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Background and Aims Thoracic continuous spinal anaesthesia (TCSA) re-emerged as a sole anaesthetic technique for major abdominal surgery in patients at high risk for General anaesthesia (GA), as it avoids airway manipulation and mechanical ventilation. This study compared the postoperative pulmonary function and outcomes in patients undergoing major abdominal surgery under GA with thoracic epidural anaesthesia (TEA) versus TCSA.Methods Sixty-four adult patients scheduled for major abdominal surgery were randomly assigned to a GA with a TEA group (n=32) or a TCSA group (n=32). GA group received a thoracic epidural catheter placed at the T9-T10 level and was induced using intravenous drugs; fentanyl (2 mcg/kg), propofol (2–3 mg/kg), and vecuronium (0.1 mg/kg), followed by endotracheal intubation. In the TCSA group, a 25G intrathecal catheter was inserted at the same spinal level, and patients received preservative-free intrathecal drugs: ketamine (0.25 mg/kg) and midazolam (0.03 mg/kg), followed by isobaric levobupivacaine 0.5% to achieve a sensory block from T4 to L1. The primary outcome was peak expiratory flow rate (PEFR) over 72 hours. Secondary outcomes included breath-holding time (BHT), lung atelectasis, postoperative pulmonary complications, change in trans-diaphragmatic excursion, and in-hospital mortality. Data were compared using the two-sided Student t-test, Mann-Whitney and Chi-square tests.Results Postoperatively, PEFR significantly declined from baseline in both groups (P<0.001), with no significant difference between them (P=0.498). However, the TCSA group showed significantly better outcomes than the GA group concerning BHT on postoperative day 1 (P=0.048) and day 2 (P=0.005), reduced lung atelectasis at 1 h post-op (P=0.03), and greater diaphragmatic excursion at 1 hour (P<0.001), day 1 (P<0.001), and day 2 (P<0.001).Conclusions TCSA was associated with better early postoperative respiratory parameters, including breath-holding time, reduced atelectasis, and improved diaphragmatic movement. These findings suggest TCSA may offer superior respiratory outcomes in the immediate postoperative period in patients undergoing major abdominal surgery.