Background and Objective: Thanks to the growing experience with the non-intubated anesthetic and surgical techniques, most pulmonary resections can now be performed by using minimally invasive techniques. The conventional method, i.e., surgery on the intubated, ventilated patient under general anesthesia with one-lung ventilation (OLV) was considered necessary for the major thoracoscopic lung resections for all patients. An adequate analgesic approach (regional or epidural anesthesia) allows videoassisted thoracoscopy (VATS) to be performed in anesthetized patients and thus the potential adverse effects related to general anesthesia and mechanical OLV can be minimized.Methods: Multiple medical literature databases (PubMed, Google Scholar, Scopus) were searched, using the terms [(non-intubated) OR (nonintubated) OR (tubeless) OR (awake)] AND [(thoracoscopic surgery)] from 2004 to December 2021. 306 scientific papers were collected. The editorials, commentaries, letters, and papers were excluded, that focus on other than the non-intubated (aka awake or tubeless) VATS technique, as well as the full text scientific papers available in languages other than English.

BackgroundIn the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS).MethodsWe performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms.ResultsBased on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential.ConclusionNITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.

Thanks to the growing experience and the improvement of video-assisted thoracoscopic surgery (VATS) technique most pulmonary resections can now be performed by minimally invasive techniques.The present and the future of the thoracic surgery should be associated with a combination of surgical and anaesthetic advancement and improvements to reduce the perioperative surgical stress to the patient.Background: Traditionally intubated, ventilated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections for all patients. An adequate analgesia technique (regional or epidural) allows VATS to be performed in anesthetized patients and the potential adverse effects related to general anaesthesia and mechanical one lung ventilation (mOLV) can be avoided. Methods:A search was carried out on the databases PubMed, Web of Science and The Cochrane Library by means of the (MeSH)terms 'non intubated thoracic surgery', 'spontaneous breathing', 'regional blockade', 'cough reflex', 'mechanical ventilation' and 'pulmonary complications' screened according following inclusion criteria: availability as full text in English, categorization as original research, reviews or metaanalyses. Conclusions:The minimally invasive, non-intubated procedures try to minimize the adverse effects of general anesthesia, tracheal intubation, and mechanical ventilation. Furthermore, patients may have also benefit by preserved hypoxic pulmonary vasoconstriction from the efficient contraction of the dependent hemidiaphragm during surgically induced pneumothorax. The non-intubated anaesthesia combined with the uniportal surgical approach represents one step forward in the minimally invasive strategies of treatment and can be reliable offer to an increasing number of patients. Therefore, educating and training programs in minimally invasive techniques with spontaneous breathing (SB) patients may be needed and the continuous evolution and findings of the better and better anesthetical and surgical methods are vital in reduction of the perioperative complications.