Nonintubated Uniportal Thoracoscopic Surgery for Peripheral Lung Nodules

Prophylactic air‐extraction strategy after thoracoscopic wedge resection

“…In our study, the incidence rate of postoperative pneumothorax was 9.8% in the OT group and 19.4% in the PC group, which are consistent with previous reports 18, 19, 20. However, on the other hand, patients in the tubeless strategy groups (OT + PC groups) had reduced postoperative pain based on NRS scores compared to the RT group (RT vs. OT vs. PC: 3.4 ± 1.1 vs. 2.3 ± 0.9 vs. 2.3 ± 0.8, respectively; P < 0.001).…”

“…The tubeless strategy, which directly omits chest tube drainage, was first used in a thoracoscopic wedge resected population 13, 14, 15, 16, 17. However, previous studies have reported that this procedure has an increased rate of complications, especially pneumothorax (5.9–40%) 15, 18, 19, 20. Thus, some investigators have suggested the use of a preset air‐extraction catheter for prophylactic or remedial air‐extraction, which we call a prophylactic air‐extraction strategy.…”

Nonintubated uniportal VATS pulmonary anatomical resections

“…First report of a nonintubated uniportal VATS anatomical resection was published by GonzalezRivas in 2014 with a right-middle lobectomy plus lymphadenectomy (10), followed by an anterior right-upper lobe anatomical segmentectomy via the same approach, reported by Hung also in 2014 (11). Some sporadic reports by the same and other teams have been reported since then (12)(13)(14). The unique case series analysis was reported in 2015 by Hung (15), with 116 patients operated through nonintubated uniportal VATS, including 7 anatomical segmentectomies and 2 lobectomies through this approach.…”

“…Performed only in highly experienced centers in nonintubated surgery and uniportal VATS, main efforts have focused more in new technical challenges and indications than in acquiring solid scientific evidence. Anatomical resections such as lobectomies or segmentectomies under intercostal and vagal blocks, with oxygenation devices such as oropharyngeal canulla can be safely performed (9,12,14,26), but some potential complications should be kept in mind and emergency protocols for the management of crisis are mandatory (20). Patients are best managed under deep sedation avoiding the stressful perception induced by surgical pneumothorax, but one of the main challenges is to achieve a surgical stable field without respiratory depression and severe hypercapnia.…”

“…For that reason, we decided to take them out from the protocol. The anesthetic depth is monitored through bispectral index (BIS) value, and usually kept between 40 and 60 (14), although some experienced teams report BIS values between 30 and 50. Urinary catheter is placed in some cases, although we have operated many patients through a tubeless approach; (III) Premedication: Normally we use between 1-3 mg of midazolam and 50-100 µg of fentanyl; (IV) Analgesia: nowadays are used either multiple intercostal blocks at the beginning and the end of the surgery, or epidural block (as in an intubated VATS).…”