Multidisciplinary approach to the challenges in the perioperative management of large merkel cell carcinoma.

An integrated multidisciplinary team-based approach to patients from the moment surgery is contemplated through to full recovery is the essence of perioperative care. The management of large soft tissue masses in the back is very challenging with multiple facets requiring precision care and erudite planning. Our Case of Merkel Cell carcinoma is an excellent manifestation of such a complex scenario. A multidisciplinary approach with closed-loop communication is essential in countering the challenges with the need for tailoring management for Immunotherapy and its complications, huge mass with areas of necrosis leading to sepsis, difficulty in mask ventilation and intubation due to limited posture, very poor vascular access, the need of rapid infuser for resuscitation, cardiac output and pulse pressure variation for hemodynamic monitoring, challenges with prone position intraoperatively with complex plastic surgery reconstruction and extubation in the lateral decubitus position.