Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery?

Abstract

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhancement of surgical instruments and high-definition cameras, most pulmonary resections can now be performed by minimally invasive surgery. The future of the thoracic surgery should be associated with a combination of surgical and anaesthetic evolution and improvements to reduce the trauma to the patient. Traditionally, intubated general anaesthesia with one-lung ventilation was considered necessary for thoracoscopic major pulmonary resections. However, thanks to the advances in minimally invasive techniques, the non-intubated thoracoscopic approach has been adapted even for use with major lung resections. An adequate analgesia obtained from regional anaesthesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and selective ventilation can be avoided. The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anaesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and postoperative nausea and vomiting. Anaesthesiologists should be acquainted with the procedure to be performed. Furthermore, patients may also benefit from the efficient contraction of the dependent hemidiaphragm and preserved hypoxic pulmonary vasoconstriction during surgically induced pneumothorax in spontaneous ventilation. However, the surgical team must be aware of the potential problems and have the judgement to convert regional anaesthesia to intubated general anaesthesia in enforced circumstances. The non-intubated anaesthesia combined with the uniportal approach represents another step forward in the minimally invasive strategies of treatment, and can be reliably offered in the near future to an increasing number of patients. Therefore, educating and training programmes in VATS with non-intubated patients may be needed. Surgical techniques and various regional anaesthesia techniques as well as indications, contraindications, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Anaesthesiology for uniportal VATS: double lumen, single lumen and tubeless

“…The need for sedation with uniportal VATS in the nonintubated patient remains unclear (20). However, sedation is preferred for prolonged operations, with the use of short-acting agents like remifentanil at below the hypnotic level being the first choice (26).…”

Uniportal thoracoscopic surgery: from medical thoracoscopy to non-intubated uniportal video-assisted major pulmonary resections

“…The same expansion occurred with the patient selection criteria as it quickly become apparent that general anesthesia was one of the most limiting factors for surgery. This led to the development of a non-intubated protocol that has allowed the uniportal approach to be used for patients who were otherwise ineligible or in a high risk category for thoracic surgery (32)(33)(34).…”

“…In the treatment of lung cancer, this has been addressed to some extent within thoracic surgery and pulmonology with the most recent clinical guidelines (40). However, the terminology and use of non-thoracic surgeons as the decision-maker for determining the patient's eligibility for surgery may require re-exploration now that uniportal and related non-intubated anesthetic approaches have been used safely and effectively on even the frailest patients (32,41).…”

From full thoracotomy to uniportal video-assisted thoracic surgery: lessons learned

“…Reducing scars and the insult of surgical trauma has become a vital end point of the entire surgical assessment and endeavour. In the pursuit of further reduction in scarring and the trauma of both minithoracotomy and conventional VATS, surgeons and Industry have combined their ingeniousness and expertise to promote two new approaches for VATS: uniportal VATS (uniVATS) and awake thoracic surgery procedures (1). UniVATS allows performing the same procedure as three-port VATS through only one incision, usually along the anterior axillary line.…”

“…UniVATS allows performing the same procedure as three-port VATS through only one incision, usually along the anterior axillary line. The most recent development of non-intubated anesthetic techniques applied to uniVATS could enhance the concept of minimal invasiveness (1). Nowadays, the combination of uniVATS and awake surgery is perceived by thoracic surgeons as the final stage of minimally invasive thoracic surgery, a stage leading to fast-tracking in thoracic surgery.…”