Nonintubated thoracoscopic surgery: state of the art and future directions

Video-assisted thoracoscopic surgery (VATS) has become a common and globally accepted surgical approach for a variety of thoracic diseases. Conventionally, it is performed under tracheal intubation with double lumen tube or bronchial blocker to achieve single lung ventilation. Recently, VATS without tracheal intubation were reported to be feasible and safe in a series of VATS procedures, including management of pneumothorax, wedge resection of pulmonary tumors, excision of mediastinal tumors, lung volume reduction surgery, segmentectomy, and lobectomy. Patients undergoing nonintubated VATS are anesthetized using regional anesthesia in a spontaneously single lung breathing status after iatrogenic open pneumothorax. Conscious sedation is usually necessary for longer and intensively manipulating procedures and intraoperative cough reflex can be effectively inhibited with intrathoracic vagal blockade on the surgical side. The early outcomes of nonintubated VATS include a faster postoperative recovery and less complication rate comparing with its counterpart of intubated general anesthesia, by which may translate into a fast track VATS program. The future directions of nonintubated VATS should focus on its long-term outcomes, especially on oncological perspectives of survival in lung cancer patients. For now, it is still early to conclude the benefits of this technique, however, an educating and training program may be needed to enable both thoracic surgeons and anesthesiologists providing an alternative surgical option in their caring patients.