Subxiphoid, Nonintubated, Opioid-Free, Video-Assisted Pneumonectomy: A New Frontier in Thoracic Surgery

Abstract

Surgical approaches to major pulmonary resections have evolved from thoracotomy to multiportal video-assisted thoracoscopy (VATS) and subsequently uniportal VATS. The efficacy of this progress has been validated in a multitude of publications demonstrating reductions in complications, patient perception of pain, and postoperative length of stay. More recent advances include subxiphoid extrathoracic access and nonintubated, opioid-free anesthesia. Early publications have demonstrated promising results with respect to safety, technical feasibility, and enhanced recovery. However, there remains a paucity of literature relating to hybrid approaches comprising both subxiphoid and nonintubated, opioid-free anesthesia in the context of pneumonectomy. The current report is the case of a patient undergoing pneumonectomy. Both subxiphoid and nonintubated, opioid-free techniques were utilized. The authors describe preoperative workup, surgical and anesthesia-related caveats, and postoperative recovery. In conclusion, this approach is technically feasible, safe, and may be associated with enhanced recovery.

Non-Intubated Thoracotomy Under an Opioid-Sparing Intravenous Sedation and Analgesia Protocol without Central or Peripheral Nerve Blocks: A Case Report with Insights into Shared Decisions

“…The multifactorial nature of thoracic pain, along with the "opioid epidemic" and opioids' side effects, has prompted a "paradigm shift" in thoracic anaesthesia, incorporating multimodal analgesia and opioid-free anaesthesia protocols [7,10]. Opioidfree anaesthesia may also enhance return to baseline function in thoracic surgery patients [13]. In our case the joint decision pathway resulted in an open, non-intubated lung resection under exclusively intravenous opioid-sparing analgesia and sedation.…”

“…Epidural or paravertebral blocks may be incorporated in thoracic opioid-free protocols [12]. Recently a non-intubated video-assisted pneumonectomy under opioid-free anaesthesia with the concurrent use of both paravertebral and subcostal transversus abdominis blocks was reported [13].…”