Nonintubated thoracoscopic lung resection: a 3-year experience with
285 cases in a single institution
1Division of Thoracic Surgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of
Medicine, Taipei, Taiwan; 2Department of Anesthesiology, National Taiwan University Hospital and National Taiwan University College of
Medicine, Taipei, Taiwan; 3Department of Surgery, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
Objective: Tracheal intubation with one-lung ventilation is considered mandatory for thoracoscopic surgery. This study
reported the experience of thoracoscopic lung resection without endotracheal intubation in a single institution.
Methods: From August 2009 through July 2012, 285 consecutive patients were treated by nonintubated thoracoscopic
surgery using epidural anesthesia, intrathoracic vagal blockade, and sedation for lobectomy, segmentectomy, or wedge
resection in a tertiary medical center. The feasibility and safety of this technique were evaluated.
Results: The final diagnosis for surgery were primary lung cancer in 159 patients (55.8%), metastatic lung cancer in
17 (6.0%), benign lung tumor in 104 (36.5%), and pneumothorax in 5 (1.8%). The operative methods consisted of
conventional (83.2 %) and needlescopic (16.8%) thoracoscopic surgery. The operative procedures included lobectomy
in 137 patients (48.1%), wedge resection in 132 (46.3%), and segmentectomy in 16 (5.6%). Collapse of the operative lung
and inhibition of coughing were satisfactory in most of the patients. Fourteen (4.9%) patients required conversion to tracheal
intubation because of significant mediastinal movement , persistent hypoxemia , dense pleural adhesions , ineffective
epidural anesthesia , bleeding , and tachypnea . One patient (0.4%) was converted to thoracotomy because of
bleeding. No mortality was noted in our patients.
Conclusions: Nonintubated thoracoscopic lung resection is technically feasible and safe in selected patients. It can be a
valid alternative in managing patients with pulmonary lesions.
Anesthesia; tracheal intubation; lobectomy; lung cancer; thoracoscopy; segmentectomy; wedge resection
J Thorac Dis 2012;4(4):347-351. DOI: 10.3978/j.issn.2072-1439.2012.08.07
Since the introduction of the double-lumen endotracheal tube,
intubated general anesthesia with one-lung ventilation has
been considered mandatory in both open and video-assisted
thoracoscopic surgery (VATS) (1
). However, adverse effects of
intubated general anesthesia occur after the operation and they
include intubation-related complications, ventilator-induced
lung injury, impaired cardiac performance, and postoperative
nausea and vomiting (2-5
). In order to reduce the adverse effects
of tracheal intubation and general anesthesia, thoracoscopic
surgery without tracheal intubation has been recently employed
for management of pneumothorax (6-8
), resection of pulmonary
), resection of solitary metastases (13
), lung volume
reduction surgery (14
), and even performing lobectomy (15
results achieved for these early surgeries are encouraging.
Although the feasibility of thoracoscopic surgery via
nonintubated anesthesia was demonstrated in some reports,
most of them are limited to small number of cases. In this
study, we reported our experience of 285 consecutive patients
undergoing nonintubated VATS or nonintubated needlescopic
VATS in a 3-year period of time to evaluate the feasibility, safety,
and indication of this innovative technique.
Patients and methods
Study design and patients
The medical records of all patients who underwent nonintubated VATS at National Taiwan University Hospital and National
Taiwan University Hospital Yun-Lin Branch, a 3,200-bed
tertiary medical center, from August 2009 to July 2012, were
retrospectively reviewed. The thoracic surgical team, both
surgeons and anesthesiologists, selected the cases upon review
of the medical records. Patients considered appropriate for
nonintubated VATS met the same criteria as for intubated
VATS. Patients with American Society of Anesthesiologists
(ASA) scores of greater than 3, bleeding disorders, sleep apnea,
or unfavorable airway or spinal anatomy were contraindicated
for nonintubated VATS in our hospital. Patient consent was
obtained after explaining the type of anesthesia and the surgical
Anesthetic setting, induction, and maintenance
Anesthetic techniques were described previously (10
Patients were pre-medicated with fentanyl 50-100 μg intravenously
(IV) and were continuously monitored electrocardiographically,
along with pulse oxymetry, respiratory rate, blood pressure, body
temperature, and urine output. Monitoring of central venous
pressure was optional. Thoracic epidural anesthesia was performed
by insertion of an epidural catheter at the T5/6 thoracic interspace
to achieve a sensory block between the T2 and T9 dermatomes,
and was maintained by continuous infusion of 2% lidocaine. Endtidal
carbon dioxide (ETCO2) was continuously monitored by
insertion of a detector into one nostril. The patient was then
asked to turn him or herself into the lateral decubitus position.
Sedation was then started by intravenous infusion of propofol
(10 mg/mL) using a target-controlled infusion method, with
incremental fentanyl injection to maintain the patient in a mildly
sedated, but communicable and cooperative level (Ramsay
sedation score III), responding to commands only (16
During the procedure, patients breathed O2 through a
ventilation mask, keeping oxygen saturation above 90%. An
iatrogenic pneumothorax was made by creating incisions
through the chest wall for thoracoscopy and the ipsilateral lung
collapsed gradually. To inhibit coughing during thoracoscopic
manipulation in selected patients, intrathoracic vagal blockade
was produced by infiltration of 2 mL of 0.25% bupivacaine
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, under direct thoracoscopic
vision. This procedure effectively inhibited the cough reflex
for 3 or more hours and was mandatory for lobectomy and
segmentectomy, especially before anatomical dissection of
the pulmonary hilum. Repeated bupivacaine infiltration was
occasionally needed in prolonged operations. During the
thoracoscopic procedure, the respiration rate was 12-20/min.
During wound closure and chest tube insertion, propofol
infusion was stopped. After the patient was fully awake, the
patient was asked to breathe deeply and cough to re-expand the
collapsed lung. The epidural catheter was used for postoperative
pain control during the following days.
Technique of thoracoscopic surgery
The detailed surgical setting and procedures performed in
our group were described before (10
lobectomy, segmentectomy, or wedge resection was performed
using a 3-port method, as described by McKenna (17
). In brief,
the patient was positioned in the full-lateral decubitus position,
with slight flexion of the table at the level of the mid-chest. The
thoracoscope was placed into the seventh or eighth intercostal
space in the midaxillary line. A working port was placed in the
sixth or seventh intercostal space in an auscultatory triangle,
and an anterior 3 cm incision was placed anteriorly in the fifth
intercostal space. After collapse of the lung, incomplete fissures,
pulmonary vessels, and bronchi were divided with endoscopic
stapling devices. The resected specimen was removed in an
organ retrieval bag through the utility incision. After staging
mediastinal lymph node dissection, a 28-French chest tube was
placed through the lowest incision. Rib spreading, rib cutting, and
retractor use were avoided in all patients, except when conversion
to thoracotomy was required. Conversion from nonintubated
anesthesia to intubated general anesthesia or from thoracoscopic
surgery to thoracotomy was decided by the attending surgeon
and anesthesiologist. Conversion from nonintubated to intubated
anesthesia was performed when epidural anesthesia was ineffective,
hypoxemia persisted (SP
<80%), hemodynamic status was
unstable, or intraoperative bleeding requiring thoracotomy. When
conversion was indicated, the surgical wounds were sealed with
transparent waterproof dressings (Tegaderm Film, 3M Health
Care, Neuss, Germany) after insertion of a chest tube to re-expand
the lung. A single-lumen endotracheal tube was inserted under the
guidance of a bronchoscope, followed by insertion of a bronchial
blocker without changing the patient’s position.
After the operation, chest radiography was performed
immediate or the next morning. Drinking and meal intake were
resumed 2-4 hours after surgery. The chest tube was removed if
no air leak was present and drainage was less 200 mL in a 24-hour
Technique of needlescopic VATS
Needlescopic VATS was mainly used for biopsy of undiagnosed peripheral lung nodules. The technique was described
). Briefly, of Two sets of independent videothoracoscopic
equipment and monitors (HD Endoscopy
System, Karl Storz, Tuttlingen, Germany), one for needlescopic
videothoracoscopy and the other for 10-mm videothoracoscopy,
were used simultaneously to save time switching scopes (28
An incision of about 15 mm in length was made in the sixth
intercostal space on the midaxillary line and a 12-mm thoracic
port was inserted through the incision. Two or three small
skin punctures were made and mini-ports were inserted for
the needlescopic instruments (3-mm instruments, Olympus,
Tokyo, Japan). Initially, the 10-mm telescope and two miniendograspers
were used to identify the nodule. Once the nodule
was identified, it was stabilized using the mini-endograsper. The
mini-endograsper in the other mini-port was withdrawn and
a needlescope was introduced to visualize the tumor. The
10-mm telescope was then withdrawn and a 45-mm endoscopic
stapler was introduced for partial lung resection including the
nodule. Resected tissue was placed into a bag inserted through
the 12-mm port and was taken out of the thoracic cavity. Upon
completion of the procedure, a chest tube was inserted via the
Data collection and analyses
The data including patient demographics, complications, and the
surgical results were collected from the institutional database,
anesthesia and surgical notes, and the medical and nursing
From August 2009 through July 2012, nonintubated
thoracoscopic lung resection was performed on 285 patients. The
demographic data of the patients are shown in Table 1
. The mean
patient age was 59.2 years and 107 patients (37.5%) were male.
Conventional VATS was performed in 237 patients (83.2%), while
needlescopic VATS was performed in 48 patients. One patient
received bilateral VATS for lesions in both lungs (11
procedures included lobectomy in 137 patients (48.1%),
followed by wedge resection and segmentectomy.
|Table 1. Clinical characteristics of the patients.
| Conventional VATS
| Needlescopic VATS
| Lung cancer
| Metastatic cancer
| Benign lung tumor
|aMean ± standard deviation (median, range); VATS = video-assisted thoracoscopic surgery.
The operative and anesthetic results are shown in Table 2
The mean duration of anesthesia induction was 34.3 minutes.
Fourteen (4.9%) patients required conversion to tracheal
intubation because of significant mediastinal movement ,
persistent hypoxemia , dense pleural adhesions ,
ineffective epidural anesthesia , bleeding , and tachypnea 
). Conversion to a thoracotomy was required in one
patient with blood transfusion due to bleeding during dissection
of pulmonary artery. After the surgery, anesthetic side effects
were noted in 23 patients (8.1%) including vomiting, sore throat, and headache. Operation complications were noted in
11 patients (3.9%) including air leaks >5 days, bleeding, and
pneumonia. No mortality or major complications were noted.
|Table 2. Treatment outcome of nonintubated thoracoscopic lung resection.
|Anesthetic side effects (%)
| Vomiting requiring medication (%)
| Sore throat (%)
|Operation complications (%)
| Air leaks >5 days
|Conversion to tracheal intubation (%)
| Wedge resection
|Conversion to thoracotomy (%)
|Table 3. Causes of conversion to tracheal intubation.
|Significant mediastinal movement
|Dense pleural adhesions
|Ineffective epidural anesthesia
Since the introduction of thoracoscopic surgery, intubated
general anesthesia with one-lung ventilation has been considered
mandatory for lung resection. To avoid intubation-related or
mechanical ventilation-associated complications, thoracoscopic
surgery without endotracheal intubation has recently been tried in
selected patients. However, the number of patients in the published
reports is small (2
). This is the first report of nonintubated
thoracoscopic lung resection applied in large number of patients.
Our results showed that nonintubated VATS is feasible and safe for
lobectomy, segmentectomy, and wedge resection.
Some concerns might arise with the use of nonintubated
epidural anesthesia for pulmonary resection, especially for
patients with compromised respiratory function. First, prolonged
one-lung breathing during surgery could lead to hypoxia and
hypercapnia in patients with already compromised respiratory
function. Secondly, epidural anesthesia-associated sympathetic
blockade could lead to increased bronchial tone and airway
hyperreactivity. Thirdly, lung movement and inadequate lung
collapse would make hilar dissection more difficult. Fourthly,
conversion to general anesthesia with intubation could be
required occasionally (15
To prevent respiratory failure, we selected patients with
good cardiopulmonary reserve during the learning curve of this
cohort. In most of the patients, SP
was maintained at 90%
or more during the whole operation. Hypercapnea was noted
in some patients, especially when the surgery was long. Our
experience showed that hypercapnia was permissive and did not
affect the hemodynamics and surgical procedures, which was
comparable to a recently published report by Dr. Dong et al.
Increased bronchial tone and airway hyper-reactivity during
manipulation of the pulmonary hilum was a major obstacle when
performing nonintubated lobectomy or segmentectomy. Using
simple intrathoracic vagal blockade, we found that the cough
reflex could be effectively abolished, without affecting the heart
rate, breathing rate, and blood pressure (15
Although non-intubated thoracoscopic lung resection could
provide an attractive alternative in managing patients with lung
diseases, they should be cautious until judicious evaluation of
the benefits and risks is complete. Fourteen patients (4.9%) in
the nonintubated group required conversion to intubated onelung
ventilation because of significant mediastinal movement,
persistent hypoxemia, dense pleural adhesions, ineffective
epidural anesthesia, bleeding, and tachypnea. We suggest that
proper patient selection, accumulated experience by performing
minor non-intubated thoracoscopic procedures, and conversion to intubated general anesthesia without hesitation are mandatory
to decrease the risk of emergency intubation and complications,
especially at the beginning of the learning curve.
In our cohort, almost two third of the patients were women.
We believe that nonintubated thoracoscopic surgery is most
applicable in small body-sized female patients. These patients
are prone to have small tracheal caliber and are susceptible
to intubation-related complications such as sore throat,
hoarseness, and subglottic stenosis, especially when doublelumen
endotracheal tubes are used. Using the nonintubated
technique, we found that the rates of postoperative sore throat
were significantly decreased. It is reasonable to suggest that the
incidence of hoarseness and tracheal injury could also have been
lower, although they were not investigated in this study.
Many of our patients presented with an undetermined solitary
pulmonary nodule when undergoing thoracoscopic surgery.
A previous study showed that wedge resection of benign lung
nodules can be performed by awake thoracoscopic surgery (9
One of the major concerns of the awake technique is that when
the frozen section shows malignancy, the procedure must
be converted to intubated general anesthesia for subsequent
lobectomy. Using our nonintubated technique, both the
diagnosis of the pulmonary nodules and curative resection of the
lung cancer can be performed under the same type of anesthesia.
Our technique extends the indication of nonintubated anesthetic
technique to a wider application. A comparison among different
types of nonintubated anesthesia techniques and applicable
thoracoscopic procedures is provided in Table 4
|Table 4 Comparison among different nonintubated anesthesia techniques and the applicable thoracoscopic procedures [modified from
works of Dr. Tseng et al. (10)].
|Local anesthesia + IV sedation
|Epidural anesthesia + IV sedation
|Epidural anesthesia + IV sedation + vagal blockade
|aIncluding pleural biopsy and management of pneumothorax and empyema; +, Technically feasible; –, Technically infeasible; IV, intravenous.
The anesthetic side effects were minimal in this patient
cohort. In a previous study of intubated one-lung ventilation for
thoracoscopic lobectomy, 40% of patients required medication
for control of vomiting and 37% had a sore throat (15
). In this
study, the rates were 4.2% and 2.2%, respectively. We attribute
these results to the avoidance of tracheal intubation and muscle
We acknowledge that this study was limited by its retrospective
design and the lack of a control group for comparison.
Nonetheless, the low conversion rate from nonintubated to
intubated anesthesia and the low complication rate indicate that
nonintubated VATS can be safely performed in selected patients.
Nonintubated thoracoscopic lung resection is safe and
technically feasible. Avoidance of intubation, mechanical
ventilation, muscle relaxants, and routine use of perioperative
epidural anesthesia in these patients was reflected in less
intubation-associated discomfort, and immediate return to
many daily life activities including drinking, eating, and walking.
Nonintubated thoracoscopic surgery is a less invasive surgery
than traditional thoracoscopy due to the combination of less thoracic trauma and less invasive anesthesia. Although the longterm
outcome and benefits remain unclear, we believe that it
can be a valid alternative of one-lung ventilated thoracoscopic
surgery in managing patients requiring lung resection.
Disclosure: The authors declare no conflict of interest.
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Cite this article as: Chen KC, Cheng YJ, Hung MH,
Tseng YD, Chen JS. Nonintubated thoracoscopic lung
resection: a 3-year experience with 285 cases in a single
institution. J Thorac Dis 2012;4(4):347-351. doi: