Non-intubated Video-Assisted Surgery: A Critical Review

A recent important development in thoracic surgery has been the introduction and widespread employment of video-assisted thoracoscopic surgery (VATS), which minimizes tissue injury, reduces postoperative pain and improves postoperative recovery. Since intraoperative pain is likewise reduced during VATS, less invasive anesthetic approaches during VATS such as avoiding intubation, providing monitored sedation, and maintaining spontaneous breathing during the procedure have been more recently explored and the concept of non-intubated VATS (NI-VATS) has emerged. During NI-VATS, sedatives and regional anesthesia have been used to provide sedation and pain relief during the procedures. Various modes of sedation used during NI-VATS have been shown to keep the patient comfortable while maintaining sufficient spontaneous breathing. Regional anesthesia used has ranged from epidural anesthesia to local anesthesia to intercostal nerves. In some series, local anesthetics have been applied to the vagal nerve to suppress cough during the procedure. Although no large prospective randomized trial has studied the short- and long-term efficacy and safety of NI-VATS, a large number of retrospective studies and some prospective studies show that NI-VATS is a feasible and, when indicated judiciously, a safe method of intraoperative care. Especially for minor VATS, increased turnover times in operating room, improved immediate recovery after surgery and reduction in material costs have been shown for NI-VATS. However, some concerns regarding short- and long-term safety still remain. Short term problems of emergency intubation during the procedure should be expected and considered a major difficult airway challenge. This major safety issue needs team education, possibly simulation, and proper preparation for each and every patient. The range of performable NI-VATS procedures should be determined by level of surgical and anesthetic expertise. Long term safety issues are also important in selecting patients for NI-VATS since properly randomized studies showing reduction of major morbidity and mortality in complex and long operations are lacking. This is especially the case for cancer surgery.