PP37 - Nonintubated video-assisted thoracoscopic surgery: a report of five cases

Abstract

In recent years, the performance of nonintubated video-assisted thoracoscopic surgery (NIVATS) has been expanding. It consists of video-assisted thoracoscopic surgery (VATS) under regional anaesthesia, with the patient awake or under sedation and with spontaneous ventilation. Its use is accepted to carry out simple interventions (drainage of pleural effusion, pneumothorax surgery or atypical lung resections), and aims to avoid the adverse effects of general anaesthesia and to accelerate postoperative recovery. We report the first 5 cases of patients undergoing NIVATS in our hospital. Five patients were selected for NIVATS, four men and one woman, aged between 31 and 72 years old. The selection of the patients excluded patient who were obese, predictors of a difficult airway, sleep apnoea syndrome and altered coagulation. Pulse oximetry, non-invasive blood pressure and electrocardiogram were monitored. In all patients, a thoracic epidural catheter was placed at T5-T6 level and 0.25% levobupivacaine was administered in bolus at doses of 8-10 ml h-1. Intravenous sedation was administered to achieve a 3-4 sedation level on the Ramsay scale. Remifentanil 0.05-0.1 μg kg-1 min-1 was used in all patients. In addition, propofol 2-3 mg kg-1 h-1 was used in three patients and the other two patients received dexmedetomidine 0.4-0.6 μg kg-1 h-1. Oxygen was administered through a face mask The interventions were performed by uniportal thocacoscopy. In three patients, lung biopsy was performed for the diagnosis of diffuse interstitial lung disease, and the other two patients underwent solitary pulmonary nodule resection. All patients adequately tolerated thoracoscopy in spontaneous ventilation, without refer pain or discomfort. Pulmonary collapse and vision were adequate in all cases. The intervention could be performed without any incident in all but one patient, in which conversion to general anaesthesia was necessary due to the difficulty in locating the nodule. Epidural anesthesia in NIVATS provides satisfactory analgesia of the chest wall and the parietal pleura. However, manipulation of the visceral pleura and hilar structures can trigger the cough reflex. In this case, some authors recommend the anaesthetic blockade of the vagus nerve at the intrathoracic level. In our patients there was no cough that interfered with the surgical procedure, and no blockage of the vagus nerve was required. The need to convert NIVATS to general anaesthesia ranges from 2.3% to 10% depending on the type of procedure and the experience, and may occur due to bleeding, presence of pleural adhesions, severe hypercapnia, insufficient pulmonary collapse and difficulties to perform the surgical technique. We had to perform general anaesthesia in one of the patients due to an inadequate visualisation of the pulmonary nodule. NIVATS is safe and feasible in simple interventions such as lung biopsies or atypical resections. Adequate patient selection is necessary.