Operating Room-Complete Venovenous Extracorporeal Membrane Oxygenation for Thoracoscopic Surgery Without Repositioning

Patients who cannot sustain gas exchange during one-lung ventilation may still require a brief thoracoscopic procedure. Venovenous extracorporeal membrane oxygenation can support them, but conventional practice involves cannulating the supine patient and then turning them laterally while they are circuit-dependent. We describe an operating-room-complete strategy in which the semi-supine position is the single operative position: femoral access and video-assisted thoracoscopic surgery proceed without repositioning, with exposure adjusted by rotating the table. The vein is cannulated with a purse-string, permitting direct repair at decannulation. No heparin is given systemically or in the prime; antithrombogenicity relies on heparin-bonded surfaces, a flow of 2.5–3.5 L/min, brief support, and predefined rescue triggers. Between October 2022 and June 2025, the strategy was applied in five of 548 thoracoscopic procedures. Operative times were 124–172 min, and venovenous extracorporeal membrane oxygenation support was 27–69 min; all were weaned in the operating room without thromboembolic or hemorrhagic complications.