From Open Operations to Nonintubated Uniportal Video-Assisted Thoracoscopic Lobectomy: Minimizing the Trauma to the Patient

[Current approaches to anesthetic management in thoracic surgery-An evaluation from the German Thoracic Registry]

BACKGROUND

While many hospitals in Germany perform thoracic surgery, anesthetic techniques and methods that are actually used are usually only known for individual departments. This study describes the general anesthetic management of three typical thoracic surgical procedures across multiple institutions.

MATERIAL AND METHODS

The German Thoracic Registry recorded 4614 patients in 5 institutions between 2016 and 2019. Hospitals with a minimum number of more than 50 thoracic procedures per year are eligible for inclusion in the registry. To analyze the anesthetic management, a matching process yielded three comparable patient groups (n = 1506) that differed solely in the surgical procedure. Three surgical procedures with varying degrees of invasiveness were selected: Group A = video-assisted thoracoscopic surgery (VATS) with wedge resection, group B = VATS with lobectomy, group C = open thoracotomy. Statistical analysis was performed descriptively using relative and absolute frequencies. Dichotomous variables were compared using the χ²-test.

RESULTS

The study enrolled patients with a median age of 65.6 years. The mean value of the American Society of Anesthesiologists (ASA) classification was 2.8. One lung ventilation was most commonly performed (group A = 98.2%, group B = 99.4%, group C = 98.0%) with double lumen tubes (DLT). Bronchial blockers (group A = 0.2%, group B = 0.4%, group C = 0%) were rarely used. Primary bronchoscopy was used to control double lumen tubes after insertion in the majority of cases (group A = 77.5%, group B = 73.1%, group C= 79.7%). Continuous positive airway pressure (CPAP, group A = 1.2%, group B = 1.4%, group C = 5.1%) and jet ventilation (group A = 1.6%, group B = 1.6%, group C = 1.4%) were rarely used intraoperatively. In group C, the administration of a vasopressor was also more frequently required (group A = 59.9%, group B = 77.8%, group C = 86%). A central venous catheter was established in 30.1% of all patients in group A, 39.8% in group B and 73.3% in group C. Patients in group A received an arterial catheter less frequently (71.7%) when compared to groups B (96.4%) and C (95.2%). Total intravenous anesthesia with propofol was used in most patients (group A = 67.7%, group B 61.6%, group C 75.7%). Propofol supplemented by volatile anesthetics was used less frequently (group A = 28.5%, group B = 35.5%, group C = 23.7%). With increasing invasiveness of the surgical procedure, placement of an epidural catheter was preferred (group A = 18.9%, group B = 29.5%, group C = 64.1%). Paravertebral catheters (group A = 7.6%, group B = 4.4%, group C = 4.8%) or a single infiltration of the paravertebral space were performed less frequently (group A = 7.8%, group B = 17.7%, group C = 11.6%). Postoperatively, some patients (3.4-25.7%) were transferred to the general ward. The largest proportion of patients transferred to a general ward underwent less invasive thoracic procedures (group A). When the extent of resection was greater (group B and group C) patients were mostly transferred to an intermediate care unit (IMC) or an intensive care unit (ICU). The insertion of invasive catheters was neither associated with the patients' ASA classification nor preoperative pathologic pulmonary function.

CONCLUSION

Our data indicate that less invasive thoracic operations are associated with a reduction of invasive anesthetic procedures. As the presented data are descriptive, further studies are required to determine the impact of invasive anesthetic procedures on patient-related outcomes. This evaluation of the anesthetic management in experienced thoracic anesthesiology departments represents the next step towards establishing national quality standards and promoting structural quality in thoracic anesthesia.

Developing a minimally-invasive anaesthesiological approach to non-intubated uniportal video-assisted thoracoscopic surgery in minor and major thoracic surgery

Background

Non-intubated uniportal video-assisted thoracoscopic surgery (niVATS) is a novel approach to major and minor lung resection. It benefits from a holistic anesthesiological concept with adequate pain relief and sedation in a minimal-invasive setup allowing thoracic procedures under spontaneous breathing. At present no anesthesiological gold standard for niVATS exists. The primary aim of our retrospective observational study was to evaluate feasibility and safety of minimally invasive niVATS for both minor and major pulmonary resections at our institution.

Methods

All 88 consecutive patients scheduled for niVATS minor or major thoracic procedures were included into the study. Anaesthesia was performed according to a departmental niVATS algorithm including both regional anaesthesia and sedation. Patient characteristics and early outcome data including intraoperative and postoperative findings were compared between groups. Prediction scores for postoperative complications (LAS VEGAS, ARISCAT, ThRCRI) were calculated and compared.

Results

No early mortality and a low overall morbidity rate of 28.4% were encountered. Conversion to orotracheal intubation was required in 6.8% of all cases. Postoperative pulmonary complications occurred in 15.9% of total cases and were lower than predicted by both LAS VEGAS and ARISCAT respectively. Cardiac complications were found in 1.1% and lower than predicted by ThRCRI. A persistent air leak occurred in 11.4% of total cases and was significantly higher in major resection. Postoperative chest tube duration and hospital length of stay in the major resection group exceeded times reported by other groups.

Conclusions

niVATS appears to be safe in both minor and major thoracic procedures. A minimally invasive anaesthesiological approach foregoing central iv lines, arterial blood pressure measurement and urinary catheterization is feasible. Our niVATS protocol appears to be a viable alternative for both minor and major thoracic procedures in selected patients.

Uniportal Thoracoscopic Wedge Resection of Lung Nodules: Paravertebral Blocks Are Better Than Intercostal Blocks

Background. Regional analgesia for tubeless, uniport, thoracoscopic wedge resection of benign peripheral nodules is generally performed by intercostal nerve block (INB). We examined the effectiveness of thoracic paravertebral block (PVB), in comparison to the traditional intercostal blocks, for the procedure. Methods. Between July 2016 and December 2016, 20 consecutive patients with solitary benign peripheral lung nodules underwent tubeless uniport thoracoscopic wedge resection using thoracic PVB (PVB group). The clinical outcomes were compared with those of 20 other consecutive patients who underwent the same procedure under the conventional INB, between January 2016 and July 2016 (INB group). In both groups, the procedures were performed without endotracheal intubation, urinary catheterization, or chest tube drainage. Results. The clinical data of patients in both groups were comparable in terms of demographic and baseline characteristics, operative and anesthetic characteristics, puncture-related complications, and postoperative anesthetic adverse events. No puncture-related complications occurred during the perioperative period in either group. The threshold values for mechanical pain at postoperative hours 4 and 8 were significantly higher in the PVB group than in the INB group. Furthermore, the incidence of nausea or vomiting in the PVB group was significantly less than that in the INB group. None of the patients required reintervention or readmission to our hospital. Conclusions. Tubeless uniportal thoracoscopic wedge resection for solitary benign peripheral lung nodules using thoracic PVB for regional analgesia is a feasible and safe procedure. Moreover, we found that thoracic PVB is less painful than INB.

Systematic mediastinal lymph node dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic lobectomy for lung cancer

BACKGROUND

To evaluate the systematic mediastinal lymph node (LN) dissection outcomes and conversion rates of uniportal video-assisted thoracoscopic surgery (UVATS).

METHODS

Patients with non-small-cell lung cancer who underwent video-assisted thoracoscopic surgery (VATS) and systematic mediastinal LN dissection between January 2015 and January 2017 were retrospectively reviewed. We categorized the patients into two groups according to the different surgical approaches. Patients' clinical data were collected and compared. The index of estimated benefit from LN dissection was used to evaluate the therapeutic value of LN dissection for each station.

RESULTS

A total of 453 patients underwent VATS, including 197 patients in the UVATS group and 256 patients in the triportal VATS (TVATS) group. There were no significant differences in the 1-, 2- and 3-year survival rates of these two groups (P > 0.05). There were no statistically significant differences in the operative time, numbers and stations of LNs, numbers and stations of N2 LNs, conversion rate or postoperative complications. The UVATS group had less intraoperative blood loss, a shorter duration of hospital stay, less chest tube drainage and a shorter duration of chest tube drainage than the TVATS group (P < 0.05). The conversion rates in the UVATS and TVATS groups were 5.1% and 4.3%, respectively, and the difference was not significant. The same degree of LN sampling was achieved in both groups.

CONCLUSION

UVATS permits the same degree of LN sampling as TVATS without a difference in the conversion rate.

Anaesthesia management for bronchoscopic and surgical lung volume reduction

Optimizing the patient's condition before the lung volume reduction (LVR) according to recommendations by American College of Cardiology/American Heart Association (ACC/AHA) guideline on perioperative cardiovascular evaluation is mandatory. Implementation of a multimodal analgesia concept and the use short-acting anaesthetics enhances recovery and avoids postoperative pulmonary complications. Normovolemia, normothermia, lung protective ventilation and an evidence-based concept of airway management (i.e., double-lumen tube, bronchus blocker) are suggested for intraoperative management of surgical lung volume reduction (SLVR). General anaesthesia (using remifentanil, propofol and mivacurium) with an i-gel^® supraglottic airway device should be used for bronchoscopic lung volume reduction (BLVR). Jet ventilation through rigid bronchoscopy or with a jet catheter may be an alternative concept. Experienced consultants should perform anaesthesia for LVR.

Prophylactic air-extraction strategy after thoracoscopic wedge resection

Background

Since the conception of enhanced recovery after surgery protocols, tubeless strategies have become popular. Herein, we introduce a previously unreported alternative air‐extraction strategy for patients who have undergone thoracoscopic wedge resection and explore its feasibility and safety.

Methods

Between January 2015 and June 2017, 264 consecutive patients underwent thoracoscopic wedge resection with different drainage strategies. Patients were divided according to the postoperative drainage strategies used: routine chest tube drainage (RT group), complete omission of chest tube drainage (OT group), and prophylactic air‐extraction catheter insertion procedure (PC group). Using the propensity score matching method, clinical parameters and objective operative qualities were compared among the three groups.

Results

Optimal 1:1 matching was used to form pairs of RT (n =36) and PC (n =36) groups and balance baseline characteristics among the three groups. The incidence rates of pneumothorax were 5.6% (2/36), 9.8% (5/51), and 19.4% (7/36) in the RT, OT, and PC groups, respectively (P = 0.07). Chest tube reinsertion incidence for postoperative pneumothorax was 19.4% (1/7) in the PC group and 60% (3/5) in the OT group. Other postoperative complications were comparable among these groups.

Conclusions

The prophylactic air‐extraction strategy may be an alternative procedure for selected patients. Remedial air extraction may reduce the occurrence of chest tube reinsertion for pneumothorax patients, but further investigation is required.

Tubeless major pulmonary resections

From its inception, cutting edge minimally invasive thoracic surgery has pursued to barely produce patient perturbation. Although state of the art techniques such as uniportal approach have achieved a remarkable reduction in postoperative morbidity, there is still a way to go in patient comfort. A new 'tubeless' concept has surfaced as an alternative to double-lumen intubation with general anaesthesia combining non-intubated spontaneous breathing video-assisted thoracic surgery (VATS) surgery under loco-regional blockade with the avoidance of central line, epidural or urinary catheter and chest tube in selected patients. Those procedures combine the most evolved and less invasive techniques in anaesthesia, video-assisted surgery and perioperative care to cause the least trauma and allow for faster recovery. Non-intubated thoracic surgery used to rise some concerns regarding spontaneous breathing collapse, oxygenation, cough reflex triggering and mediastinal shift. Today, experienced teams in high-volume centers have proven non-intubated major lung resections are feasible and safe once those drawbacks have been overcome with the proper techniques and extensive previous expertise in VATS. Tubeless thoracic surgery is currently evolving, challenging former exclusion criteria and expanding indications to major lung resections or even tracheal and carinal resections to provide better intraoperative status and promote minimal need for recovery.

Single-port video-assisted thoracic surgery (VATS)-advanced procedures & update

The uniportal approach for major pulmonary resections began in 2010, with the first case being reported by D González-Rivas and colleagues in La Coruña, Spain. Since then, in different countries, thoracic surgeons had been performing hundreds of cases, with more advanced and complex procedures. Nowadays, there are reports of uniportal tracheal resection and reconstruction, carinal resection, bronchoplastic procedures, lobectomies with en bloc chest wall excision, and vascular reconstruction with optimal outcomes. The development of technologies and the potential benefits of a direct view, anatomic instrumentation, better cosmesis, and, potentially, less postoperative pain have led uniportal video-assisted thoracic surgery to grow exponentially worldwide.

A glance at the history of uniportal video-assisted thoracic surgery

In the history of thoracic surgery, the advent of video-assisted thoracic surgery (VATS) had on effect equivalent to that provoked by a true revolution. VATS successfully allowed minor, major and complex procedures for various lung and mediastinal pathologies with small incision instead of the traditional accesses. These small incisions abolished ugly scars, generated less acute and chronic pain, reduced hospital stay and costs, allowed faster return to normal day life activities. Conventional VATS was initially performed through 3-4 ports and rapidly evolved to uniportal or single portal access [uniportal video-assisted thoracic surgery (uniVATS)]. First uniportal procedures were published in 2000. In 2010, uniportal technique for lobectomy was described. Focused experimental courses, live surgery events, the internet media favored the rapid diffusion of this technique over the world. Major and complex uniVATS lung resections involving segmentectomy, pneumonectomy, bronchoplasty and vascular reconstruction, redo VATS, en bloc chest wall resections have been accomplished with satisfactory outcomes. Interestingly, different uniportal approaches and techniques are emerging from a number of VATS centers particularly experienced in the mini-invasive thoracic surgery. As confidence grew, in 2014, the first uniVATS left upper lobectomy via the subxiphoid approach was reported. This novel technique is quite challenging but appropriate patient selection as well as availability of dedicated instruments allowed to perform procedures safely. The diffusion of uniVATS paralleled with the development of nonintubated awake anesthesia technique. In 2007 the first nonintubated lobectomy was described. In 2014 the first single port VATS lobectomy in a nonintubated patient with lung cancer of the right middle lobe was accomplished. The nonintubated uniVATS represents an intriguing technique, so that very experienced thoracoscopic surgeons may enroll to surgery elderly and high risk patients. Decreased postoperative pain and hospitalization, faster access to the radio-chemotherapy and diminished inflammatory response are important benefits of the modern approach to the thoracic pathologies. The history of uniVATS documented a constant and irresistible progress. This technique may further provide unthinkable surprises in next future.

Unisurgeon' uniportal video-assisted thoracoscopic surgery lobectomy

The video-assisted thoracoscopic surgery (VATS) for major pulmonary resections has evolved in a period of only 7 years from 3-4 incisions to a single incision approach. However, Uniportal VATS approach is different from other forms of minimally invasive thoracic surgery, and the technique of lung exposure and stapler insertion through a single hole should be learned step by step. The main advances of uniportal VATS during the last years are related to improvements in surgical technique, evolving to a concept of "advanced VATS instrumentation", and implementation of new technology. One recent advance in uniportal VATS is the possibility of using a robotic or pneumatic articulated arm that holds the camera stable and no needs a surgical assistant. This is called "unisurgeon uniportal VATS" in where the surgeon has more freedom of movements and eliminates the fatigue of assistant holding the camera. We are still in the beginning of the "unisurgeon era" that probably will be more popular in the next coming years thanks to the Implementation of wireless cameras and graspers by means of magnetic control.

Nonintubated uniportal thoracoscopic wedge resection for early lung cancer

Background

Minimal invasive surgery is current choice of treatment for lung cancer. Combined nonintubated anesthesia with uniportal thoracoscopic surgery is not well understood. Here, we report the experience of nonintubated uniportal thoracoscopic surgery in the treatment of primary non-small cell lung cancer (NSCLC).

Methods

From January 2014 to December 2015, we retrospectively reviewed 131 consecutive patients with primary NSCLC who underwent nonintubated uniportal thoracoscopic wedge resection and mediastinal lymph node dissection at a single medical center.

Results

Of the 131 patients, 110 (84%) received preoperative computed tomography-guided dye localization. Most of them were diagnosed with early stage invasive adenocarcinoma (N=112, 85.5%; pathological stage IA: 84.7%, N=111), and the mean size of the nodule was small (diameter: 0.85±0.40 cm). All section margins were free of malignancy. In total, 7 of the 131 patients (5.3%) had their treatment converted from uniportal to multi-portal video-assisted thoracoscopic surgery (VATS), and 1 (0.8%) had his treatment converted to endotracheal intubation with general anesthesia. The mean operation time was 91.1±32.6 minutes, and the postoperative complications included pneumonia (0.8%), prolonged air leaks (0.8%), and subcutaneous emphysema (1.5%).

Conclusions

Overall, nonintubated uniportal VATS is a feasible, effective and safe procedure for the treatment of early primary lung cancer.

Nonintubated video-assisted thoracic surgery lobectomy for lung cancer

Nonintubated video-assisted thoracic surgery (VATS) is now well established and is performed in different institutions as a safe and versatile procedure in selected patients. To share the surgical and anesthetic techniques for nonintubated VATS, we present a 56-year-old female patient who underwent nonintubated VATS left upper lobectomy for primary non-small cell lung cancer. Our patient was sedated in a spontaneous breathing status using a target-controlled infusion of propofol. Additionally, regional anesthesia using intercostal block and left-sided intrathoracic vagal block enabled us to do left upper lobectomy and mediastinal lymph node dissection without difficulty. After an uneventful postoperative recovery, our patient was discharged to her home on postoperative day 3. The final pathology showed a well-differentiated adenocarcinoma without any involvement of mediastinal lymph node, measuring 27 mm in its maximal dimension. Nonintubated VATS lobectomy can be a safe and effective procedure providing satisfactory clinical outcomes in the patient.

The feasibility and safety of thoracoscopic surgery under epidural and/or local anesthesia for spontaneous pneumothorax: a meta-analysis

The aim of this study was to compare thoracoscopic surgery for spontaneous pneumothorax under epidural and/or local anesthesia (ELA) with that under general anesthesia and prove the feasibility and safety of thoracoscopic surgery under ELA for spontaneous pneumothorax. Relevant studies were searched in five databases from their date of publication to June 2016. We collected and analyzed the data concerning operative time, hospital stay, complications, air leak, recurrence and perioperative mortality. A forest plot was performed to compare the differences between the two groups. There were no significant differences between the ELA group and the general anesthesia (GA) group in operative time, hospital stay, complications, air leak or recurrence. There were 6 deaths reported in two studies. However, patients in the ELA group had significantly shorter global operating room time. Our study demonstrated that ELA, in comparison with GA, is feasible and safe for thoracoscopic surgery of spontaneous pneumothorax.

Nonintubated uniportal VATS pulmonary anatomical resections

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.

Uniportal video-assisted thoracoscopic right upper posterior segmentectomy with systematic mediastinal lymphadenectomy

Uniportal video-assisted thoracoscopic surgery (VATS) has now evolved into a sophisticated technique that can be used in some of the most complex thoracic procedures; however, this approach to segmentectomy is not standardized, and the surgical procedure varies between surgeons. Here, we describe the use of our uniportal VATS procedure during right upper posterior segmentectomy in a patient with a nodule in the right upper lobe. Subsequent mediastinal lymphadenectomy was performed. The patient has recovered well after surgery. We believe that uniportal VATS segmentectomy is a technically safe and feasible alternative approach to conventional thoracoscopic techniques for treating lung cancer.

Nonintubated Thoracoscopic Pneumonectomy for Bullous Emphysema

Thoracoscopic pneumonectomy without tracheal intubation has not been reported. We describe a woman with severe bullous emphysema of the right upper lobe and hypoplasia of the remaining lung lobes who underwent thoracoscopic pneumonectomy using a nonintubated anesthetic technique of internal intercostal nerve block, vagal block, and targeted sedation. The successful results in this patient suggest that nonintubated thoracoscopic pneumonectomy is technically feasible and can be used in a specific group of patients.

Uniportal thoracoscopic surgery: from medical thoracoscopy to non-intubated uniportal video-assisted major pulmonary resections

The development of thoracoscopy has more than one hundred years of history since Jacobaeus described the first procedure in 1910. He used the thoracoscope to lyse adhesions in tuberculosis patients. This technique was adopted throughout Europe in the early decades of the 20(th) century for minor and diagnostic procedures. It is only in the last two decades that interest in minimally invasive thoracic surgery was reintroduced by two key technological improvements: the development of better thoracoscopic cameras and the availability of endoscopic linear mechanical staplers. From these advances the first video-assisted thoracic surgery (VATS) major pulmonary resection was performed in 1992. In the following years, the progress of VATS was slow until studies showing clear benefits of VATS over open surgery started to be published. From that point on, the technique spread throughout the world and variations of the technique started to emerge. The information available on internet, live surgery events and experimental courses has contributed to the rapid learning of minimally invasive surgery during the last decade. While initially slow to catch on, the traditional multi-port approach has evolved into a uniportal approach that mimics open surgical vantage points while utilizing a non-rib-spreading single small incision. The early period of uniportal VATS development was focused on minor procedures until 2010 with the adoption of the technique for major pulmonary resections. Currently, experts in the technique are able to use uniportal VATS to encompass the most complex procedures such as bronchial sleeve, vascular reconstructions or carinal resections. In contrast, non-intubated and awake thoracic surgery techniques, described since the early history of thoracic surgery, peaked in the decades before the invention of the double lumen endotracheal tube and have failed to gain widespread acceptance following their re-emergence over a decade ago thanks to the improvements in VATS techniques.

Uniportal lobectomy in Africa: a beginning

Report of the first uniportal wet lab run in South Africa. This included four university centers involving live surgery. Lobectomies as well as other video assisted procedures were performed. The results are the introduction of thorascopic programs in all four centers. The next stage in this program is to extend the outreach to the other centers in the country as well as in the neighboring countries. During 2016 a beginning will be made in Namibia as well as in Botswana.