Non-intubated Thoracoscopic Surgery-Tips and Tricks From Anesthesiological Aspects: A Mini Review.

Csongor Fabo,Theodor Horvath,Judit Lantos,Tibor Nemeth,Adam Oszlanyi,Zsanett Barta,Ferenc Rarosi,Zsolt Szabo

doi:10.3389/fsurg.2021.818456

Abstract

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.

Highlights

In the last few decades, the focus of clinicians has shifted from invasive procedures to minimally invasive techniques, as video-assisted, preferably uniportal, thoracoscopic technique has become the gold standard for major pulmonary resections [1– 4]
We 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 OR OR OR] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms
A non-randomized comparative study published in 2007 with 14 involved patients for single metastasis removal performed under sole thoracic epidural anesthesia with “Ventimask” to provide oxygen supplementation reported a shorter operative and global operating room time and shorter hospital stay

Summary

Introduction

In the last few decades, the focus of clinicians has shifted from invasive procedures to minimally invasive techniques, as video-assisted, preferably uniportal, thoracoscopic technique has become the gold standard for major pulmonary resections [1– 4]. With this surgical development, anesthesia underwent a paradigm shift. 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)

Methods

Results

Conclusion