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).

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
<ol>
	<li>Include all patients (aged &#62;18 years) undergoing pulmonary bullae resection, pulmonary wedge resection, or lobectomy.</li>
</ol>
2. Exclusion criteria
<ol>
	<li>Exclude patients based on an American Society of Anesthesiologists (ASA) physical status classification of &#62;315.</li>
	<li>Exclude patients with a body mass index (BMI)16 &#62;30 kg/m2.</li>
	<li>Exclude patients with oesophageal cancer, total pneumonectomy, and open-heart surgery with resection of the ribs.</li>
	<li>Exclude patients with a previous medical history of bronchiectasis, destroyed lung, or chronic obstructive pulmonary disease (COPD).</li>
	<li>Exclude patients with definite multiple pulmonary infections or inflammation prior to surgery, as well as other severe systemic diseases.</li>
	<li>Exclude patients with coagulation disorders and severe psychiatric or neurological disorders.</li>
</ol>
3. Preparation before the anesthesia
<ol>
	<li>Fast the patient for 8 h before the surgery.</li>
	<li>Adjust the operating room temperature to be between 24 &#176; C and 26 &#176; C.</li>
	<li>Insert a 20 G top-winged infusion needle into the non-surgical dorsal vein of the hand.</li>
	<li>Monitor the electrocardiography, blood pressure, pulse oxygen saturation (SpO2), and respiratory rate of the patient.</li>
	<li>Apply a bispectral index (BIS) quatro sensor to the forehead of each patient. 
	NOTE: Continuously monitor the radial arterial pressure and central venous pressure, if necessary.</li>
</ol>
4. Ultrasound-guided thoracic paravertebral blockade
<ol>
	<li>Place the patient in a lateral decubitus position.</li>
	<li>Place the ultrasound probe directly above the spinous processes of the third thoracic and seventh thoracic vertebrae, and obtain a cross-sectional image of the spinous processes. 
	NOTE: In the middle of the image is the hyperechoic spinous process with a posterior acoustic shadow, and the bony structures with a posterior acoustic shadow on either side of the spinous process are, in order, the vertebral plate and the transverse process.</li>
	<li>Move the ultrasound probe laterally to show the transverse process in its entirety.</li>
	<li>Move the ultrasound probe outward to visualize the transverse process, transverse rib joints, and ribs.</li>
	<li>Move the ultrasound probe caudally until the transverse process, the pleura, and the thoracic paravertebral space between them are detected in the image.</li>
	<li>Locally anesthetize the skin by injecting 2 mL of 1% lidocaine.</li>
	<li>Insert the block needle from lateral to medial with the in-plane approach under ultrasound guidance.</li>
	<li>Carefully increase the aspiration before the injection. Ensure that no blood reflux is observed. 
	&#8203;NOTE: The purpose of this step is to prevent systemic toxicity from the local anesthetic.</li>
	<li>Inject 2 mL of saline, and then visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space with the ultrasound.</li>
	<li>Inject 15 mL of 0.375% ropivacaine at the levels of T3 and T7.</li>
</ol>
5. Anesthetic induction
<ol>
	<li>Spray 1% levobupivacaine (3 mL) onto the throat.</li>
	<li>Inject 1.5 &#181;g/kg of fentanyl and 1-1.5 mg/kg of propofol.</li>
	<li>For continuous oxygen administration, place a facial mask, or insert a laryngeal mask airway (double-tube mask; #3 for 30-50 kg, #4 for 50-70 kg, #5 for 70-100 kg). Oxygen enters the patient&#39;s airway via the facial mask or laryngeal mask. 
	&#8203;NOTE: Adjust the injection dose to achieve a BIS value between 40-6016.</li>
</ol>
6. Maintenance of anesthesia
<ol>
	<li>Maintain an oxygen flow rate of 0.5-1 L/min.</li>
	<li>Maintain the concentration of sevoflurane at 1.5%-2.0% after the artificial pneumothorax. 
	NOTE: Inject 0.5 &#181;g/kg of fentanyl if the intraoperative spontaneous respiratory rate is higher than 20 breaths/min or when there is mediastinal flutter or coughing. Sevoflurane enters the patient&#39;s airway via the facial mask or laryngeal mask.</li>
	<li>Monitor the inhaled oxygen concentration and the end-tidal carbon dioxide (ETCO2&#160;&#60; 60 mmHg).</li>
	<li>Monitor the body temperature. Monitor the level of consciousness, and maintain a BIS value of 40-6016,17.</li>
	<li>Inject 20&#181;g/kg of atropine if the patient develops sinus bradycardia (HR &#8804; 50 beats/min).</li>
	<li>Continuously perfuse 2 &#181;g/kg/h of norepinephrine using an infusion pump if the systolic blood pressure is lower than 30% or 90 mmHg.</li>
	<li>Perform arterial blood gas analysis 15 min before the end of the surgery.</li>
	<li>Inject 1 mg/kg of flurbiprofen 30 min before the end of the surgery.</li>
</ol>
7. Thoracoscopic vagal block techniques and pleural infiltration anesthesia
<ol>
	<li>Use a 24 G top-winged infusion needle to produce an infiltration of 0.375% ropivacaine (3 mL) near the vagus nerve at the level of the lower trachea when performing right-sided procedures.</li>
	<li>Use a 24 G top-winged infusion needle to produce an infiltration of 0.5% ropivacaine (3 mL) near the vagus nerve at the level of the aortopulmonary window when performing left-sided procedures.</li>
	<li>Spray 10 mL of 2% lidocaine onto the surface of the visceral pleura using a 10 mL syringe.</li>
</ol>
8. Conversion from non-intubated anesthesia to intubated general anesthesia
<ol>
	<li>Convert the non-intubated anesthesia to intubated general anesthesia if the patient meets one of the following conditions: 
	-Severe hypoxemia (pulse oximetry &#60; 80%) 
	-Severe hypercapnia (PaCO2 &#62; 80 mmHg) 
	-Hemodynamic instability: intractable arrhythmias and right ventricular failure 
	-Persistent coughing resulting in surgery becoming difficult or impossible 
	-Intraoperative bleeding requiring thoracotomy</li>
</ol>
9. Post-operative care
<ol>
	<li>After fully waking, ask the patient to take a deep breath and cough to re-expand the collapsed lung.</li>
	<li>Connect a patient-controlled intravenous analgesia (PCA) pump to the intravenous catheter with a 100 mL solution in a PCA reservoir bag (containing 1 &#181;g/kg of sufentanil and a 0.9% sodium chloride injection), and titrate 2 mL/h of the PCA solution.</li>
	<li>Remove the chest drain when there is no air leak on coughing, no obvious fluid pneumothorax on the review of the chest X-ray, and a 24 h drainage of &#60;300 mL.</li>
</ol>

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

The authors have nothing to disclose.

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&#39;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...

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 increased risk of complications in such patients, including delayed emergence from anesthesia, airway complications, hoarseness, hypoxia, and arytenoid dislocation5,6,7,8,9. In contrast, multiple studies have documented shorter hospital stays among patients managed with NIVATS, as well as a reduction in respiratory complications compared to general anesthesia among low-risk patients10; additionally, successful surgery has even been reported in high-risk patients with very poor pulmonary function11,12,13.
Spontaneous ventilation during surgery is achieved with carefully administered local anesthesia or a regional nerve block supplemented with sedation, but the cough reflex with unexpected lung movement can be problematic during NIVATS. There is little emphasis on and no standard treatment for mediastinal flutter, irritating cough, or tachypnoea, which may disrupt a surgical procedure. In preliminary observations, the results showed that sevoflurane could decrease the respiratory rate and the occurrence of mediastinal flutter during NIVATS while maintaining spontaneous breathing14. Therefore, it could be hypothesized that sevoflurane inhalation may prevent coughing and reduce the requirement for mechanical ventilation, thereby reducing post-operative pulmonary complications (PPCs).
Firstly, this report presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. Secondly, a retrospective study was conducted to investigate the potential benefits of non-intubated anesthesia on post-operative outcomes.

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

non-intubated video-assisted thoracoscopic surgery

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.

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.
<p class="jove_...

Watch this Scientific Journal Video about A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia at JoVE.com

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

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

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

non-intubated-video-assisted-thoracoscopic-surgery

Research

JoVE Journal

Medicine

1.4K Views.  Second Affiliated Hospital of Zhejiang University School of Medicine. Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Video: Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

A Novel Rescue Technique for Difficult Intubation and Difficult Ventilation

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which works especially well with poor mask fit.
Can not intubate, can not ventilate" (CICV) is a potentially life threatening situation. In this video we present a simulation of the technique we used in a case of CICV where oxygenation and ventilation were maintained by inserting an endotracheal tube (ETT) nasally down to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.
A 13 year old patient was taken to the operating room for incision and drainage of a neck abcess and direct laryngobronchoscopy. After preoxygenation, anesthesia was induced intravenously. Mask ventilation was found to be extremely difficult because of the swelling of the soft tissue. The face mask could not fit properly on the face due to significant facial swelling as well. A direct laryngoscopy was attempted with no visualization of the larynx. Oxygen saturation was difficult to maintain, with saturations falling to 80%. In order to oxygenate and ventilate the patient, an endotracheal tube was then inserted nasally after nasal spray with nasal decongestant and lubricant. The tube was pushed gently and blindly into the hypopharynx. The mouth and nose of the patient were sealed by hand and positive pressure ventilation was possible with 100% O2 with good oxygen saturation during that period of time. Once the patient was stable and well sedated, a rigid bronchoscope was introduced by the otolaryngologist showing extensive subglottic and epiglottic edema, and a mass effect from the abscess, contributing to the airway compromise. The airway was secured with an ETT tube by the otolaryngologist.This video will show a simulation of the technique on a patient undergoing general anesthesia for dental restorations.

We describe a technique to maintain oxygenation and ventilation using an endotracheal tube inserted nasally to the level of the naso-pharynx while sealing the mouth and nares for successful positive pressure ventilation.

We describe a novel non surgical technique to maintain oxygenation and ventilation in a case of difficult intubation and difficult ventilation, which ...

Substernal Thyroid Biopsy Using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the lack of a standardized definition for STG. Biopsy is often required to differentiate benign from malignant lesions. Unlike cervical thyroid, the overlying sternum precludes ultrasound-guided percutaneous fine needle aspiration of STG. Consequently, surgical mediastinoscopy is performed in the majority of cases, causing significant procedure related morbidity and cost to healthcare. Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA) is a frequently used procedure for diagnosis and staging of non-small cell lung cancer (NSCLC). Minimally invasive needle biopsy for lesions adjacent to the airways can be performed under real-time ultrasound guidance using EBUS. Its safety and efficacy is well established with over 90% sensitivity and specificity. The ability to perform EBUS as an outpatient procedure with same-day discharges offers distinct morbidity and financial advantages over surgery. As physicians performing EBUS gained procedural expertise, they have attempted to diversify its role in the diagnosis of non-lymph node thoracic pathologies. We propose here a role for EBUS-TBNA in the diagnosis of substernal thyroid lesions, along with a step-by-step protocol for the procedure.

Substernal thyroid lesions are common, and need to be differentiated from malignancy. Obtaining percutaneous fine needle biopsy is not possible due to its retrosternal location. This article proposes a protocol for biopsy of substernal thyroid lesions using Endobronchial Ultrasound-guided Transbronchial Needle Aspiration (EBUS-TBNA).

Substernal thyroid goiter (STG) represents about 5.8% of all mediastinal lesions1. There is a wide variation in the published incidence rates due to the ...

The Rigid Tube as an Alternative in Controlling the Problematic Airway

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is an alternative to the majority of the rigid instruments used for tracheal intubation, which follow the midline to access the glottis. This single-center, prospective case-series study offers an option to conventional laryngoscopy in case of a poor glottic view, introducing an instrument (the rigid tube for laryngoscopy) that uses the retromolar approach to accomplish tracheal intubation. If after anesthesia induction, the modified Cormack-Lehane glottis view grade &#62;2b, the intubation is carried further with the rigid tube. The tube follows the direction of the thyroid cartilage while advancing from the labial commissure, displacing the tongue to the contralateral side. Adjusting the position of the larynx with the nondominant hand by gently pushing the thyroid cartilage and following an imaginary line towards it while advancing it improves the time needed for proper glottis visualization. Once the epiglottis is in sight, the practitioner progresses slowly, lifting the epiglottis and aiming the tip of the tube more anteriorly. When the glottis appears in the visual field, the intubating tube introducer is placed in the trachea, and a lubricated cuffed intubating tube is advanced over the introducer after the rigid tube is extracted. This tool was tested on 30 patients with an unsatisfactory glottic view when using the Macintosh laryngoscope and obtained excellent results with respect to intubation time and complications. The reduced visual field is the main limitation of this method, which requires a training period for reasonable expertise. This simple, robust, and cheap instrument could be a rescue option in case of a difficult airway.

Presented here is a protocol of tracheal intubation over an intubating tube introducer using a rigid tube for laryngoscopy with an attached light source. The main characteristics of this maneuver are the retromolar approach and the use of the thyroid cartilage as a landmark while advancing the rigid tube.

The unexpected problematic airway represents a large proportion of anesthesia-related morbidity and mortality. The retromolar or paraglossal approach is ...

Endotracheal Intubation Using a Flexible Intubation Endoscope as a Standardized Model for Safe Airway Management in Swine

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway or high ventilation pressures. Endotracheal intubation is a challenging skill,&#160;requiring a minimum number of successful endotracheal intubations to achieve a high success rate under optimal conditions, which is often unachievable for non-anaesthesiology researchers. Due to the specific porcine airway anatomy, a difficult airway can usually be assumed. The impossibility of establishing a secure airway can result in injury, adverse events, or death of the laboratory animal. Using a prospective, randomized, controlled evaluation approach, it has been shown that fiberoptic-assisted endotracheal intubation takes longer but has a higher first-pass success rate than conventional intubation without causing clinically relevant drops in oxygen saturation. This model presents a standardized regimen for endoscopically guided endotracheal intubation, providing a secured airway, especially for researchers who are inexperienced in the technique of endotracheal intubation via direct laryngoscopy. This procedure is expected to minimize animal suffering and unnecessary animal losses.

The use of pigs in research has increased in recent years. Nevertheless, pigs are characterized by difficult airway anatomy. By demonstrating how to perform endoscopically guided endotracheal intubation, the present protocol aims to further increase laboratory animals' safety to avoid animal suffering and unnecessary death.

Endotracheal intubation is often a basic requirement for translational research in porcine models for various interventions that require a secured airway ...

Image Acquisition using Portable Sonography for Emergency Airway Management

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of patients, but also to address the potential benefits of employing ultrasound in airway management. The benefits of point of care ultrasound (POCUS) include its portability, the speed at which it can be utilized, and its lack of invasiveness or exposure of the patient to radiation of other imaging modalities.
Two primary indications for airway POCUS include confirmation of endotracheal intubation and identification of the cricothyroid membrane in the event a surgical airway is required. In this article, the technique of using ultrasound to confirm endotracheal intubation and the relevant anatomy is described, along with the associated ultrasonographic images. In addition, identification of the anatomy of the cricothyroid membrane and the ultrasonographic acquisition of appropriate images to perform this procedure are reviewed.
Future advances include utilizing airway POCUS to identify patient characteristics that might indicate difficult airway management. Traditional bedside clinical exams have, at best, fair predictive values. The addition of ultrasonographic airway assessment has the potential to improve this predictive accuracy. This article describes the use of POCUS for airway management, and initial evidence suggests that this has improved the diagnostic accuracy of predicting a difficult airway. Given that one of the limitations of airway POCUS is that it requires a skilled sonographer, and image analysis can be operator dependent, this paper will provide recommendations to standardize the technical aspects of airway ultrasonography and promote further research utilizing sonography in airway management. The goal of this protocol is to educate researchers and medical health professionals and to advance the research in the field of airway POCUS.

Point of care ultrasound (POCUS) is increasingly being utilized in airway management. Presented here are some clinical utilities of POCUS, including differentiating endotracheal and esophageal intubation, identification of the cricothyroid membrane in the event a surgical airway is required, and measuring anterior neck soft tissue to predict difficult airway management.

With its increasing popularity and accessibility, portable ultrasonography has been rapidly adapted not only to improve the perioperative care of ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...

Anesthetic Thoracoscopy for Diagnosis of Pleural Effusions

Local Anesthetic Thoracoscopy for Undiagnosed Pleural Effusion

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed pleural effusions. This single-port procedure is conducted with the patient under mild sedation and involves a contralateral decubitus position. It is performed in a sterile setting, typically a bronchoscopy suite or surgical theater, by a single operator with support from a procedure-focused nurse and a patient-focused nurse.
The procedure begins with a thoracic ultrasound to determine the optimal entry point, usually in the IV-V intercostal space along the midaxillary line. Lidocaine/mepivacaine, with or without adrenaline, is used to anesthetize the skin, thoracic wall layers, and parietal pleura. A designated trocar and cannula are inserted through a 10 mm incision, reaching the pleural cavity with gentle rotation. The thoracoscope is introduced through the cannula for systematic inspection of the pleural cavity from the apex to the diaphragm. Biopsies (typically six to ten) of suspicious parietal pleura lesions are obtained for histopathological evaluation and, when necessary, microbiological analysis. Biopsies of the visceral pleura are generally avoided due to the risk of bleeding or air leaks. Talc poudrage may be performed before inserting a chest tube or indwelling pleural catheter through the cannula. The skin incision is sutured, and intrapleural air is removed using a three-compartment or digital chest drainage system. The chest tube is removed once there is no airflow, and the lung has satisfactorily re-expanded. Patients are usually discharged after 2-4 h of observation and followed up on an outpatient basis. Successful LAT relies on careful patient selection, preparation, and management, as well as operator education, to ensure safety and a high diagnostic yield.

Local anesthetic thoracoscopy (LAT) is essential for diagnosing recurrent, undiagnosed pleural effusion when a guideline-based workup fails to provide a specific cause. LAT can be performed as a day-case procedure by chest physicians. Here, we present a step-by-step approach for a successful and safe procedure.

Local anesthetic thoracoscopy (LAT) is a minimally invasive diagnostic procedure gaining recognition among chest physicians for managing undiagnosed ...

Tracheotomy-Based Endotracheal Intubation Protocol for Non-Survival Rat Models

Endotracheal Intubation via Tracheotomy and Subsequent Thoracotomy in Rats for Non-Survival Applications

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that require controlled or high ventilation pressures or access to the thoracic cavity and organs. Conventional endoorotracheal intubation using the anatomically existing route through the mouth is well suited for survival experiments. However, this procedure poses some challenges, including generally higher levels of the required experience and technical skill, more advanced equipment, and greater time effort with relevant intubation failure rates and complications such as tracheal perforation, temporary systemic hypooxygenation, and relevant aerial leakage.
This manuscript, therefore, presents a detailed step-by-step protocol for endotracheal intubation through tracheotomy in non-survival rat models when guaranteed intubation success, constant oxygenation levels, high ventilation pressures, or open thoracotomy are required.
The protocol emphasizes the importance of meticulous surgical technique to ensure consistent and reliable outcomes, especially for researchers who are inexperienced or lack routine in the technique of endoorotracheal intubation via direct laryngoscopy. This procedure is, therefore, expected to minimize animal suffering and unnecessary animal losses.

Here we introduce a standardized procedure for endotracheal intubation via tracheotomy followed by thoracotomy in rats, aimed at enhancing the precision and reproducibility of non-survival applications requiring invasive ventilation and exposure of thoracic organs in in vivo rat models.

Endotracheal intubation and subsequent ventilation are often basic requirements for translational research in rat models for various interventions that ...

Removal of Subcostal Specimen After Complete Portal Robotic Lobectomy

Subcostal Specimen Removal in Completely Portal Robotic Lobectomy

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional robot-assisted lobectomy (RAL). CPRL-4 integrates a fourth robotic arm and CO2 insufflation, resulting in superior visualization within the intrathoracic cavity owing to enhanced lung deflation. While CPRL-4 effectively achieves pulmonary resection, extracting specimens typically necessitates an intercostal utility thoracotomy, which may pose risks. To address potential damage associated with this method, we introduced a subcostal trans-diaphragmatic access port during resection, later enlarging it for specimen removal post-lobectomy. This study evaluated the efficacy and feasibility of this subcostal trans-diaphragmatic specimen removal approach following CPRL-4 procedures for pulmonary malignancies, all performed by a single surgical team. The findings suggest that subcostal specimen removal post-CPRL-4 offers several advantages, including reduced risk of thoracotomy-related complications, making it a practical, feasible, and safe method. This innovation has the potential to improve outcomes and patient care in pulmonary malignancy surgeries significantly.

This protocol describes the removal of lung specimens following a completely portal robotic lobectomy. Determining the optimal location for specimen extraction is a pertinent question, as both intercostal and subcostal routes can serve as potential extraction paths following robotic or video-thoracoscopic lobectomy. We choose subcostal lung specimen removal over intercostal removal.

The Completely Portal Robotic Lobectomy (CPRL-4) technique is increasingly favored for lobectomy procedures due to its advancements over traditional ...

Awake Intubation in Difficult Airways: A Flexible Video Laryngoscope Method

The Flexible Rhino-Laryngoscope for Awake Nasotracheal Intubation

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies obstructing airway access are at risk of airway management failure once they lose spontaneous respiration. Awake flexible scope intubation is considered the gold standard for controlling the airway in such patients. Following a feasibility trial involving 25 patients with challenging airways, this article presents a step-by-step protocol for awake nasotracheal intubation using a flexible video rhino-laryngoscope, which is significantly shorter than conventional intubating flexible scopes. The flexible video laryngoscope only exceeds the intubating tube length by a few centimeters, allowing the tube to closely follow the flexible scope during the procedure. Once the scope reaches the pharynx, it can be easily manipulated with one hand, enabling the operator to focus on the safe advancement of the scope-intubating tube assembly through the glottis. Based on previous results and experience gained, this article highlights the potential benefits of the technique: the opportunity for a minimally invasive "quick look" preoperatively to establish a final management plan, a more convenient and safer tool for navigating distorted anatomy with a lower chance of intubating tube impingement and airway injury, and a fast and smooth procedure resulting in improved patient satisfaction.

Author Spotlight: Advancing Awake Nasotracheal Intubation with Flexible Video Rhino-Laryngoscopes

Presented here is a protocol for awake nasotracheal intubation using a flexible rhino-laryngoscope with a 300 mm working length. As this tool is minimally invasive and easy to manipulate, awake intubation performed with a flexible rhino-laryngoscope is well-tolerated, fast, and safe for patients with difficult airways.

Difficulties or failures in securing the airway still occur and can lead to permanent disabilities and mortality. Patients with head and neck pathologies ...