JoVE Logo
Faculty Resource Center

Sign In

Summary

Abstract

Introduction

Protocol

Representative Results

Discussion

Acknowledgements

Materials

References

Medicine

Non-Intubated Video-Assisted Thoracoscopic Surgery

Published: May 26th, 2023

DOI:

10.3791/65235

1Department of Anesthesia, Second Affiliated Hospital of Zhejiang University School of Medicine, 2Department of Anesthesia, The First Affiliated Hospital of Ningbo University, 3Health Science Center, Ningbo University
* These authors contributed equally

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

In the past decade, non-intubated video-assisted thoracic surgery (NIVATS) anesthesia has gradually been accepted in clinical practice1,2,3. Although this novel strategy enhances the rapid recovery of patients and avoids the complications of general anesthesia (GA) and one-lung ventilation4, many surgeons regard this approach as less desirable than the traditional lung isolation technique.

Blood oxygen levels decline with age, and some patients may have decreased or borderline pulmonary function. GA may be associated with an....

Log in or to access full content. Learn more about your institution’s access to JoVE content here

The study was approved by the Ethics Committee of the Affiliated Hospital of Ningbo University School of Medicine (KY20181215) on December 10, 2018.

1. Inclusion criteria

  1. Include all patients (aged >18 years) undergoing pulmonary bullae resection, pulmonary wedge resection, or lobectomy.

2. Exclusion criteria

  1. Exclude patients based on an American Society of Anesthesiologists (ASA) physical status c.......

Log in or to access full content. Learn more about your institution’s access to JoVE content here

Clinical data were retrospectively collected on 58 consecutive patients undergoing non-intubated video-assisted thoracoscopic surgery from January 2016 to December 2022. The patients were given a preoperative visit by the anesthesiologist and provided with a detailed explanation of the contents of the anesthesia informed consent form prior to the anesthesia. The patients were allowed to choose one of the two groups (the NIVATS group or GA group) of anesthesia, and they signed an informed consent form.

Log in or to access full content. Learn more about your institution’s access to JoVE content here

The advantages of this protocol are as follows: (i) providing a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery; (ii) minimizing over-sedation while providing a safe and pain-free operating environment for patients undergoing thoracic surgery; (iii) minimizing the patient's spontaneous breathing and mediastinal oscillations during the procedure, taking into account the associated technical challenges. This was achieved by providing pre-emptive intraoperative local ane.......

Log in or to access full content. Learn more about your institution’s access to JoVE content here

This work was supported by the third batch of the Ningbo Health Youth Technical Cadre program (Dr. Binbin Zhu), and the Zhejiang Medical Association Clinical Research Fund Project (Dr. Bin Gao) (2018ZYC-A66).

....

Log in or to access full content. Learn more about your institution’s access to JoVE content here

Name Company Catalog Number Comments
20-G top-winged infusion needle BD Intima II 383012 Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.
24-G top-winged infusion needle BD Intima II 383033 Thoracoscopic vagal block techniques
Anesthesia machine Drager A300 Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate
Atropine Jiuquan Dadeli Pharma H62020772 Control of heart rate
BIS COVIDIEN B277243 Monitor the level of consciousness
Disposable nerve block needle Tuoren Medical Device  202303007 Nerve block
Facial mask Emedica EM01-105S Provides an effective non-invasive breathing circuit
Fentanyl. Renfu Pharma 21D04021 Analgesia
Flurbiprofen Daan Pharma H20183054 Analgesia
Laryngeal mask  Ambu Aura-i 2012-2664652 Airway management to preserve voluntary breathing
Levobupivacaine Rundu Pharma H20050403 Local Anaesthesia
Lidocaine Kelun Pharma F221129C Local skin infiltration
Norepinephrine Lijun Pharma H61021666 Control of blood pressure
Portable color doppler ultrasound SonoSite M-Turbo Guided nerve block
Propofol Guorui Pharma H20030114 Sedation and hypnosis
Ropivacaine Aspen Pharma 6091403219940 Paravertebral nerve block
Saline Kelun Pharma c221201E1 Assisted subsonic localisation
Sevoflurane  Shanghai Hengrui Pharmaceutical Co.,Ltd 9081931 Anesthesia induction and maintenance
Sufentanil Jiangsu Enhua Pharmaceutical Co., Ltd H20203650 Postoperative analgesia

  1. Sedrakyan, A., vander Meulen, J., Lewsey, J., Treasure, T. Video assisted thoracic surgery for treatment of pneumothorax and lung resections: Systematic review of randomised clinical trials. British Medical Journal. 329 (7473), 1008 (2004).
  2. Luh, S. P., Liu, H. P. Video-assisted thoracic surgery--The past, present status and the future. Journal of Zhejiang University Science B. 7 (2), 118-128 (2006).
  3. Hung, M. H., Hsu, H. H., Cheng, Y. J., Chen, J. S. Nonintubated thoracoscopic surgery: State of the art and future directions. Journal of Thoracic Disease. 6 (1), 2-9 (2014).
  4. Kelkar, K. V. Post-operative pulmonary complications after non-cardiothoracic surgery. Indian Journal of Anaesthesia. 59 (9), 599-605 (2015).
  5. Knoll, H., et al. Airway injuries after one-lung ventilation: A comparison between double-lumen tube and endobronchial blocker: a randomized, prospective, controlled trial. Anesthesiology. 105 (3), 471-477 (2006).
  6. Zhong, T., Wang, W., Chen, J., Ran, L., Story, D. A. Sore throat or hoarse voice with bronchial blockers or double-lumen tubes for lung isolation: a randomised, prospective trial. Anaesthesia and Intensive. 37 (3), 441-446 (2009).
  7. Mikuni, I., et al. Arytenoid cartilage dislocation caused by a double-lumen endobronchial tube. British Journal of Anaesthesia. 96 (1), 136-138 (2006).
  8. Kurihara, N., et al. Hoarseness caused by arytenoid dislocation after surgery for lung cancer. General Thoracic and Cardiovascular Surgery. 62 (12), 730-733 (2014).
  9. Ceylan, K. C., et al. Intraoperative management of tracheobronchial rupture after double-lumen tube intubation. Surgery Today. 43 (7), 757-762 (2013).
  10. Yu, M. G., et al. Non-intubated anesthesia in patients undergoing video-assisted thoracoscopic surgery: A systematic review and meta-analysis. PloS One. 14 (11), (2019).
  11. Ambrogi, V., Sellitri, F., Perroni, G., Schillaci, O., Mineo, T. C. Uniportal video-assisted thoracic surgery colorectal lung metastasectomy in non-intubated anesthesia. Journal of Thoracic Disease. 9 (2), 254-261 (2017).
  12. Guo, Z., et al. Video-assisted thoracoscopic surgery segmentectomy by non-intubated or intubated anesthesia: A comparative analysis of short-term outcome. Journal of Thoracic Disease. 8 (3), 359-368 (2016).
  13. Liu, J., et al. The impact of non-intubated versus intubated anaesthesia on early outcomes of video-assisted thoracoscopic anatomical resection in non-small-cell lung cancer: A propensity score matching analysis. European Journal of Cardio-Thoracic Surgery. 50 (5), 920-925 (2016).
  14. Hausman, M. S., Jewell, E. S., Engoren, M. Regional versus general anesthesia in surgical patients with chronic obstructive pulmonary disease: Does avoiding general anesthesia reduce the risk of postoperative complications. Anesthesia and Analgesia. 120 (6), 1405-1412 (2015).
  15. Grott, M., et al. Thoracic surgery in the non-intubated spontaneously breathing patient. Respiratory Research. 23 (1), (2022).
  16. Hung, M. H., et al. Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation. European Journal of Cardio-Thoracic Surgery. 46 (4), 620-625 (2014).
  17. Guo, Z., et al. Analysis of feasibility and safety of complete video-assisted thoracoscopic resection of anatomic pulmonary segments under non-intubated anesthesia. Journal of Thoracic Disease. 6 (1), 37-44 (2014).
  18. Jammer, I., et al. Standards for definitions and use of outcome measures for clinical effectiveness research in perioperative medicine: European Perioperative Clinical Outcome (EPCO) definitions: a statement from the ESA-ESICM joint taskforce on perioperative outcome measures. European Journal of Anaesthesiology. 32 (2), 88-105 (2015).
  19. Pompeo, E., Mineo, D., Rogliani, P., Sabato, A. F., Mineo, T. C. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. The Annals of Thoracic Surgery. 78 (5), 1761-1768 (2004).
  20. Ali, J. M., Volpi, S., Kaul, P., Aresu, G. Does the 'non-intubated' anaesthetic technique offer any advantage for patients undergoing pulmonary lobectomy. Interactive Cardiovascular and Thoracic Surgery. 28 (4), 555-558 (2019).
  21. Okuda, K., Nakanishi, R. The non-intubated anesthesia for airway surgery. Journal of Thoracic Disease. 8 (11), 3414-3419 (2016).
  22. Prince, J., Goertzen, C., Zanjir, M., Wong, M., Azarpazhooh, A. Airway complications in intubated versus laryngeal mask airway-managed dentistry: A meta-analysis. Anesthesia Progress. 68 (4), 193-205 (2021).
  23. Amer, G. F., Abdeldayem, O. T., Lahloub, F. M. F. Effect of local anesthesia and general anesthesia using I-gel laryngeal mask airway in diabetic patients undergoing cataract surgery: Comparative study. Anesthesia, Essays and Researches. 13 (2), 209-213 (2019).
  24. Sorbello, M., Afshari, A., De Hert, S. Device or target? A paradigm shift in airway management: Implications for guidelines, clinical practice and teaching. European Journal of Anaesthesiology. 35 (11), 811-814 (2018).
  25. Yamaguchi, T., et al. Feasibility of total intravenous anesthesia by cardiologists with the support of anesthesiologists during catheter ablation of atrial fibrillation. Journal of Cardiology. 72 (1), 19-25 (2018).
  26. Koyama, T., et al. Laryngeal mask versus facemask in the respiratory management during catheter ablation. BMC Anesthesiology. 20 (1), (2020).
  27. Qamarul Hoda, ., Samad, M., Ullah, K., H, ProSeal versus Classic laryngeal mask airway (LMA) for positive pressure ventilation in adults undergoing elective surgery. The Cochrane Database of Systematic Reviews. 7 (7), (2017).
  28. van Esch, B. F., Stegeman, I., Smit, A. L. Comparison of laryngeal mask airway vs tracheal intubation: A systematic review on airway complications. Journal of Clinical Anesthesia. 36, 142-150 (2017).
  29. Vanni, G., et al. Impact of awake videothoracoscopic surgery on postoperative lymphocyte responses. The Annals of Thoracic Surgery. 90 (3), 973-978 (2010).
  30. Liu, J., et al. Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study. Surgical Innovation. 22 (2), 123-130 (2015).
  31. Tacconi, F., Pompeo, E., Sellitri, F., Mineo, T. C. Surgical stress hormones response is reduced after awake videothoracoscopy. Interactive Cardiovascular and Thoracic Surgery. 10 (5), 666-671 (2010).
  32. Lai, H. C., et al. Sevoflurane is an effective adjuvant to propofol-based total intravenous anesthesia for attenuating cough reflex in nonintubated video-assisted thoracoscopic surgery. Medicine. 97 (42), (2018).
  33. Navarro-Martínez, J., et al. Intraoperative crisis resource management during a non-intubated video-assisted thoracoscopic surgery. Annals of Translational Medicine. 3 (8), 111 (2015).
  34. Melnyk, V., Ibinson, J. W., Kentor, M. L., Orebaugh, S. L. Updated retrospective single-center comparative analysis of peripheral nerve block complications using landmark peripheral nerve stimulation versus ultrasound guidance as a primary means of nerve localization. Journal of Ultrasound in Medicine. 37 (11), 2477-2488 (2018).
  35. Reynolds, R. P., Effer, G. W., Bendeck, M. P. The upper esophageal sphincter in the cat: The role of central innervation assessed by transient vagal blockade. Canadian Journal of Physiology and Pharmacology. 65 (1), 96-99 (1987).
  36. Neville, A. L., et al. Esophageal dysfunction in cervical spinal cord injury: a potentially important mechanism of aspiration. The Journal of Trauma. 59 (4), 905-911 (2005).
  37. Nishino, T., Kochi, T., Ishii, M. Differences in respiratory reflex responses from the larynx, trachea, and bronchi in anesthetized female subjects. Anesthesiology. 84 (1), 70-74 (1996).
  38. Regli, A., von Ungern-Sternberg, B. S. Anesthesia and ventilation strategies in children with asthma: part I - preoperative assessment. Current Opinion in Anaesthesiology. 27 (3), 288-294 (2014).
  39. Regli, A., von Ungern-Sternberg, B. S. Anesthesia and ventilation strategies in children with asthma: part II - intraoperative management. Current Opinion in Anaesthesiology. 27 (3), 295-302 (2014).
  40. Hung, M. H., et al. Nonintubated thoracoscopic lobectomy for lung cancer using epidural anesthesia and intercostal blockade: A retrospective cohort study of 238 cases. Medicine. 94 (13), 727 (2015).
  41. Solli, P., Brandolini, J., Bertolaccini, L. Tubeless thoracic surgery: Ready for prime time. Journal of Thoracic Disease. 11 (3), 652-656 (2019).
  42. Deng, H. Y., et al. Non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery: A meta-analysis. Interactive Cardiovascular and Thoracic Surgery. 23 (1), 31-40 (2016).
  43. Liu, C. Y., et al. Tubeless single-port thoracoscopic sublobar resection: Indication and safety. Journal of Thoracic Disease. 10 (6), 3729-3737 (2018).
  44. Wu, C. Y., et al. Feasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patients. The Annals of Thoracic Surgery. 95 (2), 405-411 (2013).
  45. Pompeo, E., et al. Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery. The Journal of Thoracic and Cardiovascular Surgery. 143 (1), 47-54 (2012).
  46. Murphy, G. S., et al. Postoperative residual neuromuscular blockade is associated with impaired clinical recovery. Anesthesia and Analgesia. 117 (1), 133-141 (2013).
  47. Bevilacqua Filho, ., T, C., et al. Risk factors for postoperative pulmonary complications and prolonged hospital stay in pulmonary resection patients: A retrospective study. Brazilian Journal of Anesthesiology. 71 (4), 333-338 (2021).

This article has been published

Video Coming Soon

JoVE Logo

Privacy

Terms of Use

Policies

Research

Education

ABOUT JoVE

Copyright © 2024 MyJoVE Corporation. All rights reserved