Irons Joanne Frances, Martinez Guillermo
Department of Anaesthesia and Intensive Care, Papworth Hospital NHS Foundation Trust, Cambridge, UK.
J Vis Surg. 2016 Mar 23;2:61. doi: 10.21037/jovs.2016.02.22. eCollection 2016.
General anaesthesia with intubation and single lung ventilation has always been considered essential for thoracic surgery. Over the last decade there has been a huge evolution in thoracic surgery with the development of multiport and uniportal minimally invasive techniques. The development of a non-intubated technique during which thoracic surgery is performed on patients who are spontaneously ventilating awake, under minimal sedation with the aid of local or regional anaesthesia or under general anaesthesia with a supraglottic airway device is winning acceptance as a valid alternative technique. The concept is to allow the creation of a spontaneous pneumothorax as the surgeon enters the chest. This can provide excellent lung isolation without the need for positive pressure ventilation on the dependant lung. Awake and minimal sedation techniques, which avoid the need for general anaesthesia, maintain a more physiological cardiopulmonary and neurological status and avoid postoperative nausea and vomiting. However, general anaesthesia with a supraglottic airway device is the technique that provides a more stable airway and facilitates oxygenation in cases where an unexpected conversion to open thoracotomy in needed. For non-intubated thoracic surgery a regional analgesic technique is essential; nonetheless a 'multimodal' approach to analgesia is recommended. Non-intubated anaesthetic techniques for thoracic surgery are innovative and exciting and drive to reduce the invasiveness of the procedures. We recommend that centres starting out with non-intubated techniques begin by performing minor video-assisted thoracic surgery (VATS) procedures in selected low risk patients. Early elective conversion should be employed in any unexpected surgical difficulty or cardiopulmonary problem during the learning curve to reduce the risk of emergency conversion and complications. Further research is needed to establish which patients benefit more from the technique and what is the real impact on perioperative mortality and morbidity.
全身麻醉下插管并进行单肺通气一直被认为是胸外科手术的必要条件。在过去十年中，随着多端口和单端口微创技术的发展，胸外科手术有了巨大的进步。一种非插管技术正在被广泛接受，该技术是在局部或区域麻醉辅助下的轻度镇静或使用声门上气道装置的全身麻醉下，对清醒自主通气的患者进行胸外科手术。其理念是在外科医生进入胸腔时允许形成自发性气胸。这可以在无需对非依赖侧肺进行正压通气的情况下实现良好的肺隔离。清醒和轻度镇静技术避免了全身麻醉的需要，维持了更接近生理状态的心肺和神经状态，并避免了术后恶心和呕吐。然而，在需要意外转为开胸手术的情况下，使用声门上气道装置的全身麻醉技术能提供更稳定的气道并便于氧合。对于非插管胸外科手术，区域镇痛技术至关重要；尽管如此，仍推荐采用“多模式”镇痛方法。胸外科手术的非插管麻醉技术具有创新性且令人兴奋，旨在降低手术的侵入性。我们建议刚开始采用非插管技术的中心，先在选定的低风险患者中进行小型电视辅助胸腔镜手术（VATS）。在学习曲线期间，一旦出现任何意外的手术困难或心肺问题，应尽早进行选择性转换，以降低紧急转换和并发症的风险。还需要进一步研究以确定哪些患者能从该技术中获益更多，以及其对围手术期死亡率和发病率的实际影响。
