To evaluate the feasibility and safety of thoracoscopic lobectomy without endotracheal intubation. General anesthesia with single-lung ventilation is considered mandatory for thoracoscopic lobectomy for non-small cell lung cancer (NSCLC). Nonintubated thoracoscopic lobectomy has not been reported previously. From August 2009 through June 2010, some 30 consecutive patients with clinical stage I or II NSCLC were treated by nonintubated thoracoscopic lobectomy using epidural anesthesia, intrathoracic vagal blockade, and sedation. To evaluate the feasibility and safety of this novel technique, they were compared with a control group consisting of 30 consecutive patients with clinical stage I or II NSCLC who underwent thoracoscopic lobectomy using intubated general anesthesia from August 2008 through July 2009. Collapse of the operative lung and inhibition of coughing were satisfactory in the nonintubated patients, induced by spontaneous breathing, and vagal blockade. Three patients in the nonintubated group required conversion to intubated-single lung ventilation because of persistent hypoxemia, poor epidural anesthesia pain control, and bleeding. One patient in each group was converted to thoracotomy because of bleeding. The 2 groups had comparable anesthesia durations, surgical durations, blood loss, and numbers of dissected lymph nodes. Patients who underwent nonintubated surgery had lower rates of sore throat (6.7% vs 40.0%, P = 0.002) and earlier resumption of oral intake (mean, 4.7 hours vs 18.8 hours, P < 0.001). Patients undergoing nonintubated surgery also had a trend toward better noncomplication rates (90% vs 66.7%, P = 0.057) and shorter postoperative hospital stays (mean, 5.9 days vs 7.1 days, P = 0.078). Nonintubated thoracoscopic lobectomy is technically feasible and is as safe as lobectomy performed with intubation in highly selected patients. It can be a valid alternative of single-lung-ventilated thoracoscopic surgery in managing early-stage NSCLC.

Thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation without endotracheal intubation is a promising technique for selected patients, but little is known about its feasibility and safety. We evaluated 109 patients with lung (105), mediastinal (3) or pleural (1) tumours treated using non-intubated thoracoscopic surgery. Internal, intercostal nerve block was performed at the T3–T8 intercostal level and vagal block was performed adjacent to the vagus nerve at the level of the lower trachea for right-sided operations and at the level of the aortopulmonary window for left-sided operations. Sedation was performed with propofol infusion to achieve a bispectral index value between 40 and 60. Thoracoscopic lobectomy was performed in 43 patients, wedge resection in 50, segmentectomy in 12 and mediastinal or pleural tumour excision in 4. Three patients (2.8%) required conversion to intubated one-lung ventilation because of vigorous mediastinal movement and dense diaphragmatic adhesions. Anaesthetic induction and operation had a median duration of 10.0 and 127.0 min, respectively. Operative complications developed in 13 patients with air leaks for more than 3 days and 1 patient required transfusion of blood products. The median postoperative chest drainage and hospital stay were 2.0 and 4.0 days, respectively. Non-intubated thoracoscopic surgery using internal intercostal nerve block, vagal block and targeted sedation is technically feasible and safe in surgical treatment of lung, mediastinal and pleural tumours in selected patients.

Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution