regional technique for big back lipoma removal

63 years old patient have history of big mass like lipoma in upper back, and it started as small mass in back of neck then became more enlarged in past 2 years ago….patient have history of hypertension and ECG not exclude old ischemia (sign of old ischemia) with LVH,he is ex smoker and did quit before 2 months after 40 years heavy smoking, patient suffer from exertional dyspnea when walking and exercise intolerance, on examination there is big goiter with MP 3 and mild limitation in neck movement,with severe tracheal deviation appeared in CT scan . Patient postponed from different anaesthetist and surgeons during last year and all them told him about the risk and highly mortality rate when receive GA in prone position with his systemic disease ASA3….so patient came to me and he told me he is suffering from this mass and even the sleep begun difficult and no way just to operate and finish this disasters….he deadly refuse GA and need regional anaesthesia and awake surgery as he know the risk of general anaesthesia….patient scheduled to Tuesday list and the plan now give regional anaesthesia….
I will discuss my steps with you and hope to share your practice and advise me if am wrong in any step because my goal to this patient to discharge him well from hospital postoperative….the surgeon plan to remove this lipoma in prone position by mid sagittal incision and evacuate it by tissue dissection used cuttery and then approximation and close the skin…I get benefit from MRI to pointing the level of extension and cover this area as I will show you in anatomy and select the regional block,…this video of lipoma removal by regional technique which it collected from multiple phones recorded the procedures….sorry for not full English language because all the listeners were Arabian doctors but i add caption to video…video publish consent taken from patient before end of video as you will see ….
hope it helpful…….after 2 years of suffering and discomforts due to this ugly big mass…this patient did liberate from his disaster….complete regional anaesthesia without any sedation or analgesia during operation,prone position monitoring ,very cooperative was…..from start i checked the airway by awake veido laryngoscope procedure .the bilateral glossopharangeal nerve blocked to block gag reflex from palatoglossal arch(recorded in video) good patency and easy to intubate(just to check the ability to intubate the patient if any disaster occurred intra op)….right sided USG cervical plexus block done by 5 ml 1% lidocaine with adrenaline with local infiltration to posterior cutaneous branches of thoracic spinal intercostal nerves…i used spinal needle G 24 and maked a mark in skin by calculated the distance between each mark by length of needle to avoid any missed segment…total dose of LA was 300 mg lidocaine with adrenaline+75 mg 0.5% bupivacaine diluted in NS separately for skin and base infiltration…duration of surgery was 90 minutes, good anaesthesia with good analgesia got…patient walked directly post op… he is laying supine to sleep with full pleasure and comforts… consent took from patient to publish his pictures and procedure as he just speak Arabic and written consent taken also…
weight of mass was 2700 gram

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