Surgical tips for a Non-intubated Uniportal VATS RLL lobectomy

Two days ago I performed a uniportal VATS right-lower lobectomy under spontaneous breathing in a middle age woman with a slow growth adenocarcinoma without clinical nodal involvement.

From a surgical point of view, strict selection criteria are mandatory, because these procedures can not be safely performed in all patients. It is important that the patient is not obese; despite there is no consensus of BMI limit, probably lower than 25 are the best patients (not easy in western countries!). Second, exclude patients with poor respiratory function (DLCO<30%, ppoFEV1<30%, PaO2<60 mmHg), and if possible, select patients with normal or minimally lowered parameters. Exclude also patients with ASA>3 and with predicted difficult airway should a complication happens. And I reccomend that you select easy cases for anatomical major resections such as lobectomies and anatomical segmentectomies; don't try with difficult cases because the nonintubated approach adds some inherent difficulties.

Second, I gave up the initial idea that we performed succesfully of doing major resections in an awake patient: forget that, perform the anatomical resection in a patient under spontaneous breathing but not awake; it is better to get deep sedation because it decreases the stress feeling of the patient that makes breathing deeper and mediastinal movement harder. The main challenge of major resections under deep sedation will be achieving a good balance between deep sedation and hypercapnia, as my colleague Dr Navarro will explain soon in a new post.

Third, set up everything for an emergent situation in two operating nurse tables: one including with the surgical instrumentation the sterile chest tube, sterile pleurevac and a dressing for closing the incision with the tube; and the other one with all necessary for the anesthesiologist should a conversion to intubation is required, including different sizes orotracheal tubes and laryngoscope.

Then, after positioning the patient in lateral decubitus and achieving deep sedation, I infiltrate with short action local anesthetic (lidocaine 2% i.e.) the skin incision, muscle layers and intercostal muscle space, while the assitant is scrubbing.

After entering the pleural cavity and putting the soft wound retractor, surgical pneumothorax makes the pleural pressure possitive so the lung collapses; it takes a few minutes until you get the definitive collapse, so keep calm.

It's very important that you perform then the regional analgesia technique, that in my case is the intercostal block with 1-1.5 cc of Bupivacaine 0.5% from 2 intercostal spaces above the incision to 2 spaces below. The regional block decreases the hypertensive response to pain, and makes the patient feel more comfortable so initial tachypnea progressively dissapears. Then I perform the vagal block, that in right procedures is better performed in the lower paratracheal area (4R), close to the vagus nerve: I pull gently the lung downwards with a sponge stick to avoid triggering cough, and using an irrigation system I inject 2-3 cc of Bupivacaine 0.5% below the mediastinal pleural until you see a kind of "bubble" there. Wait a couple of minutes and you will see that you can pull and push the lung without cough reflex.

Then it's time to operate as you would usually do; with these indications you will be able of perform safely the procedure for at least 3 hours, and if necessary, repeat the blockades. Depending on the balance of sedation and hypercapnia you achieve during the procedure, you will notice no mediastinal movement or some. A mild mediastinal movement during spontaneous breathing is not troublesome and lets you dissect and divide vascular structures without any risk; but if you notice that the mediastinal shift is getting harder, consider a conversion to general anesthesia and orotracheal intubation. Intraoperative non-invasive and invasive monitoring is mandatory to check the CO2 status.

If you feel uncomfortable during the RLL lobectomy due to the diaphragm contraction (remember the patient is under spontaneous breathing!), do not hesitate of blocking the phrenic nerve with 1-2 cc of bupivacaine 0.5%, but it is only necessary in strong contractions for dissecting the lower vein.

After finishing the procedure, test the air leak by immersion in saline solution and with a tight facial mask ventilation, so you can check your technique and the stapling lines.

Hope you find these indications useful, please leave your comments below and indicate if you like this publication!!!

(Author declares no conflict of interest)