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Abstract
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Background and Aims After radical mastectomy, many patients undergo breast reconstruction. Autologous flap reconstruction avoids many issues despite being longer and complex. The DIEP (deep-inferior-epigastric-perforator) flap is the most common procedure, involving the transfer of skin and subcutaneous fat from the abdomen to the chest. The procedure takes many hours and requires optimal intraoperative analgesia and hemodynamic stability. Flap perfusion may benefit from spontaneous breathing. We considered spinal anesthesia with fascial-plane-blocks an alternative to general anesthesia to improve outcomes and recovery.
Methods A 59-year-old woman (history of breast cancer, mastectomy, failed breast implant reconstruction) scheduled for reconstruction with DIEP flap. After signing informed consent and premedication with midazolam and atropine, spinal anesthesia and bilateral inter-transverse-process block (ITP) were performed. For spinal anesthesia at T10 with 27G needle, we administered 5 ml of ropivacaine 2mg/ml, fentanyl 20 mcg, and dexmedetomidine 5 mcg. For ITP block at T7: 30 ml of ropivacaine 0.2% and dexamethasone 4 mg each side
Results The 7-hour surgery was conducted under moderate sedation with propofol. No bradycardia occurred; moderate hypotension was corrected with ephedrine. Mean arterial pressure remained stable. Oxygenation was maintained with O2 via nasal cannula. Additional fentanyl was administered at the end of surgery. The patient awakened pain-free and was monitored for flap perfusion and oxygenation for 24 hours; began early refeeding and mobilization without pain or nausea and was discharged home earlier.
Conclusions High-volume/high-level spinals with adjuvants can be valid alternatives to epidural and general anesthesia for long-duration procedures like DIEP flap breast reconstruction. Trials are needed to evaluate advantages.
Different phases of the DIEP flap breast reconstruction