Ultrasound guided surgery under Dilutional Local Anaesthesia and no sedation in breast cancer patients

Background: Breast cancer surgery under local anaesthesia (LA) can be challenging due to limitation of dose and quantity of anaesthetic agent that can be used safely. Elderly patients with breast cancer and with multiple co-morbidities are often prevented from having a standard treatment as they are considered unfit for general anaesthesia. We describe a technique of surgery under local anaesthesia without sedation that employs dilution to generate large volumes of LA and infiltration under ultrasound guidance. Methods: We present a case series by a single surgeon of breast cancer patients who underwent surgery under LA. 40 mls of 1% lignocaine with 1:200,000 adrenaline was diluted with 160 mis of normal saline to make a total of 200 mis, resulting in dilution to a concentration of 0.2% lignocaine. Radioactive isotope having been injected before patient's arrival in theatre, 1 ml of diluted anaesthetic solution is used with 2 mis of 2.5% patent blue to inject in the sub-areolar space. Local anaesthetic is infiltrated at operative site under ultrasound guidance using a long echogenic needle. Results: A total of 71 patients with breast cancer underwent surgery under the LA between September 2015 and October 2018. 64 (90%) patients had wide local excisions and 7 (10%) had mastectomies. All had axillary surgery, 65 (91.5%) had dual technique sentinel lymph node biopsy as a day case and 6 (8.5%) patients had axillary clearance. 8 patients had re excision (12.5%). All patients had '0' pain score and no postoperative analgesia was required in recovery. Local anaesthetic used did not exceed the maximum safe dose in any of the cases. One patient returned to theatre for postoperative wound bleeding. No other postoperative complication was observed. Conclusion: Ultrasound guided infiltration allows accurate placement of large volume of diluted local anaesthetic solution safely and provides effective anaesthesia. Crown Copyright (C) 2019 Published by Elsevier Ltd on behalf of Royal College of Surgeons of Edinburgh (Scottish charity number SC005317) and Royal College of Surgeons in Ireland. All rights reserved.