Non-intubated thoracic surgery—the surgeon perspective

Non-intubated thoracic surgery—the surgeon perspective

Duilio Divisi, Gino Zaccagna, Andrea De Vico, Roberto Crisci

Department of MeSVA, University of L’Aquila, Thoracic Surgery Unit, “Giuseppe Mazzini” Hospital, Teramo, Italy

Contributions: (I) Conception and design: D Divisi; (II) Administrative support: None; (III) Provision of study materials or patients: D Divisi, G Zaccagna; (IV) Collection and assembly of data: A De Vico; (V) Data analysis and interpretation: D Divisi, R Crisci; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors.

Correspondence to: Duilio Divisi, Prof, PhD. Piazza Italia n.1, 64100 Teramo, Italy. Email:

Received: 17 January 2021; Accepted: 03 February 2021; Published: 15 June 2021.

doi: 10.21037/vats-21-6

The introduction of the double-lumen tracheal tube represented a turning point in thoracic surgery. With one-lung ventilation (OLV) it is possible to operate more easily based on an excellent exposure of the lung and mediastinal structures (1). The interest in “non-intubated thoracic surgery” (NITS) was aroused about 20 years ago, when Mukaida et al. (2) described pneumothorax patient operated under local anesthesia. Currently, this technique is a very valid alternative to general anesthesia especially in functionally compromised patients, allowing to avoid the negative effects that heavy drugs and the intubation inevitably entails (3-5). These considerations are even more significant considering the widespread use of video-assisted thoracic surgery (VATS). In fact, VATS in reduced volume ventilation or in spontaneous breathing without positive pressure ventilation shows a double benefit: (I) the minimally invasive surgical technique with less invasiveness, reduced postoperative pain, shorter hospitalization and rapid recovery of patient; (II) the targeted anesthesia tolerated even by patients with a high index of comorbidity. Although non-intubated VATS was reserved in the past only for minor interventions, several studies displayed recently excellent results also in the treatment of mediastinal pathologies, in major lung resections or in the surgical treatment of pleural empyema (6,7). Chen et al. (8) demonstrated that non-intubated VATS can be used to perform lobectomies in early stages non-small cell lung cancer (NSCLC) patients, allowing the levels of efficacy and safety comparable to the standard technique. Liu et al. (9), in a randomized control study, compared patients underwent “non-intubated VATS” with patients underwent intubation under general anesthesia. The first group showed faster recovery and less drug use in the postoperative period. Obviously, the experience of surgeon and anesthesiologist and the skill in the management of the airways must be taken into account, as absolute contraindications are still previous thoracic surgery or radiotherapy for the high risk to develop parenchymal adhesions (10). The selection of patients is a key point. In fact, patients with high comorbidities and compromised respiratory reserve benefit significantly from this minimally invasive method but must be able to tolerate tracheal intubation and general anesthesia in case of adverse events. Although the American Society of Anesthesiologists refers to grade 1 or 2 patients the ideal clinical status to proceed with non-intubated method, many studies (11-15) reported excellent results in high-risk patients for severe lung or cardiac diseases. Gonzalez-Rivas et al. (16), in a review of literature, verified the safety of the technique and its easy application in major and minor resections, underlining how the associated uniportal approach should be the new challenge of thoracic surgery. A further advantage of “non-intubated VATS” is the lower rate of complications than single-lung ventilation, due to hypoxia and/or hypercapnia (17). These conditions are accentuated by pulmonary hypoventilation linked to selective intubation, with inevitable systemic impact especially in patients with high pulmonary or intracranial pressures or cardiac arrhythmias. An important aspect is the cough control resulting from inadequate sedation, which often makes the procedure difficult. The role of the anesthesiologist is fundamental as the dosage of the drug must be related to both the need of surgeon and the stabilization of patient, avoiding significantly depressing the breath. Some authors proposed the use of lidocaine spray on the surface of the pulmonary parenchyma and by inhalation to prevent bronchial reactivity or vagal nerve block (16,18). In “non-intubated VATS” the reported conversion rate ranges from 0 to 10% (10), caused by surgical (difficulty in exposing lung and mediastinal structures, presence of adhesions and/or bleeding) or anesthetic (respiratory or cardiocirculatory instability) complications. Therefore, the advantages/disadvantages ratio must always be considered. On the one hand: low invasiveness or impact on the respiratory and cardiovascular system, fast recovery times and low activation of stress hormones with less effects on the immune system and on the lymphocytes activation (19). On the other hand: less airway control, reduced room for maneuver, involuntary movements of the patient, difficulty in immediate conversion. In conclusion, “non-intubated VATS” is currently a rational choice in patients with high comorbidity index or respiratory and hemodynamic instability. Surgeons who wish to approach this method should: (I) start with minor and then move on to more complex interventions; (II) select patients very carefully, better with a multidisciplinary decision; (III) consider and recognize the essential role of anesthesiologist; (IV) create a team able to manage all difficulties and complications that this technique inevitably entails.


Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Video-Assisted Thoracic Surgery for the series “Non-Intubated Thoracic Surgery. A Global Perspective”. The article did not undergo external peer review.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at The series “Non-Intubated Thoracic Surgery. A Global Perspective” was commissioned by the editorial office without any funding or sponsorship. RC served as the unpaid Guest Editor of the series and serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from Sep 2019 to Aug 2021. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See:


  1. Chen JS. Nonintubated thoracoscopic lobectomy for lung cancer. Ann Surg 2011;254:1038-43. [Crossref] [PubMed]
  2. Mukaida T, Andou A, Date H, et al. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65:924-6. [Crossref] [PubMed]
  3. Buckingham WW, Beatty AJ, Brasher CA, et al. An analysis of 607 surgical procedures done under epidural anesthesia. Mo Med 1950;47:485-7. [PubMed]
  4. Hofmann HS, Rettig G, Radke J, et al. Iatrogenic ruptures of the tracheobronchial tree. Eur J Cardiothorac Surg 2002;21:649-52. [Crossref] [PubMed]
  5. Murphy GS, Szokol JW, Avram MJ, et al. Postoperative residual neuromuscolar blockade is associated with impaired clinical recovery. Anesth Analg 2013;117:133-41. [Crossref] [PubMed]
  6. Cox SE, Katlic MR. Non-intubated video-assisted thoracic surgery as the modality of choice for treatment of recurrent pleural effusion. Ann Transl Med 2015;3:103. [PubMed]
  7. Zhang K, Chen HG, Wu WB, et al. Non-intubated video-assisted thoracoscopic surgery vs. intubated video-assisted thoracoscopic surgery for thoracic disease: a systematic review and meta-analysis of 1,684 cases. J Thorac Dis 2019;11:3556-68. [Crossref] [PubMed]
  8. Chen JS, Cheng YJ, Hung MH, et al. Nonintubated thoracoscopic lobectomy for lung cancer. Ann Surg 2011;254:1038-43. [Crossref] [PubMed]
  9. Liu J, Cui F, Pompeo E, 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 scores matching analysis. Eur J Cardiothorac Surg 2016;50:920-5. [Crossref] [PubMed]
  10. Irons JF, Martinez G. Anaesthetic consideration for non-intubated thoracic surgery. J Vis Surg 2016;2:61. [Crossref] [PubMed]
  11. Wu CY, Chen JS, Lin YS, et al. Feasibility and safety of nonintubated thoracoscopic lobectomy for geriatric lung cancer patients. Ann Thorac Surg 2013;95:405-11. [Crossref] [PubMed]
  12. Ambrogi V, Mineo TC. VATS biopsy for undetermined interstitial lung disease under non-general anesthesia: comparison between uniportal approach under intercostal block vs three-ports in epidural anesthesia. J Thorac Dis 2014;6:888-95. [PubMed]
  13. Pompeo E, Rogliani P, Tacconi F, et al. Randomized comparison of awake nonresectional versus nonawake resectional lung volume reduction surgery. J Thorac Cardiovasc Surg 2012;143:47-54, 54.e1.
  14. Matsumoto I, Oda M, Watanabe G. Awake endoscopic thymectomy via an infrasternal approach using sternal lifting. Thorac Cardiovasc Surg 2008;56:311-3. [Crossref] [PubMed]
  15. Bertolaccini L, Zaccagna G, Divisi D, et al. Awake non-intubated thoracic surgery: an attempt of systematic review and meta-analysis. Video-assist Thorac Surg 2017;2:59. [Crossref]
  16. Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated video-assisted thoracoscopic lung resection: the future of thoracic surgery? Eur J Cardiothorac Surg 2016;49:721-31. [Crossref] [PubMed]
  17. Liu J, Cui F, Li S, et al. Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study. Surg Innov 2015;22:123-30. [Crossref] [PubMed]
  18. Chen KC, Cheng YJ, Hung MH, et al. Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation. J Thorac Dis 2014;6:31-6. [PubMed]
  19. Vanni G, Tacconi F, Sellitri F, et al. Impact of awake videothoracoscopic surgery on postoperative lymphocyte responses. Ann Thorac Surg 2010;90:973-8. [Crossref] [PubMed]
doi: 10.21037/vats-21-6
Cite this article as: Divisi D, Zaccagna G, De Vico A, Crisci R. Non-intubated thoracic surgery—the surgeon perspective. Video-assist Thorac Surg 2021;6:12.