelines include:
• The use of paracetamol and conventional NSAIDs or COX-2-selective inhibitors as basic analgesia, unless contraindicated 1.
• The use of pre-operative gabapentin and a single intra-operative dose of i.v. dexamethasone as analgesic adjuncts 1.
• The consideration of regional anaesthetic techniques such as paravertebral block or pectoral nerves block for additional pain relief in major breast surgery 1.
• The use of opioids as rescue medication only if non-opioid analgesics and regional analgesic techniques do not provide effective pain control 1.

From the Research

Anaesthetic Management for Excision of Breast Lesion and LICAP Flap

The anaesthetic management for excision of a breast lesion and Latissimus Dorsi (LD) flap with Internal Mammary Artery Perforator (LICAP) involves several considerations.

• The use of multilevel paravertebral nerve blockade has been reported as an effective method for providing opioid-free postoperative analgesia after LD flap breast reconstruction 2.
• This technique involves the placement of unilateral paravertebral catheters at multiple levels, such as T3/4 and T7/8, and the infusion of local anesthetics like ropivacaine 0.2% until the day of discharge.
• The LICAP flap is a pedicled perforator flap that can be used for lateral breast defect reconstruction, offering advantages such as minimal donor site morbidity, better aesthetic results, and higher patient satisfaction 3.
• The surgical procedure for the LICAP flap involves marking the lateral intercostal artery perforators with ultrasound and drawing "lazy S" lines to mark the flap, followed by wide local excision and flap mobilization to fill the defect 4.
• The anaesthetic management should take into account the potential for postoperative pain and the need for effective analgesia, as well as the possibility of complications such as bleeding or respiratory problems.
• The use of regional anesthesia techniques, such as paravertebral nerve blocks, can help to reduce the risk of complications and improve postoperative outcomes.
• In addition to the anaesthetic management, the surgical team should also consider the use of other techniques, such as the use of ultrasound to mark the perforators and the design of the flap, to optimize the outcome of the procedure 5, 6.

Key Considerations

• Effective postoperative analgesia is crucial for patient comfort and satisfaction.
• The use of multilevel paravertebral nerve blockade can provide opioid-free postoperative analgesia.
• The LICAP flap offers advantages such as minimal donor site morbidity and better aesthetic results.
• The anaesthetic management should take into account the potential for complications and the need for effective analgesia.
• The use of regional anesthesia techniques and other surgical techniques can help to optimize the outcome of the procedure.