Nonintubated uniportal VATS pulmonary anatomical resections

Abstract

Nonintubated procedures have widely developed during the last years, thus nowadays major anatomical resections are performed in spontaneously breathing patients in some centers. In an attempt for combining less invasive surgical approaches with less aggressive anesthesia, nonintubated uniportal video-assisted thoracic surgery (VATS) lobectomies and segmentectomies have been proved feasible and safe, but there are no comparative trials and the evidence is still poor. A program in nonintubated uniportal major surgery should be started in highly experienced units, overcoming first a learning period performing minor procedures and a training program for the management of potential crisis situations when operating on these patients. A multidisciplinary approach including all the professionals in the operating room (OR), emergency protocols and a comprehensive knowledge of the special physiology of nonintubated surgery are mandatory. Some concerns about regional analgesia, vagal block for cough reflex control and oxygenation techniques, combined with some specific surgical tips can make safer these procedures. Specialists must remember an essential global concept: all the efforts are aimed at decreasing the invasiveness of the whole procedure in order to benefit patients' intraoperative status and postoperative recovery.

Keywords: Thoracoscopy/video-assisted thoracic surgery (VATS); anesthesia; lung cancer surgery.

Figure 1

Position of the patient during lateral decubitus intubation: neutral position, using a couple of surgical pillows and an occipital support to prevent the head going backwards during the laryngoscopy.

Figure 2

Flowchart of anesthesia during nonintubated uniportal VATS procedures. OR, operating room; VATS, video-assisted thoracic surgery. *, arterial gases recommended.

Figure 3

Routine monitoring during nonintubated uniportal anatomical resections: electrocardiogram, blood pressure, heart and respiratory rate, pulse-oximetry, bispectral index (BIS) monitoring.

Figure 4

Epidural catheter placement during thoracic surgery

Figure 5

Intercostal multiple block with local anesthesia with direct thoracoscopic view (27). Available online: http://www.asvide.com/articles/1679

Figure 6

Oxygenation devices used during nonintubated procedures: from left to right on the top, nasal prongs, facial mask, high-flow oxygen nasal prongs. At the bottom, oropharyngeal cannula.

Figure 7

Oropharyngeal cannula in the setting-up of a nonintubated uniportal VATS right-upper lobectomy.

Figure 8

Vagal block with local anesthesia, performed in the right lower paratracheal area or in the left aortopulmonary window (29). Bupivacaine 0.5% is commonly used due to the duration of the effect. Available online: http://www.asvide.com/articles/1680

Figure 9

Nonintubated uniportal VATS right-upper lobectomy plus lymphadenectomy in early stage lung adenocarcinoma (30). Available online: http://www.asvide.com/articles/1681

Figure 10

Nonintubated uniportal VATS left-lower lobe upper segmentectomy (S6) due to a colorectal carcinoma metastasis (31). Available online: http://www.asvide.com/articles/1682

Figure 11

Emergency Table elements: the picture shows the required elements for management of a crisis during nonintubated uniportal VATS anatomical resections, as detailed in Table 3.