The incidence of traumatic diaphragmatic rupture (TDR) is around 0.5% of all trauma patients, located more frequently on the left side (80%), with penetrating trauma being more predominantly the cause (63%) than blunt injuries (37%). TDR typically develops during thoracoabdominal injuries and outcome depends on the severity of the associated organ lesion. Diagnosis is sometimes very difficult: chest X-ray can verify TDR in only 25–70% of cases, although the specificity of a multidetector computed tomography (MDCT) is 100% and 83% for left and right-sided ruptures, respectively. When TDR is a part of a polytrauma, the management of the patient must follow the ATLS (Advanced Trauma Life Support) protocol and surgery is rarely based on the primary survey. The usual scenario involves cases detected during the secondary survey. In acute cases approach is determined by the site of the life-threatening injuries. In the daily surgical routine, in cases of acute TDR, laparotomy provides the best approach to manage the associated abdominal injuries and diaphragmatic rupture. Alternatively a transthoracic approach offer access to reconstruction in cases of delayed. A transdiaphragmatic procedure is offered when during an exploration (laparotomy or thoracotomy), any sign of an injury (bleeding, perforation) is verified through the rupture of the diaphragm in the other cavity (abdomen or chest and vice versa): the injury via a transdiaphragmatic way can be managed. Usually, a simple and small rupture up to 5–6 cm can be reconstructed with No. 0 or 1 monofilament non-absorbable or absorbable interrupted sutures, while for larger defects, interrupted figure-of-eight or horizontal mattress sutures are required. Mesh prosthesis is rarely needed.

Systemic inflammation (SI) is a response of the immune system to infectious or non-infectious injuries that defends the body homeostasis. Every surgical intervention triggers SI, the level of which depends on the extent of damage caused by the surgery. During the first few hours after the damage, the innate or natural immunity, involving neutrophils, macrophages, and natural killer cells, plays a main role in the defense mechanism, but thereafter the adaptive immune response ensues. The number of leukocytes is elevated, the levels of lymphocytes and natural killer cells are reduced, and the cytokines released after surgery correlate with surgical damage. Minimally invasive thoracic surgery procedures induce less inflammatory response and reduce the immune defense in patients to a more moderate level compared with the open surgery procedures; this immunosuppression can be further diminished in spontaneous ventilation cases. The normal functioning of the immune defense is important in controlling the perioperative circulatory tumor cells. Moreover, elevated levels of inflammatory cytokines before immune therapy have a negative impact on the response, and significantly shorten the progression-free survival. Clinically, the lower are the levels of cytokines released during lung surgery, the lesser is the postoperative morbidity, especially pneumonia and wound infection. The return to normal levels of lymphocytes and cytokines occurs faster after spontaneous ventilation surgery. The use of locoregional anesthesia can also reduce SI. Herein, we review the current knowledge on the effects of different operative factors on postoperative SI and defense mechanism in lung cancer surgery.

Background: The major limitations of widespread use of non-intubated thoracic surgery (NITS) is the fear of managing complications. Here we present our practice of converting from uniportal video-assisted thoracic surgery (VATS) NITS to open NITS in cases of surgical complications. Methods: The study period was from January 26, 2017, to November 30, 2018. Total intravenous anesthesia was provided with propofol guided by bispectral index, and the airway was maintained with a laryngeal mask with spontaneous breathing. Local anesthesia with 2% lidocaine at the skin incision, and intercostal and vagus nerve blockades were induced using 0.5% bupivacaine. For conversion with surgical indications, a thoracotomy was performed at the incision without additional local or general anesthetics. Results: In 160 complete NITS procedures, there were 145 VATS NITS and 15 open NITS (9 conversions to open NITS and 6 intended NITS thoracotomies). In the 15 open NITS cases (2 pneumonectomies, 1 bilobectomy, 1 sleeve lobectomy, 7 lobectomies, 3 sublobar resections, 1 exploration), the mean operative time was 146.7 (105–225) and 110 (75–190) minutes in the converted and intended open NITS groups, respectively. There were no significant differences between systolic blood pressure (P=0.316; 95% CI, −10.469 to 3.742), sat O2% (P=0.27; 95% CI, −1.902 to 0.593), or propofol concentration in the effect site (P=0.053; 95% CI, −0.307 to 0.002) but significant differences in pulse (P=0.007; 95% CI, −10.001 to −2.72), diastolic blood pressure (P=0.013; 95% CI, −9.489 to −1.420) and in end-tidal CO2 (P=0.016; 95% CI, −7.484 to −0.952) before versus after thoracotomy, but there was no clinical relevance of the differences. Conclusions: For conversion with surgical indications during the VATS-NITS procedure, NITS thoracotomy can be performed safely at the site of the utility incision without the need for additional drugs, and the major lung resections can be performed through this approach.