Cite this article as: Gonzalez-Rivas D, Bonome C, Fieira E, Aymerich H, Fernandez R, Delgado - PowerPoint Presentation

Slide1

Cite this article as: Gonzalez-Rivas D, Bonome C, Fieira E, Aymerich H, Fernandez R, Delgado M et al. Non-intubated video-assisted thoracoscopic lung

resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2016;49:721–31.

Non-intubated video-assisted thoracoscopic lung resections:

the future of thoracic surgery?

Diego Gonzalez-Rivas *, Cesar Bonome , Eva Fieira , Humberto Aymerich , Ricardo Fernandez

a,b,

c

b

d

a,b

,

Maria Delgado , Lucia Mendez and Mercedes de la Torre

b

b

a,b

a

Minimally Invasive Thoracic Surgery Unit (UCTMI), Coruña, Spain

b

Department of Thoracic Surgery, Coruña University Hospital, Coruña, Spain

c

Department of Anesthesia, San Rafael Hospital, Coruña, Spain

d

Department of Anesthesia, Quirón Hospital, Coruña, Spain

* Corresponding author. Department of Thoracic Surgery, Coruña University Hospital, Xubias 84, 15006 Coruña, Spain. Tel: +34-981-178286; fax: +34-981-178235;

e-mail: diego.gonzalez.rivas@sergas.es (D. Gonzalez-Rivas).

Received 17 January 2015; received in revised form 26 February 2015; accepted 9 March 2015

Summary

Thanks to the experience gained through the improvement of video-assisted thoracoscopic surgery (VATS) technique, and the enhance-

ment 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 improve-

ments 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 anaes-

thesia techniques allows VATS to be performed in sedated patients and the potential adverse effects related to general anaesthesia and se-

lective 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 post-

operative 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 an-

aesthesia 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, contraindi-

cations, criteria to conversion of sedation to general anaesthesia in non-intubated patients are reviewed and discussed.

Keywords: Non-intubated patient • Awake surgery • Lobectomy • Spontaneous ventilation • Local anaesthesia • Uniportal

‘Only the people who study the past can define the future’—

Confucius

INTRODUCTION

During the last decade, there have been huge developments of new

minimally invasive surgical techniques for major pulmonary resec-

tions [

1

,

2

]. Advances in anaesthesiology include thoracic operations

performed without the employment of general anaesthesia, through

maintaining spontaneous ventilation and with minimally sedated

patients. One-lung spontaneous ventilation is more physiological

and has more advantages than mechanical ventilation. However,

open pneumothorax in a non-intubated patient may compromise

ventilation and oxygenation. Movements of the patient during

surgery, coughing, mediastinal shift and diaphragmatic displacement

can make surgical manoeuvres in video-assisted thoracoscopic

surgery (VATS) more technically demanding [

3

].

Non-intubated minor and major thoracic surgery can be per-

formed safely by VATS through regional anaesthesia and sedation in

spontaneously breathing patients [

4

, 5]. Non-intubated thoracic

surgery for major procedures is not risk free, and the ideal standard

management in daily practice still needs to be better elucidated.

A BRIEF HISTORICAL PERSPECTIVE OF

ANAESTHESIA IN NON-INTUBATED

THORACIC SURGERY

Before 1930, the performance of thoracic surgery through a thora-

cotomy in a slightly anaesthetized patient with spontaneous

© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

REVIEW

European Journal of Cardio-Thoracic Surgery 49 (2016) 721–731

REVIEW

doi:10.1093/ejcts/ezv136 Advance Access publication 19 April 2015

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

ventilation was very daring and the results on patients’ survival

were disappointing. In 1928, Guedel introduced the endotracheal

tube and 3 years later, Gale and Waters [

6] put this tube in the

bronchus of the healthy lung to achieve one-lung ventilation(OLV). However, up until the 1960’s, mechanical ventilation was ventilation-to-perfusion mismatch, and promotes further inflam-

not introduced. Ventilation was either spontaneous or manually

assisted, diaphragm activity was preserved, and lung mobility was

present until the surgeon managed iatrogenic pneumothorax. In

1956, Vischnevski developed a multimodal technique with block-

ading of the phrenic and vagus nerves in the neck, adding an ex-

tensive intercostal blockade, and finally by administering

novocaine in the lung hilum after opening the hemithorax.

Through this technique, Vischnevski [7] performed more than 600

major lung procedures. In 1960, Ossipov [

8] published a series of volume ventilation, positive end-expiratory pressure, lower FiO ,

more than 3000 operations performed with a similar technique.

After 1960, the introduction of mechanical ventilation and new

improvements for OLV allowed the further development of thor-

acic surgery. Moreover, the development of endoscopic surgery

with minimal surgical trauma led surgeons to reconsider those

techniques and to evaluate their real advantages over the stand-

ard thoracic surgery.

In 2004, Pompeo et al. [

9] proved it was possible, through

the use of epidural anaesthesia, to perform thoracic surgery in the

awake patient. However, in patients requiring lobectomies, the

procedure was done under general anaesthesia.

Reviewing the anaesthesia in endoscopic thoracic surgery, we

can find some differences between the operations performed in

non-intubated patients. Those performed with the patient awake

or minimally sedated are mainly wedge or peripheral nodule resec- thoracic surgery has been related to a higher mortality, morbidity

tions [4

, 9–15], and the others performed with deeper sedation

include major lung surgery (segmentectomy or lobectomy) [

5, 16].

In 2007, Al-Abdullatief et al. [ 17

] showed the possibility of per-forming some cases of major thoracic surgery, even thoracotomy the lung is collapsed, therefore producing associated complica-

for lung resection, with the patient awake or minimally sedated.

Nowadays, the evolution of video-assisted thoracic surgery to

less invasive techniques, such as uniportal VATS (with only one

incision of 3 cm and involving only one intercostal space) allows

us to consider the possibility of avoiding intubated general

anaesthesia [18].

ADVERSE EFFECTS OF INTUBATED GENERAL

ANAESTHESIA

The main advantage of non-intubation surgery is to avoid the

perioperative morbidity derived from the deleterious effect of

general anaesthesia and OLV, in addition to the beneficial effects

of spontaneous ventilation in a non-intubated patient.

The beneficial effects of the use of loco-regional techniques areoften highlighted in non-intubated surgery. However, as often

shown in publications, it is wrong to attribute the beneficial effects

mainly to the loco-regional techniques. These techniques (such as protective effects in inflammatory response [

29].

paravertebral block, epidural and intercostal block) are frequently

used intraoperatively in thoracic surgery along with general anaes-

thesia [19].

Mechanical ventilation has a series of potential side-effects ventricular function and PaCO levels up to 70 mmHg are likely to

such as airway pressure-induced injury, damage caused by lung

overdistension, shear stress of repetitive opening, closing of

alveoli and the release of a variety of pro-inflammatory mediators.

Atelectasis in the dependent lung is frequent during OLV with

muscle paralysis [20, 21]. The formation of atelectasis in the non- mediators related to mechanical ventilation [

31, 32]. Spontaneous

operative lung is highly undesirable during OLV because it

worsens the already high shunt fraction, increasing the probability

of hypoxaemia. It can also increase the risk of postoperative

pulmonary complications. In the dependent lung, OLV induces

matory changes (low V/Q regions increased in the ventilated lung

or signs of alveolar damage), suggesting that OLV has more dam-

aging consequences than a period of complete lung collapse and

surgical manipulation. Ventilator-related lung injury occurs inabout 4% of major lung resections and carries a mortality rate as

high as 25%. However, subclinical lung injury leading to minor re-

spiratory impairment is more

frequent and related to post-

operative complications. Protective ventilation with low tidal

2

lower ventilation pressures, permissive hypercapnia and recruit-

ment manoeuvres are all mandatory in mechanical ventilation in

thoracic surgery to minimize lung injury [22].

High-frequency jet ventilation may be an alternative way of

ventilation in thoracic surgery, with lower peak inspiratory pres-

sure and shunt fraction but we need general anaesthesia and oro-

tracheal intubation [

23].

Orotracheal and bronchial intubation can also have potential

local complications, including throat pain, mucosal ulceration and

laryngeal or tracheal injuries. Tracheobronchial rupture may carry

a mortality rate as high as 22% [

24].

General anaesthesia also has deleterious systemic side-effects

that do not occur in regional anaesthetic techniques in awake

patients or those minimally sedated. Deep anaesthesia used in

and cognitive dysfunction postoperatively [

25

].

The use of muscle relaxants has been known to produce dia-

phragmatic dysfunctions, particularly in the hemithorax, where

tions as a result of residual muscle block [

26

]. The intravenous

analgesics during general anaesthesia, primarily opioids, are asso-

ciated with important postoperative complications such as hyper-

algesia, vomiting and/or nausea and ventilatory depression. These

can reduce the patient’s comfort and increase the need for post-

operative analgesics and prolong the postoperative stay [

27

].

Patients with spontaneous ventilation avoid these complica-

tions, proving that spontaneous ventilation has a series of benefi-

cial effects. The resulting ventilation/perfusion mismatch increases

the risk of hypoxaemia, but is preserved in awake patients using

spontaneous ventilation. This is due to a more efficient contrac-

tion of the dependent hemidiaphragm and the increase in the al-

veolar pressure with mechanical ventilation attenuates the

efficiency of the hypoxic pulmonary vasoconstriction (HPV) [

28

].

Hypercapnia is a central component in non-intubated thoracic

surgery related to hypoventilation. However, ‘permissive hypercap-

nia’ is frequently used in ventilatory strategies for patients under

OLV. It has been suggested that permissive hypercapnia may

improve haemodynamics and the ventilation/perfusion match and

Hypercapnia should be avoided in patients with elevated pul-

monary pressures, major cardiac rhythm disturbances or increased

intracranial pressure. Patients awake or sedated, with normal right

2

tolerate it well [

30

].

Moreover, the perioperative surgical stress response could be

attenuated in non-intubated patients undergoing VATS as a result of

the reduced postoperative stress hormones and pro-inflammatory

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

722

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

ventilation is less aggressive than mechanical ventilation and only

reductions of tidal volume and subsequently decreased peak

airway pressures have significant effects on alveolar tumor necrosis

factor, soluble intercellular adhesion molecule 1 and IL-10 concen-

trations after OLV and in the postoperative course [

20]. In the non-

intubated patient, a regional anaesthetic technique is mandatory.

Thoracic epidural anaesthesia, paravertebral block and intercostal

block all improve postoperatively respiratory function, absence of

diaphragmatic relaxation and mechanical irritation of the airwaysensuring better ventilation than with general anaesthesia. Regional

anaesthesia attenuates immunosuppression and neuroendocrine

stress with potential improvement of survival and cancer recurrence

[33

]. However, regional anaesthetic techniques are used in general

anaesthesia and these beneficial effects are not exclusive to non-

intubated surgery.

PATHOPHYSIOLOGY OF SURGICAL

PNEUMOTHORAX IN NON-INTUBATED PATIENTS

In an anaesthetized patient, OLV in a lateral decubitus position pro-

duces a ventilation/perfusion mismatch and the non-dependent

lung increases its compliance while the dependent lung receives

better perfusion as a result of gravity, increasing the risk of hypox-

aemia. Nevertheless, thematch of ventilation/perfusion is preserved

in non-intubated spontaneous ventilation due to a more efficient

contraction of the dependent hemidiaphragm; consequently

ventilation and perfusion is better maintained in the dependent

lung [

34].

In the anaesthetized patient, the non-dependent lung receives

zero ventilation and perfusion decreases due to HPV, gravity, sur-

gical interference and pre-existing disease. However, hypoxaemia

is frequent due to the collapsed lung as it continues to be perfused

without being ventilated, which may lead to a large right-to-left

intrapulmonary shunt. The lung volume can have deleterious

effects on HPV. If the delivered tidal volume and the total positive

end-expiratory result in overdistension of the ventilated alveoli,

blood flow may be diverted to the atelectatic or hypoxic alveoli,

attenuating the HPV response and worsening V/Q mismatch.

Volatile anaesthetics have been reported to inhibit HPV and may

promote hypoxaemia during OLV [35].

In non-intubated patients, once the incision is opened, the

negative pressure is lost and paradoxical respiration occurs. On ex-

piration, gas flow may enter the lung in the open hemithorax and

on inspiration the reversal phenomenon occurs. The continuousatmospheric pressure environment in the open hemithorax leads

to mediastinal movement towards the dependent hemithorax

during inspiration. However, the modified pattern of ventilation

induced by the open pneumothorax is well tolerated.

The perfusion to the dependent ventilated lung is better in non-

intubated surgery because of the low or negative pressure in this

lung. Respiratory efficiency and lung recruitment is increased by

the maintained diaphragmatic function. Intrapulmonary shunt and

hypoxaemia is reduced compared with OLV-intubated patients.

There is a risk of experiencing hypercapnia rebreathing effect

from the initial paradoxical respiration and hypoventilation due to

collapse of the operated lung and sedation. However, it is rare to

need support ventilation, and this is only needed in patients with

severe restrictive or obstructive ventilatory defect. Ventilatory ob-

struction and hyperinflation in dependent ventilated lung produce

intrinsic positive end-expiratory pressure, decrease mediastinalshift, increasing functional residual capacity and decreasing atelec-

tasis and thus the risk of hypoxaemia is reduced contrary to the re-

strictive ventilatory defect [3].

ANAESTHESIATECHNIQUES IN

NON-INTUBATED THORACIC SURGERY

The realization of non-intubated thoracic surgery requires the im-

plementation of a protocol including description of indications-

contraindications, exclusion criteria, patient consent, the most

appropriate anaesthetic technique for the surgical procedure and

criteria for conversion to general anaesthesia. Moreover, the ac-

ceptance and knowledge of this method by surgeons with exten-

sive experience in VATS is required.

The criteria for non-intubated VATS in minor or pleural proce-dures are different from those in major pulmonary resections and

recommendations have been established in patients with increased

risk, using general anaesthesia. Inclusion criteria included all

selected patients in whom the avoidance of morbidity of conven-

tional thoracotomy and the risk of intubated general anaesthesia

could be reduced [3, 36

–39].

Patient exclusion criteria are given in Table 1 (according to our

experience and the experience from other major research groups).

Non-intubated VATS entails thoracoscopic procedures per-

formed under regional anaesthetic techniques in spontaneously

breathing patients. The regional anaesthetic techniques consist of

local anaesthesia, intercostal nerve blocks, interpleural block,

paravertebral blocks or thoracic epidural anaesthesia [

12, 40–

42].

The anaesthetic technique used is what will determine whether

there is a need for sedation. In uniportal surgery, a single intercos-

tal space block is usually sufficient to control the afferent nerves.

These local anaesthetic techniques are insufficient to control the

pleural surface, other level handling intercostal spaces, hilar and

bronchi, so additional sedation and analgesia is required [12,

18

,

41

,

42

]. Our preliminary results with uniportal VATS suggest that a

good management is obtained with an infiltration of a single

intercostal space under thoracoscopic view and topic anaesthesia

on the surface of the lung and the hilum. Oxygen (6–9 l/min) is

Table 1: Exclusion criteria in non-intubated VATS major

pulmonary resections

Patients with expected difficult airway management evaluated by the

anaesthesiologists

Haemodynamically unstable patients

Obesity (body mass index >30)

Inexperienced and poorly cooperative surgical team

Coagulopathy (international normalized ratio >1.5)

Persistent cough or high airway secretion

Patient with elevated risk of regurgitation

Neurological disorders: risk of seizure, unable to cooperate, intracranial

mass or brain oedema

Extensive pleural adhesions or previous pulmonary resections (related

to surgeons’ skills)

Hypoxaemia (PaO <60) or hypercarbia (PCO >50)

2

2

Central hypoventilation syndrome

Any contraindications for use of regional anaesthesia technique

specifically selected

Procedures requiring lung isolation to protect the contralateral lung

from contamination

REVIEW

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

723

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

supplied via facial mask. Standard monitoring must include elec-

trocardiogram, non-invasive blood pressure, pulse oximetry and

respiratory rate, along with an approximation of the end-tidal

carbon dioxide with a catheter placed in one nostril. The pharma-

cological management is based on a target-controlled infusion of

remifentanil and propofol, with a premedication of midazolam

(0.15–0.25 mg/kg) and atropine (0.01 mg/kg) 15 min before an-

aesthesia, adjusting real-time rate of infusion with the aggressive-

ness of each period during the surgery. The use of a nebulization

of 5 ml of lidocaine 2% 30 min before helps to avoid coughingthat could be troublesome when performing lung traction and

intense hilar manipulation during surgery [

18].

A greater extension of the regional block in thoracic surgery is

achieved by paravertebral blocking. Using this technique with asingle administration of local anaesthetic level T –T , a block of

4 5

several intercostal spaces is achieved in order to avoid any reac-

tion of the patient due to the surgical incision.

None of these techniques are able to achieve an analgesic

block and allow the performance of thoracic surgery without sed-

ation. Hypnotic doses administered are similar to general anaes-

thesia, in this case using more than light sedation or anxiolysis, we

use the term monitored anaesthesia care (MAC). This term also

includes the possibility of using anaesthetics and opioids for sed-

ation and the use of supraglottic devices to improve ventilation

and prevent obstruction of the airway [

18, 37–

42].

The majority of the reported techniques in thoracic surgery with

non-intubated and spontaneously breathing patients include epi-

dural anaesthesia in their strategies. This technique allows to

achieve a more extensive and deeper blockade, and depending onthe placement level (usually T –T ), the dosage and the volume of

the anaesthetic administered can be adjusted [13–

15]. The epidural

3 5anaesthesia has allowed surgeons to perform numerous proce-

dures in thoracic surgery with patients awake and with minimal

sedation. However, major pulmonary resections (lobectomy or

pneumonectomy) are not possible without a MAC protocol

[37

, 43]. The combination of hypnotic drugs (mainly propofol) and

ultra-short action opioids (remifentanil) in a continuous perfusion

is indispensable because the epidural anaesthesia does not block

the phrenic nerve nor the vagus nerve, which are the main nerves

responsible for the cough reflex [42]. The peripheral manipulation

of the lung tissue does not produce a high degree of stimulation to

the vagus nerve, and for this reason, the peripheral resections of

small nodules or other minor resection are susceptible to be per-

formed in the patients awake. However, the bronchi and the

trachea can highly stimulate this nerve and their manipulation cangenerate haemodynamic effects and coughing, which can impede

the realization of the surgery. Apart from a deep sedation, the dif-

ferent groups that perform VATS lobectomies try to control the

cough reflex, either through intrathoracic vagus nerve infiltration

or pre-emptive inhalation of nebulization of lidocaine 2% for 30

min before surgery. In shorter procedures, an incremental intra-

venous remifentanil is applied in place of vagal block for the sake

of decreasing cough suppression duration. However, intrathoracic

vagal block is easily performed and comes with minimal secondary

effects [3, 36–

38]. Spontaneous ventilation in non-intubated

patients can be done with oxygen support through the use of afacial mask. With deeper sedation, supraglotic devices are well tol-

erated and useful, as nasopharyngeal tube or Guedel cannula, to

prevent positive pressure in the airway during the expiration and

to avoid the insuflation of the collapsed lung. Laryngeal mask can

be useful in selected patients. It can be a good alternative to facial

mask in case of deeper sedation, because it guarantees a

permeable airway before reaching the glottis. It allows spontan-

eous ventilation with monitoring ventilator pressure and volumes,

therefore reducing the risk of bronchoaspiration. Moreover, in

case of hypoxaemia or hypercapnia due to hypoventilation, we

can introduce ventilation with support pressure. A positive pres-sure of 5–8 mmHg is sufficient to improve the lung volumes in the

lung with spontaneous ventilation and non-intubated patient. It

even allows for the introduction of a bronchoscopy-guided endo-bronchial blockade in the operated lung while administering posi-

tive pressure with OLV and without intubation [

44].

We can conclude that, to perform a major pulmonary resection

in non-intubated patients, MAC is mandatory, due to the absence

of the phrenic and vagus nerve blockade. However, we do not

know if a minimal sedation in combination with epidural anaes-

thesia and the phrenic and vagus nerves blockade is enough. This

anaesthestic technique could provide a stress-free surgery, due to

the existence of a complete sensitive blockade of the whole in-

nervation of the thorax [45

].Nowadays, our team is introducing a new anaesthetic protocol

while aiming to perform a totally awake major thoracic surgery,

using epidural anaesthesia (level T –T

3 4

, sensitive blockade T –T

2 10

)

in combination with vagus and phrenic nerve blockades under

ultrasound control at the neck. In Table

2, we show the different

anaesthetic possibilities in non-intubated thoracic surgery both

from our point of view and through other published studies.

CONVERSION TO INTUBATED GENERAL

ANAESTHESIA

To ensure patient safety, a clearly defined protocol for elective or

urgent intubation must be determined prior to the operation.

Table 2: Anaesthesia techniques for VATS minor and major

pulmonary resections

Anaesthesia

technique

Minor resection Multiportal VATS Uniportal VATS

procedures

lobectomy

lobectomy

Local infiltration – intercostal block

Awake

+

− −

− −

Sedation

++

MAC

+++

++

+++

Paravertebral blockade

Awake

+

− −

Sedation

++

−

+

MAC

+++

++

+++

Epidural blockade

Awake

++

− −

Sedation

+++

+

++

MAC

+++

+++

+++

Epidural + nerve vagus blockade

Awake

N

− −

Sedation

N

+

++

MAC

N

+++

+++

Epidural + phrenic + vagus nerve blockade

Awake

N

?

?

Sedation

N

++

+++

MAC

N

+++

+++

Not recommended (−), possible (+), technical feasibility (++),

recommended (+++), not proved (?), not necessary (N)

MAC: monitored anaesthesia care.

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

724

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

Sometimes, intraoperative conversion to general anaesthesia is in- superiority of the awake thoracoscopic surgery in the treatment of

evitable and the surgical team must have a plan to minimize the

risk to the patient (Table

3). Intubation in the lateral decubitus

position is a technical challenge to anaesthesiologists. The anaes-

thesiologist must be skilled in placing a double-lumen tube, laryn-

geal mask, fibreoptic bronchoscopic intubation, video-assisted

system management and endobronchial blocker in order to se-

curely choose the most appropriate device depending on thepatient’s airway, the position of the patient, time of completion of

the procedure and the causes that have led to the conversion to

general anaesthesia.

In any case, continuous and effective communication between

surgical and anaesthetic teams is paramount.

FROM AWAKE MINOR PROCEDURES TO

NON-INTUBATED UNIPORTAL LOBECTOMIES

Awake or non-intubated surgical procedures must be divided in

minor procedures such as pleural, lung or mediastinal biopsies,

resections of peripheral nodules, thymectomies, lung volume re-

duction surgery and major anatomical pulmonary resections. A

summary of anaesthetic protocols employed in both awake and

non-intubated procedures as well as postoperative results from

different groups are given in Table

4.

Minor procedures

The most common thoracoscopic procedures reported in the litera-

ture performed under local anaesthesia or sedation have been for

the management of pleural effusions [60]ortalcpleurodesis[

46].

The first series of thoracoscopic pulmonary resections under

local anaesthesia were published in 1997, showing a low rate of

complications and shorter hospital stay [47]. Mukaida et al. [

48] perior in terms of the global in-operating theatre time, post-

reported several cases of VATS for pneumothorax under local and

epidural anaesthesia in 1998 in high-risk patients contraindicated

for general anaesthesia. In this publication, patients experienced

well-managed pain and cough reflex and well-maintained breath-

ing during the surgery.Pompeo and Mineo have been the most active team in awake

surgery for non-anatomic pulmonary resections. They showed the

pleural effusion [

61],pulmonary biopsies [54],mediastinal biopsies

[14], metastatic tumours

[15], spontaneous pneumothorax

[

62],

empyema thoracis [51] and emphysematous bulla including lung

volume reduction surgery [63].

In 2007, in a small randomized trial [50], these authors com-

pared VATS bullectomy and pleural abrasion performed in awake

patients with spontaneous pneumothorax and epidural anaesthe-

sia versus patients under general anaesthesia with OLV. Results of

this study have suggested that awake VATS bullectomy with pleural

abrasion was feasible and resulted in shorter hospital stay as well

as reduced procedure-related costs equal to procedures per-

formed under general anaesthesia.

Other non-intubated minor VATS procedures were also reported

by other authors to manage pericardial effusion [64] and hyperhi-

drosis [

65].

Resection of pulmonary nodulesMineo and Pompeo published exhaustive reviews describing the

state-of-the-art awake surgery for nodule resection and other

minor procedures [4, 66

, 67]. In these reviews, quicker recovery,

less morbidity and the possibility of offering surgery to very high-

risk patients for general anaesthesia are all shown. They also high-

light the potential impact of attenuation of the immune response

and the decreasing levels of hormones released by stress that

could lead to future oncological perspectives. They emphasize the

use of this technique when considering the development of fast-

track programmes and outpatient thoracic surgery.

In a randomized study performed by Pompeo et al.

[9], 60patients with pulmonary nodules were randomized to undergo

wedge resection through either non-intubation with epidural or

general anaesthesia with double-lumen intubation with epidural.

They concluded that the awake thoracoscopic approach was su-

operative recovery, need for nursing care and overall hospital stay

in comparison with the conventional thoracoscopic approach

under general anaesthesia. In the awake group, 47% of the patients

were discharged within the second postoperative day compared

with 17% of the patients in the general anaesthesia group.

Bilateral surgery can also be performed without intubation. Tsai

and Chen [

68], reported a case of bilateral resection with a non-

intubated thoracoscopic technique. It is logical to think that pro-

longed sequential single-lung breathing could lead to excessive

hypoxia and hypercapnia when major pulmonary resections are

needed, being feasible and well tolerated when performing a bi-

lateral wedge resection.

Other small series of patients show advantages of the non-

intubated procedures over conventional anaesthesia [

53, 69].

Thymectomy in myasthenic patients

In patients with myasthenia gravis, muscle relaxants are associated

with prolonged mechanical ventilation or reintubation. In

addition, risks of intubated general anaesthesia could be increased

when an anterior mediastinal mass compresses the airway after

the muscle relaxation. Several authors reported the feasibility of

and satisfactory results with awake VATS thymectomy, using

thoracic epidural anaesthesia and avoiding muscle relaxants

[

10

,

17

,

49

].

Table 3: Reasons for conversion to general anaesthesia

Surgical complications: major bleeding, strong pleural adhesions, large

tumours, lack of progress during the intervention related to the

surgeon’s thoracoscopic experience

Severe hypoxaemia (PaO <60%), hypercapnia (PaCO >80) and acidosis

2

2

(pH <7.1)

Haemodynamic instability: severe hypotension, cardiac index

decreased, intractable arrhythmias and right ventricular failure

Persistent cough that creates difficulty or prevents performing surgery

Excessive movement of the diaphragm or mediastinum, causing unsafe

surgery

Failure of regional block where MAC is insufficient and decreases the

safety of the procedure

Inability to collapse the lung: paradoxically maintained ventilation,

Positive end-expiratory pressure intrinsic, dynamic hyperinflation …

REVIEW

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

725

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

Table 4: Awake and non-intubated VATS minor and major pulmonary resections performed by different thoracic groups

Name of author Year of

publication of

Number Anaesthetic technique

patients

Epidural

Other blockades Oxygen

supplement

Surgical procedure

% conversion Days of HOS

to general

anaesthesia

(mean)

Main outcome

Tschopp [

46

]

1997

89

Local anaesthesia

No

Not reported

Spontaneous

pneumothorax (talc

insufflation)

0

5.2

9 redo procedures

reported

No mortality

Nezu [

47

]

1997

34

Local

anaesthesia + sedation

No

Nasal cannula

Spontaneous

pneumothorax (bleb

resection)

0

4.5

Minor morbidity: 3

patients (10%)

No mortality

Smit [81]

1998

45Local anaesthesia

No

Nasal cannula

Pleural diseases

0

4.1

No major

complications

No mortality

Mukaida [48]1998

4

Awake

Yes

Local anaesthesia Facial mask

Secondary

pneumothorax

surgery (only one bleb

resection)0

Not reported

No significant

postoperative

complicationsNo mortality

Tsunezuka [49]

2004

3

Awake

Yes

Local anaesthesia Room air or

(occasionally)

naso-oral

oxygen

Extended thymectomy

0Not reported

No postoperative

complications

No mortality

Pompeo [

9]

2004

30

Awake

Yes

Local anaesthesia Ventimask

(occasionally)

Wedge resections

6.7 (n = 2)

2

No mortality

Sakuraba [

82

]

2006

32

Local anaesthesia

No

Not reported

Tubercular effusions

0

Not reported

No major

complications

Mineo [

13

]

2006

12

Awake

Yes

Venturimask/face Non-resectional lung

volume reduction

surgery

8.3 (n = 1)

7.8

No mortality

Pompeo [

15

]

2007

14

Awake

Yes

Local anaesthesia Ventimask

(occasionally)

Thoracoscopic

metastasectomy

0

2.5

No major morbidity

No mortality

Pompeo [

50

]

2007

21

Awake

Yes

Local anaesthesia Not reported

(occasionally)

Spontaneous

pneumothorax

0

2

No significant

complications

No mortality

Al-Abdullatief

[

17

]

2007

79

Awake

Yes

Stellate ganglion Facemask

(occasionally)

Major and minor

resections

11 (n = 9)

1.5

2% hospital mortality

No operative

mortality

Katlic [

83

]

2010

353

Local anaesthesia +

sedation

No

Facemask

Minor thoracoscopic 0

procedures (including

lung biopsy and

pleural diseases)

Not reported

Morbidity: 3%

No mortality

Tacconi [

51

]

2010

19

Awake

Yes (15)

No (4)

Paravertebral

block (4)

Local anaesthesia

(occasionally)

Ventimask

Decortication for

empyema thoracis

0

6

No major morbidity

No mortality

Macchiarini [

11

] 2010

20

Awake

Yes

Automized local Facemask

anaesthesia

Tracheal resections

5 (n = 1)

3.1

No early

complications

Minor morbidity:

20%

Pompeo [

52

]

2011

41

Awake

Yes

Local anaesthesia Venturi mask face Non-resectional lung

(2)

volume reduction

surgery

4.9 (n = 2)

6

No mortality

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

726

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

Chen [

16

]

2011

30

Regional anaesthesia +

targeted sedation

Yes

Vagal blockade Ventilation mask

Thoracoscopic

lobectomies

10.0 (n = 3)

5.9

No mortality

Dong [

53]

2012

22

Regional anaesthesia +

targeted sedation

Yes

Vagal blockade Nasopharyngeal

airway and face

mask

VATS wedge resections

0

Not reported

Not reported

Tseng [84]

2012

46

Regional anaesthesia +

targeted sedation

Yes

Vagal blockade Ventilation mask

Needlescopic VATS for 4.3 (n = 2)

lung nodule surgery

(wedge resections)2.7

Minor morbidity:

8.7%

No mortality or

major

complicationsNoda [

85]

201215

Awake

Yes

Local anaesthesia Not reported

Secondary spontaneous 0

pneumothorax (blebresection and

abrasion)

2.6

4 patients with

prolonged

air-leaks

No mortality

Chen [5]

2012

285Regional anaesthesia +

targeted sedation

Yes

Vagal blockade Ventilation mask Major and minor

procedures

4.9 (n = 14)

Not reported

Postoperative

complications3.9%

No mortality

Pompeo [54]

2013

30Awake

Yes (20)

No (10)

Intercostal

blockade (10)

Venturi mask

(if needed)

Thoracoscopic lung

biopsy of interstitial

lung disease

0

1.4

One minor

complication

(3.3%)

No operative

mortality

Wu [55]

2013

36

Regional anaesthesia +

targeted sedation

Yes

Vagal blockade Ventilation mask

VATS lobectomies in

geriatric patients

2.8 (n = 1)

6.7

Postoperative

complications in

25%

No mortality

Chen [

56

]

2014

446

Regional anaesthesia +

targeted sedation

Yes (290)

No (156)

Vagal blockade

Intercostal

blockade (156)

Ventilation mask

Major and minor

procedures

3.6 (n = 16)

Not reported

Postoperative

complications

3.1%

No mortality

Hung [

57

]

2014

32

Regional anaesthesia + No

targeted sedation

Vagal blockade

Intercostal

blockade

Ventilation mask

Minor and major

(1 lobectomy)

3(n = 1)

3

Operative

complications 6%

Guo [

58

]

2014

15

Regional anaesthesia +

sedation

Yes

Vagal blockade Ventilation mask Anatomic

segmentectomies

0

5

Postoperative

complications in

13.4%

No mortality

Ambrogi [

59

]

2014

40

Awake

Yes (20)

No (20)

Intercostal

blockade (20)

Venturi mask

VATS biopsy of

interstitial lung

disease

5(n =1)

5(n =1)

3.7

3.0

Major morbidity 5%

per group (n =1)

No mortality

Gonzalez-Rivas

unpublished

2014

30

Regional or local

anaesthesia + targeted

sedation

No

Intercostal

blockade

Ventilation mask Major pulmonary

resections

2 (6.6%)

3

No mortality.

Postoperative

complications

10%

REVIEW

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

727

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

Emphysema and lung volume reduction surgery

Lung volume reduction surgery carries a high rate of complica-

tions. The use of lung resection techniques for emphysematous

patients under spontaneous ventilation is controversial. In 2006,

Mineo et al. [

13] published a novel technique to perform lung Stridor was noted in 3 patients and delirium in 4 in the intubated

volume reduction surgery in awake patients under thoracic epi-

dural anaesthesia. Their further studies included a randomized

trial showing that awake non-resectional lung volume reduction

surgery caused significantly more functional improvement, in-cluding an increase in several parameters of pulmonary function

tests. In comparison with conventional intubated general anaes-

thesia, durations of postoperative air leak and hospital stay were

significantly shorter in awake technique, while 3-year survival was

comparable [

52, 70].

Major anatomic pulmonary resections by

conventional video-assisted thoracoscopic surgery

There is an important difference between the performance of

minor procedures and anatomical resections in non-intubated intubated technique for anatomical segmentectomy with good

patients. The risk of a surgical complication during a wedge or

lung biopsy cannot be compared with the potential risk of major

bleeding in the pulmonary hilum during a lobectomy in a patient

with spontaneous ventilation. The performance of a lobectomy

with mediastinal lymph node dissection by VATS is usually asso-

ciated with longer operative time, frequent lung traction and hilar

manipulation, which can trigger cough reflex in awake patients.

thoracoscopic surgery

Rates of conversion to intubated general anaesthesia were reported

between 2.3 and 10.0%, depending on the type of procedure and

the experience of the team. Previous experience in VATS lobectomy

and minor awake thoracoscopic procedures is crucial.

To date, only four groups have reported results of major pul-

monary resections. Al-abdullatief et al. reported a series of 79

patients operated on with no intubation and epidural catheter,

with blockade of stellate ganglion. This series includes open pro-

cedures such as thoracotomies and sternotomies, VATS lobecto-

mies, thymectomies and even pneumonectomies but these

authors do not clearly describe which cases were performed by

VATS. They reported not negligible intraoperative complications

such as cardiac arrest or right ventricle opening and an 11% rate

of conversion to general anaesthesia. Only 5 patients went to the

intensive care unit and they conclude that this is a feasible and

safe technique reducing hospitalization and minimizing costs [17].

Chen et al. reported their initial experience with non-intubated

major resections in 2011. They used a three-port VATS technique

and epidural for pain control and ipsilateral intrathoracic vagal

block to control the cough reflex [16]. They concluded that non-

intubated VATS lobectomy and segmentectomy with mediastinal

lymphadenectomy for early stage non-small-cell lung cancer

could be safely performed [5].

The same group published the largest series of non-intubated

surgery, which included 446 patients within a period of 4 years

[56]. A total of 290 of the patients were controlled with epidural

and the rest with intercostal block. The median induction time

was 30 min with epidural and 10 min with intercostal block.

Reasons for conversion to general anaesthesia (3.6%) were exces-

sive mediastinal movement (7 patients), persistent hypoxaemia

(2 patients), severe adhesions (2 patients), ineffective epidural

(2 patients), bleeding (2 patients) and tachypnoea (1 patient). This

group also published several reviews about non-intubated major

and minor pulmonary resections [43].

In the study of Wu et al., the feasibility of non-intubated major

procedures in geriatric patients was studied. They compared 36

non-intubated cases with 48 patients under tracheal intubation.

group, but none occurred in the non-intubated group. Surgical op-

erative time and hospital stay showed similar results [55].

Recently, Liu et al. conducted a randomized trial with 354

patients, comparing the results of awake thoracoscopic surgery,

minor resections and lobectomy, versus those of a control group

treated under general anaesthesia with single-lung ventilation. In

their study, 174 patients underwent the awake approach, whilethe remaining 180 patients served as a control group. Seven (4%) of

the 174 subjects in the awake group required conversion to general

anaesthesia with single-lung ventilation. The authors demonstrated

that concentration of tumour necrosis factor-α level in the bronch-

oalveolar lavage fluid was lower and fasting time and duration

of postoperative antibiotics were shorter in a non-intubated

group. The rates of postoperative complications in the awake group

were significantly lower than those of the control group [

71].

Several authors published their experience with the non-

postoperative results [58,

72]. Most of the cases were early stage

tumours and the median hospital stay was 5 days.

Non-intubated uniportal video-assisted

In recent years, VATS has evolved from a multiport to a single inci-

sion approach, representing the least invasive way to operate on

lung pathologies. Uniportal or single incision VATS has been

shown to reduce postoperative pain, residual paresthesia and hos-

pital stay compared with conventional multiport VATS [

73, 74].

The choice of a single incision technique combined with the

avoidance of general anaesthesia could minimize even more the

invasiveness of the procedure. There are several case reports pub-

lished showing that non-intubated uniportal wedge resection can

be performed in an awake patient. Rocco et al. described the

awake technique of nodule resection, under mild sedation and

giving a single-shot epidural regional anaesthesia. Under guidance

provided by a bronchoscope, a Fogarty balloon was positioned to

occlude the lobar bronchus to facilitate collapse of the targeted

parenchyma [

75

]. Another case report published by the same

author includes a young patient operated on for pneumothorax,

using a similar technique, and noting that the patient could be dis-

charged on the first postoperative day [

41

].

Galvez et al. [

76

] describe a case of uniportal awake wedge re-

section under epidural anaesthesia in a patient with a previous

contralateral lobectomy with the aim to prevent mechanical ven-

tilation in the remaining lobe in the contralateral side.

Our group published the first non-intubated single port VATS

lobectomy in a patient with lung cancer, discharging the patient

36 h after the operation with excellent postoperative recovery.

For this first case, we used a laryngeal mask and sevofluorane but

now we manage the patients by using a facial mask, propofol and

remifentanil [

18

] (Fig.

1

;

Vid

eo

1

).

These non-intubated major pulmonary resections must only be

performed by very experienced uniportal thoracoscopic surgeons,

preferably skilled and experienced with complex or advanced

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

728

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

cases and bleeding control through uniportal VATS [

77, 78]. We

consider it very important to reduce the surgical and anaesthestic

trauma in high-risk patients for general intubated anaesthesia such

as elderly patients or those with poor pulmonary function [79

].

When performing a uniportal approach, we can easily apply

blockade of the single intercostal space under thoracoscopic view.

The importance of avoiding epidural thoracic blockade is obvious:

if we are able to control postoperative pain without opioids, it willresult in faster recovery and return to daily activities.

Recently, Ambrogi et al. compared interstitial biopsies under

uniportal VATS with intercostal block versus three-port VATS tech-

nique with epidural. They concluded that uniportal VATS biopsies

under intercostal block provide better intraoperative and post-

operative outcomes [59

].

Hung et al. reported a series of 32 patients with peripheral

nodules operated by uniportal VATS with no epidural, using a

combination of intercostal nerve block and intrathoracic vagal

block with bupivacaine. Within this group of patients, there was

only one major pulmonary resection attempted by single port, but it

was converted to a multiport VATS. Conversion to intubated general

anaesthesia was necessary in 1 patient (vigorous diaphragmatic and

mediastinal movement). Postoperative pain intensity was evaluated,

using a numeric pain intensity scale showing little pain [

57].

The same group also published an anatomical uniportal VATS

anterior segmentectomy in a patient with lung cancer. They used

intercostal and vagus blockade, a single incision and a wound pro-

tector, 5 mm 30° scope and endoscopic instruments [80].

Our initial experience with uniportal VATS major pulmonary

resections is promising (Table 4

). Most of the cases were lobecto-

mies for lung cancer (

Video

2

). The mean surgical time was

90.8 ± 22.3 min. Only 2 patients were converted to traditional

intubated surgery (6.6%): one because of bleeding controlled by

uniportal VATS, and the other because of excessive movement of

the diaphragm. These 2 cases were finished by uniportal VATS and

postoperative outcomes were satisfactory.

CONCLUSIONS

According to the literature and based on our experience, non-

intubated VATS major and minor resections are safe procedures,

technically feasible and successfully managed with facial mask, re-

gional anaesthesia and sedation. Patients remain stable intrao-

peratively, without severe hypoxemia or hypercapnia, coughing or

a decreased mediastinal shift throughout the operation.

Although the long-term benefits remain unclear, we suggest that

it can potentially be an attractive alternative of intubated one-lung

ventilated thoracoscopic surgery, especially for patients with high

risk for intubation. In a modern era of minimally invasive thoraco-

scopic procedures, adequate training of awake or non-intubated

VATS surgery will be essential. Uniportal VATS and non-intubated

spontaneous breathing represent a less invasive approach to con-

sider. This surgical and anaesthetic combination is on the fast track

to becoming an indispensable and fully reliable tool within thoracic

surgery programmes.

Conflict of interest: none declared.

REFERENCES

[1] Ng CS, Lau KK, Gonzalez-Rivas D, Rocco G. Evolution in surgical approach

and techniques for lung cancer. Thorax 2013;68:681.

[2] Toker A. Robotic thoracic surgery: from the perspectives of European

chest surgeons. J Thorac Dis 2014;6:211–6.

Video 1: Instrumentation during non-intubated uniportal VATS lobectomy.

Video 2: Non-intubated uniportal VATS left lower lobectomy.

Figure 1: Non-intubated uniportal video-assisted thoracoscopic lobectomy.

REVIEW

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

729

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

[3] Kao MC, Lan CH, Huang CJ. Anesthesia for awake video-assisted thoracic

surgery. Acta Anaesthesiol Taiwan 2012;50:126–30.

[4] Pompeo E, Mineo TC. Awake operative videothoracoscopic pulmonaryresections. Thorac Surg Clin 2008;18:311–20.

[5] Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoraco-

scopic lung resection: a 3-year experience with 285 cases in a single insti-

tution. J Thorac Dis 2012;4:347–51.

[6] Guedel AE, Waters R. A new intratracheal catheter. Anesth Analg 1928;7:238–39.

[7] Vischnevski AA. Local anesthesia in thoracic surgery: lungs, heart and

esophagus. Minerva Anestesiol 1954;20:432–5.

[8] Ossipov BK. Local anesthesia in thoracic surgery: 20 years experience with3265 cases. Anesth Analg 1960;39:327–32.

[9] Pompeo E, Mineo D, Rogliani P, Sabato AF, Mineo TC. Feasibility and

results of awake thoracoscopic resection of solitary pulmonary nodules.Ann Thorac Surg 2004;78:1761–8.

[10] Matsumoto I, Oda M, Watanabe G. Awake endoscopic thymectomy via an

infrasternal approach using sternal lifting. Thorac Cardiovasc Surg 2008;56:

311–3.

[11] Macchiarini P, Rovira I, Ferrarello S. Awake upper airway surgery. AnnThorac Surg 2010;89:387–90.

[12] Katlic MR. Video-assisted thoracic surgery utilizing local anesthesia and

sedation. Eur J Cardiothorac Surg 2006;30:529–32.

[13] Mineo TC, Pompeo E, Mineo D, Tacconi F, Marino M, Sabato AF. Awakenonresectional lung volume reduction surgery. Ann Surg 2006;243:131–6.

[14] Pompeo E, Tacconi F, Mineo TC. Awake video-assisted thoracoscopic

biopsy in complex anterior mediastinal masses. Thorac Surg Clin 2010;20:

225–33.

[15] Pompeo E, Mineo TC. Awake pulmonary metastasectomy. J Thorac

Cardiovasc Surg 2007;133:960–6.

[16] Chen JS, Cheng YJ, Hung MH, Tseng YD, Chen KC, Lee YC. Nonintubatedthoracoscopic lobectomy for lung cancer. Ann Surg 2011;254:1038–43.

[17] Al-Abdullatief M, Wahood A, Al-Shirawi N, Arabi Y, Wahba M, Al-Jumah M

et al. Awake anaesthesia for major thoracic surgical procedures: an obser-

vational study. Eur J Cardiothorac Surg 2007;32:346–50.

[18] Gonzalez-Rivas D, Fernandez R, de la Torre M, Rodriguez JL, Fontan L,

Molina F. Single-port thoracoscopic lobectomy in a nonintubated patient:

the least invasive procedure for major lung resection? Interact CardioVasc

Thorac Surg 2014;19:552–5.[19] Von Dossow V, Welte M, Zaune U, Martin E, Walter M, Ruckert J et al.

Thoracic epidural anesthesia combined with general anesthesia: the pre-

ferred anesthetic technique for thoracic surgery. Anesth Analg 2001;92:

848–54.

[20] Della Rocca G, Coccia C. Acute lung injury in thoracic surgery. Curr OpinAnaesthesiol 2013;26:40–6.

[21] Schilling T, Kozian A, Huth C, Buhling F, Kretzschmar M, Welte T et al. The

pulmonary immune effects of mechanical ventilation in patients undergo-

ing thoracic surgery. Anesth Analg 2005;101:957–65.[22] Gothard J. Lung injury after thoracic surgery and one-lung ventilation.

Curr Opin Anaesthesiol 2006;19:5–10.

[23] Munoz JF, Ibanez V, Real MI, Gonzalez O, Munoz P, German MJ et al.

High-frequency jet ventilation in thoracic surgery. Rev Esp AnestesiolReanim 1998;45:353–4.

[24] Fitzmaurice BG, Brodsky JB. Airway rupture from double-lumen tubes.J Cardiothorac Vasc Anesth 1999;13:322–9.

[25] Sessler DI, Sigl JC, Kelley SD, Chamoun NG, Manberg PJ, Saager L et al.

Hospital stay and mortality are increased in patients having a "triple low"

of low blood pressure, low bispectral index, and low minimum alveolar

concentration of volatile anesthesia. Anesthesiology 2012;116:1195–203.

[26] Murphy GS, Szokol JW, Avram MJ, Greenberg SB, Shear T, Vender JS et al.

Postoperative residual neuromuscular blockade is associated withimpaired clinical recovery. Anesth Analg 2013;117:133–41.

[27] Hausman MS Jr, Jewell ES, Engoren M. Regional versus general anesthesia

in surgical patients with chronic obstructive pulmonary disease: does

avoiding general anesthesia reduce the risk of postoperative complica-tions? Anesth Analg 2015;120:1405–12.

[28] Guldner A, Braune A, Carvalho N, Beda A, Zeidler S, Wiedemann B et al.

Higher levels of spontaneous breathing induce lung recruitment and

reduce global stress/strain in experimental lung injury. Anesthesiology

2014;120:673–82.

[29] Sinclair SE, Kregenow DA, Lamm WJ, Starr IR, Chi EY, Hlastala MP.

Hypercapnic acidosis is protective in an in vivo model of ventilator-induced lung injury. Am J Respir Crit Care Med 2002;166:403–8.

[30] Kregenow DA, Swenson ER. The lung and carbon dioxide: implications forpermissive and therapeutic hypercapnia. Eur Respir J 2002;20:6–11.

[31] Tacconi F, Pompeo E, Sellitri F, Mineo TC. Surgical stress hormones re-

sponse is reduced after awake videothoracoscopy. Interact CardioVascThorac Surg 2010;10:666–71.

[32] Vanni G, Tacconi F, Sellitri F, Ambrogi V, Mineo TC, Pompeo E. Impact of

awake videothoracoscopic surgery on postoperative lymphocyte

responses. Ann Thorac Surg 2010;90:973–8.

[33] Gottschalk A, Sharma S, Ford J, Durieux ME, Tiouririne M. Review article:

the role of the perioperative period in recurrence after cancer surgery.Anesth Analg 2010;110:1636–43.

[34] Grichnik KP, Clark JA. Pathophysiology and management of one-lung ven-

tilation. Thorac Surg Clin 2005;15:85–103.[35] Nagendran J, Stewart K, Hoskinson M, Archer SL. An anesthesiologist’s

guide to hypoxic pulmonary vasoconstriction: implications for managing

single-lung anesthesia and atelectasis. Curr Opin Anaesthesiol 2006;19:

34–43.[36] Yan TD. Video-assisted thoracoscopic lobectomy-from an experimental

therapy to the standard of care. J Thorac Dis 2013;5:175–6.

[37] Yan TD, Cao C, D’Amico TA, Demmy TL, He

J, Hansen H et al.

Video-assisted thoracoscopic surgery lobectomy at 20 years: a consensusstatement. Eur J Cardiothorac Surg 2014;45:633–9.

[38] Shaw JP, Dembitzer FR, Wisnivesky JP, Litle VR, Weiser TS, Yun J et al.

Video-assisted thoracoscopic lobectomy: state of the art and future direc-

tions. Ann Thorac Surg 2008;85:705–9.

[39] Mineo TC, Tacconi F. Nonintubated videothoracoscopic operations inthoracic oncology. J Surg 2014;10:22–30.

[40] Piccioni F, Langer M, Fumagalli L, Haeusler E, Conti B, Previtali P. Thoracic

paravertebral anaesthesia for awake video-assisted thoracoscopic surgery

daily. Anaesthesia 2010;65:1221–4.

[41] Rocco G, La Rocca A, Martucci N, Accardo R. Awake single-access (unipor-

tal) video-assisted thoracoscopic surgery for spontaneous pneumothorax.

J Thorac Cardiovasc Surg 2011;142:944–5.

[42] Inoue K, Moriyama K, Takeda J. Remifentanil for awake thoracoscopic bul-lectomy. J Cardiothorac Vasc Anesth 2010;24:386–7.

[43] Hung MH, Hsu HH, Cheng YJ, Chen JS. Nonintubated thoracoscopic

surgery: state of the art and future directions. J Thorac Dis 2014;6:2–9.

[44] Arevalo Ludena J, Arcas Bellas JJ, Lopez Perez V, Cuarental Garcia A,

Alvarez-Rementeria Carbonell R. Placement of a bronchial blocker

through the I-gel supraglottic airway device for single-lung ventilation:preliminary study. Rev Esp Anestesiol Reanim 2010;57:532–5.

[45] Ihn CH, Joo JD, Choi JW, Kim DW, Jeon YS, Kim YS et al. Comparison of

stress hormone response, interleukin-6 and anaesthetic characteristics of

two anaesthetic techniques: volatile induction and maintenance of anaes-

thesia using sevoflurane versus total intravenous anaesthesia using propo-

fol and remifentanil. J Int Med Res 2009;37:1760–71.

[46] Tschopp JM, Brutsche M, Frey JG. Treatment of complicated spontaneous

pneumothorax by simple talc pleurodesis under thoracoscopy and local

anaesthesia. Thorax 1997;52:329–32.

[47] Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Thoracoscopic

wedge resection of blebs under local anesthesia with sedation for treat-

ment of a spontaneous pneumothorax. Chest 1997;111:230–5.

[48] Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation

for secondary pneumothorax under local and epidural anesthesia in high-

risk patients. Ann Thorac Surg 1998;65:924–6.

[49] Tsunezuka Y, Oda M, Matsumoto I, Tamura M, Watanabe G. Extended

thymectomy in patients with myasthenia gravis with high thoracic

epidural anesthesia alone. World J Surg 2004;28:962–5; discussion

65–6.

[50] Pompeo E, Tacconi F, Mineo D, Mineo TC. The role of awake

video-assisted thoracoscopic surgery in spontaneous pneumothorax.

J Thorac Cardiovasc Surg 2007;133:786–90.

[51] Tacconi F, Pompeo E, Fabbi E, Mineo TC. Awake video-assisted pleural de-

cortication for empyema thoracis. Eur

594–601.

J Cardiothorac Surg 2010;37:

[52] Pompeo E, Tacconi F, Mineo TC. Comparative results of non-resectional

lung volume reduction performed by awake or non-awake anesthesia. Eur

J Cardiothorac Surg 2011;39:51–8.

[53] Dong Q, Liang L, Li Y, Liu J, Yin W, Chen H et al. Anesthesia with nontra-

cheal intubation in thoracic surgery. J Thorac Dis 2012;4:126–30.

[54] Pompeo E, Rogliani P, Cristino B, Schillaci O, Novelli G, Saltini C. Awake

thoracoscopic biopsy of interstitial lung disease. Ann Thorac Surg 2013;95:

445–52.

[55] Wu CY, Chen JS, Lin YS, Tsai TM, Hung MH, Chan KC et al. Feasibility and

safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer

patients. Ann Thorac Surg 2013;95:405–11.

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

730

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017

[56] Chen KC, Cheng YJ, Hung MH, Tseng YD, Chen JS. Nonintubated thoraco-

scopic surgery using regional anesthesia and vagal block and targeted sed-

ation. J Thorac Dis 2014;6:31–6.

[57] Hung MH, Cheng YJ, Chan KC, Han SC, Chen KC, Hsu HH et al.

Nonintubated uniportal thoracoscopic surgery for peripheral lungnodules. Ann Thorac Surg 2014;98:1998–2003.

[58] Guo Z, Shao W, Yin W, Chen H, Zhang X, Dong Q et al. Analysis of feasibil-

ity and safety of complete video-assisted thoracoscopic resection of ana-

tomic pulmonary segments under non-intubated anesthesia. J Thorac Dis

2014;6:37–44.

[59] Ambrogi V, Mineo TC. VATS biopsy for undetermined interstitial lungdisease under non-general anesthesia: comparison between uniportal ap-

proach under intercostal block vs. three-ports in epidural anesthesia.

J Thorac Dis 2014;6:888–95.

[60] Alrawi SJ, Raju R, Acinapura AJ, Cunningham JN Jr., Cane JS. Primary thora-

coscopic evaluation of pleural effusion with local anesthesia: an alternativeapproach. JSLS 2002;6:143–7.

[61] Pompeo E, Dauri M, Awake Thoracic Surgery Research G. Is there any

benefit in using awake anesthesia with thoracic epidural in thoracoscopic

talc pleurodesis? J Thorac Cardiovasc Surg 2013;146:495–7.e1.

[62] Mineo TC, Ambrogi V. Awake thoracic surgery for secondary spontaneous

pneumothorax: another advancement. J Thorac Cardiovasc Surg 2012;

144:1533–4.

[63] Pompeo E, Rogliani P, Tacconi F, Dauri M, Saltini C, Novelli G et al.

Randomized comparison of awake nonresectional versus nonawake resec-

tional lung volume reduction surgery. J Thorac Cardiovasc Surg 2012;143:47–54.

[64] Guarracino F, Gemignani R, Pratesi G, Melfi F, Ambrosino N. Awake

palliative thoracic surgery in a high-risk patient: one-lung, non-invasive

ventilation combined with epidural blockade. Anaesthesia 2008;63:

761–3.

[65] Elia S, Guggino G, Mineo D, Vanni G, Gatti A, Mineo TC. Awake one stage

bilateral thoracoscopic sympathectomy for palmar hyperhidrosis: a safe

outpatient procedure. Eur J Cardiothorac Surg 2005;28:312–7.

[66] Pompeo E. Awake thoracic surgery-is it worth the trouble? Semin ThoracCardiovasc Surg 2012;24:106–14.

[67] Pompeo E. Awake Thoracic Surgery. In: Publishers BS, (ed). Bentham

eBooks, 2012:212.

[68] Tsai TM, Chen JS. Nonintubated thoracoscopic surgery for pulmonarylesions in both lungs. J Thorac Cardiovasc Surg 2012;144:95–7.

[69] AmbrogiMC, Fanucchi O, Korasidis S, Davini F, Gemignani R, Guarracino F

et al. Nonintubated thoracoscopic pulmonary nodule resection under

spontaneous breathing anesthesia with laryngeal mask. Innovations 2014;

9:276–80.

[70] Tacconi F, Pompeo E, Mineo TC. Duration of air leak is reduced after

awake nonresectional lung volume reduction surgery. Eur J CardiothoracSurg 2009;35:822–8; discussion 28.

[71] Liu J, Cui F, Li S, Chen H, Shao W, Liang L et al. Nonintubated

video-assisted thoracoscopic surgery under epidural anesthesia compared

with conventional anesthetic option: a randomized control study. SurgInnov 2015;22:123–30.

[72] Hung MH, Hsu HH, Chen KC, Chan KC, Cheng YJ, Chen JS. Nonintubated

thoracoscopic anatomical segmentectomy for lung tumors. Ann ThoracSurg 2013;96:1209–15.

[73] Jutley RS, KhalilMW, Rocco G. Uniportal vs standard three-port VATS tech-

nique for spontaneous pneumothorax: comparison of post-operative pain

and residual paraesthesia. Eur J Cardiothorac Surg 2005;28:43–6.

[74] Chen PR, Chen CK, Lin YS, Huang HC, Tsai JS, Chen CY et al. Single-incision thoracoscopic surgery for primary spontaneous pneumothorax.

J Cardiothorac Surg 2011;6:58.

[75] Rocco G, Romano V, Accardo R, Tempesta A, La Manna C, La Rocca A et al.

Awake single-access (uniportal) video-assisted thoracoscopic surgery for

peripheral pulmonary nodules in a complete ambulatory setting. Ann

Thorac Surg 2010;89:1625–7.

[76] Galvez C, Bolufer S, Navarro-Martinez

J, Lirio F. Awake uniportal

video-assisted thoracoscopic metastasectomy after a nasopharyngeal car-cinoma. J Thorac Cardiovasc Surg 2014;147:24–6.

[77] Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez

L et al. Uniportal video-assisted thoracoscopic lobectomy: two years of ex-perience. Ann Thorac Surg 2013;95:426–32.

[78] Gonzalez D, Paradela M, Garcia J, Dela Torre M. Single-port video-assistedthoracoscopic lobectomy. Interact CardioVasc Thorac Surg 2011;12:514–5.

[79] Gonzalez-Rivas D, Fernandez R. Single port video-assisted thoracoscopic

lobectomy under spontaneous ventilation in a high risk patient.

CTSNet

2014.

http://www.ctsnet.org/article/single-portvideo-assis

ted-

thoracoscopic-lobectomy-un

der-spontaneous-ventilationhigh-risk

(18

November 2014, date last accessed).

[80] Hung MH, Cheng YJ, Hsu HH, Chen JS. Nonintubated uniportal thoraco-scopic segmentectomy for lung cancer. J Thorac Cardiovasc Surg 2014;

148:234–5.

[81] Smit HJ, Schramel FM, Sutedja TG, Ter Laak-Uytenhaak LS, Nannes-Pols

MHPostmus PE. Video-assisted thoracoscopy is feasible under local anes-thesia. Diagn Ther Endosc 1998;4:177–82.

[82] Sakuraba M, Masuda K, Hebisawa A, Sagara Y, Komatsu H. Thoracoscopic

pleural biopsy for tuberculous pleurisy under local anesthesia. Ann Thorac

Cardiovasc Surg 2006;12:245–8.

[83] Katlic MR, Facktor MA. Video-assisted thoracic surgery utilizing local anes-thesia and sedation: 384 consecutive cases. Ann Thorac Surg 2010;90:240–5.

[84] Tseng YD, Cheng YJ, Hung MH, Chen KC, Chen JS. Nonintubated

needlescopic video-assisted thoracic surgery for management of

peripheral lung nodules. Ann Thorac Surg 2012;93:1049–54.

[85] Noda M, Okada Y, Maeda S, Sado T, Sakurada A, Hoshikawa Y et al. Is

there a benefit of awake thoracoscopic surgery in patients with secondary

spontaneous pneumothorax?. J Thorac Cardiovasc Surg 2012;143:613–6.

REVIEW

D. Gonzalez-Rivas et al. / European Journal of Cardio-Thoracic Surgery

731

Downloaded from https://academic.oup.com/ejcts/article-abstract/49/3/721/2465113/Non-intubated-video-assisted-thoracoscopic-lung

by guest

on 27 September 2017