Single Port Video-Assisted Thoracoscopic Lobectomy Under Spontaneous Ventilation in a High Risk Patient

Background

Intubated general anesthesia with one-lung ventilation is commonly considered necessary for thoracoscopic major pulmonary resections. However, non-intubated thoracoscopic lobectomy has been reported recently using conventional and uniportal video-assisted thoracoscopic surgery (VATS). Here, the authors present a video showing the procedure in a patient with high risk for intubated general anesthesia.

Material and Methods

An 86-year-old female, non- smoker was admitted to the authors’ department for surgery. A CT scan revealed a mass in the lower lobe of the left lung and signs of pulmonary fibrosis (the patient had a personal history of rheumatoid arthritis treated over many years). The patient was proposed for non-intubated VATS surgery. A laryngeal mask was used to control the airway. Propofol and continued perfusion of Remifentanil were administered for sedation. No epidural catheter was placed. The skin and the single intercostal space were infiltrated with Levobupivacaine. A 4 cm incision was made in the 5th intercostal space. A 4 cm mass was detected in the left lower too deep for wedge resection. The fissure was complex (incomplete and oblique) so a left-lower lobectomy was performed by using the fissureless technique. The total surgical time was 80 minutes. A single chest tube was inserted through the incision at the end of the procedure.

Results

The patient was sent to a recovery room for one hour, and then to the ward. The chest tube was removed on the second postoperative day, and the patient was discharged home on the third postoperative day. The final pathological result revealed a 4 cm adenocarcinoma with no lymph node involvement.

Conclusions

Uniportal video-assisted thoracoscopic lobectomy under spontaneous ventilation is a feasible procedure, and represents a good option for patients who are a high risk for intubated general anesthesia, such as the elderly or patients with associated pulmonary fibrosis. This procedure should only be performed by experienced anesthesiologists and thoracoscopic surgeons.

Discussion

The first non-intubated video-assisted thoracoscopic surgery (VATS) for lobectomy was initially described in 2007 as an attempt to reduce the aggression to the patient, improve outcomes, and reduce cost [1]. Since then, only two groups have published their results using a thoracoscopic approach with several incisions [2, 3]. However, the lobectomy with spontaneous ventilation can be performed by using only one port [4].

The success in performing lobectomies by uniportal approach in non-intubated patients is a result of skill and experience accumulated over time by performing many uniportal VATS surgeries [5, 6, 7]. The advantage of uniportal VATS surgery is that vision is direct to the target tissue, providing a similar angle of view as for open surgery. Another advantage of the uniportal VATS technique is that instruments inserted parallel to the camera mimic inside the chest maneuvers performed during open surgery [8].

The authors developed the technique of uniportal VATS lobectomy in June 2010 [9]. To date, the authors have performed more than 500 major pulmonary resections with good postoperative outcomes.

The non-intubated procedures try to minimize the adverse effects of tracheal intubation and general anesthesia, such as: intubation-related airway trauma [10], ventilation-induced lung injury, residual neuromuscular blockade [11], and postoperative nausea and vomiting. Avoidance of general anesthesia also results in a faster recovery with immediate return to daily life activities.

The authors consider this procedure feasible for selected patients classified as ASA I-II and Mallampati grade I-II, with no obesity, good cardiopulmonary function, and tumors not bigger than 6 cm. In addition, this surgery should only be performed by experienced anesthesiologists and thoracoscopic surgeons (preferably skilled and experienced in complex or advanced cases and bleeding control through VATS).

Postoperative acute exacerbation of pulmonary fibrosis is a serious complication with increased postoperative morbidity and mortality, especially in elderly patients. There are studies that support that patients with pre-operative interstitial lung disease have a severe risk for postoperative acute exacerbation of interstitial pneumonia after a pulmonary resection. This complication is more frequent in patients with advanced age, those who underwent lobectomy, and intubated patients under mechanical ventilation [12].

Major pulmonary resections alter the immune system in the perioperative course. The performance of thoracotomy produces more aggression to the immunologic function. Several studies suggest that mechanical ventilation produces pulmonary inflammation and increases the risk of acute lung injury [13].

The future of the thoracic surgery is to reduce the surgical and anesthetic trauma. The combination of nonintubated or awake thoracoscopic surgery and the single-port VATS approach is promising because it represents the least invasive procedure for pulmonary resections. Thanks to the avoidance of intubation, mechanical ventilation, and muscle relaxants, the anesthetic side effects are minimal. This allows most of the patients to be included in a fast protocol, avoiding the stay in an intensive-care unit. This is especially important in elderly patients or cases with interstitial pulmonary diseases.

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