The success and evolution of video-assisted thoracic surgery (VATS) renewed the interest for thoracoscopic operations in awake patients. Non-intubated, or tubeless, procedures found progressive credit and uptake. In particular, non-intubated uniportal VATS represents the latest stage in its evolution. An increasing number of more complicated procedures have been successfully carried out with this combined modality.
In the early 2000s, the Awake Thoracic Surgery Research Group at the University of Rome Tor Vergata started an investigational programme of thoracic operations performed without general anaesthesia and one-lung ventilation. Since that date >1,000 operations have been successfully carried out. Initially, non-intubated anaesthesia was successfully employed in non-oncologic conditions such as pneumothorax, emphysema, pleural infection, and interstitial lung disease. Oncologic conditions such as malignant pleural effusion, peripheral lung nodules, and mediastinal tumours were successively approached. Major operations are now being performed in this way. Uniportal access was progressively adopted with significant positive outcomes in postoperative recovery, patient acceptance, and economical costs. Operations of this kind overcome many anatomical and technical challenges satisfying the patient, surgeon, physician, nurse, and economical administrator. The hindrance caused by operating with a breathing lung is that it requires a particular set of skills but experience demonstrates that the learning curve is no longer than that required for any other new endoscopic procedure.
Other investigations have involved the biological impact of the procedure, demonstrating lower concentrations of inflammatory and stress mediators with a lower degree of immune-depression. Psychological preselection of the most suitable patients for non-intubated surgery is one of our fields of investigation. Non-intubated thoracic surgery is projected towards the future and still represents a nearly unexplored and potentially fruitful field.
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