Essentials in spontaneous ventilation video-assisted thoracoscopic surgery: how we do it

Spontaneous ventilation non-intubated thoracic surgery (NITS) has roots in authentic tradition, and yet is radically new.It appreciates inherent physiological functions and engages up-to-date knowledge of physiology, pharmacology, and device technology.The interdisciplinary collaboration between surgery and anaesthesia is refined.The compliance of the lungs and the thoracic wall is supported by high-flow nasal oxygenation (HFNO).The depth of anaesthesia with propofol is monitored by bispectral index (BIS).BIS score is optimally maintained between 40-60.The procedures include foreign body extraction, pulmonary wedge resections, thoracic wall or mediastinal tumours extirpation, anatomical pulmonary resection, lobar or sublobar, up to pneumonectomy.The method significantly reduces preoperative preparation and postoperative care.During the preparatory stage of the operation, artificial pneumothorax (PNO) is introduced under propofol sedation and HFNO is performing the utility incision(s) in local anaesthesia.Bupivacaine and lidocaine are used.Then inner intercostal regional anaesthesia in the third to the eighth intercostal space is administered.A vagal block follows using a sheathed long needle.Thereafter, routine thoracic surgery continues without any technical difference in comparison with established video-assisted thoracoscopic surgery (VATS) with intubation and artificial breathing.NITS has one specific feature: the three types of unwitting pulmonary, mediastinal and thoracic wall movement than can emerge after PNO introduction: 1/mild, 2/moderate, 3/severe (significant).It is not possible to predict which of these will appear.In mild and moderate types (about 90% of patients) every kind of procedure is feasible.The severe type signals the need for conversion to an intubation procedure with artificial breathing.Contraindications of NITS include obesity, gastroesophageal reflux disease, large pleural adhesions, and significant pulmonary movement.