Single-port thoracoscopic lobectomy in a nonintubated patient: the least invasive procedure for major lung resection?

General anaesthesia with single-lung ventilation was always considered a condition for thoracoscopic major pulmonary resections. However, nonintubated thoracoscopic lobectomy has been reported recently by using conventional video-assisted thoracoscopic surgery (VATS), epidural anaesthesia and vagus blockade. Here, we present a technique that reduces the surgical access trauma even more: single-incision VATS approach with no need for epidural or vagus blockade in a nonintubated patient.

A 46-year old male smoker was admitted to our department for surgery. A computed tomography scan revealed a 1.5-cm nodule in the right middle lobe. A positron emission tomography scan demonstrated uptake (5.4 SUV) with no lymph node involvement. The patient was proposed for nonintubated uniportal VATS surgery. The patient received intramuscular midazolam and atropine 30 min before anaesthesia. No epidural catheter was placed. A laryngeal mask was used to control the airway and for oxygen inhalation. Sevoflurane gas and continued perfusion of remifentanil were administered for sedation. The patient was positioned in a left lateral decubitus position. The skin and the fifth intercostal space were infiltrated with levobupivacaine.

A VATS approach through a single 2.5-cm incision was made at the level of the fifth intercostal space on the right side. No intrathoracic vagus blockade was necessary. A wedge resection of a 1.5-cm tumour on the middle lobe was performed. The frozen section confirmed a carcinoid tumour and so a middle lobectomy and a lymph node dissection were completed. The total surgical time was 80 min. The chest tube was removed within the next 16 h and the patient was discharged home 36 h after the operation.

Single-port video-assisted thoracoscopic lobectomy in nonintubated patients seems to be feasible and safe, and probably represents the least invasive approach to lobectomy. Further studies are necessary to evaluate the results with a series of patients.