Fabo Csongor, Oszlanyi Adam, Lantos Judit, Rarosi Ferenc, Horvath Theodor, Barta Zsanett, Nemeth Tibor, Szabo Zsolt
Department of Anesthesiology and Intensive Care, University of Szeged, Szeged, Hungary.
Department of Cardiac Surgery, Zala County St. Raphael Hospital, Zalaegerszeg, Hungary.
Front Surg. 2022 Feb 11;8:818456. doi: 10.3389/fsurg.2021.818456. eCollection 2021.
In the last few decades, surgical techniques have been developed in thoracic surgery, and minimally invasive strategies such as multi-and uniportal video-assisted thoracic surgery (VATS) have become more favorable even for major pulmonary resections. With this surgical evolution, the aesthetic approach has also changed, and a paradigm shift has occurred. The traditional conception of general anesthesia, muscle relaxation, and intubation has been re-evaluated, and spontaneous breathing plays a central role in our practice by performing non-intubated thoracoscopic surgeries (NITS-VATS).
We performed a computerized search of the medical literature (PubMed, Google Scholar, Scopus) to identify relevant articles in non-intubated thoracoscopic surgery using the following terms [(non-intubated) OR (non-intubated) OR (awake) OR (tubeless) OR (regional anesthesia)] AND [(VATS) OR (NIVATS)], as well as their Medical Subject Headings (MeSH) terms.
Based on the outcomes of the reviewed literature and our practice, it seems that pathophysiological concerns can be overcome by proper surgical and anesthetic management. All risks are compensated by the advantageous physiological changes that result in better patient outcomes. With the maintenance of spontaneous breathing, the incidence of potential adverse effects of mechanical ventilation, such as ventilator-induced lung injury and consequent postoperative pulmonary complications, can be reduced. The avoidance of muscle relaxants also results in the maintenance of contraction of the dependent hemidiaphragm and lower airway pressure levels, which may lead to better ventilation-perfusion matching. These techniques can be challenging for surgeons as well as for anesthetists; hence, a good knowledge of physiological and pathophysiological changes, clear inclusion and exclusion and intraoperative conversion criteria, and good communication between team members are essential.
NITS-VATS seems to be a feasible and safe method in selected patients with evolving importance as a part of the minimally invasive surgical and anesthetic conception and has a role in reducing perioperative complications, which is crucial in the thoracic surgical patient population.
在过去几十年中，胸外科手术技术不断发展，多通道和单通道电视辅助胸腔镜手术（VATS）等微创策略即使对于大型肺切除术也变得更受青睐。随着这种手术的发展，美学方法也发生了变化，出现了范式转变。全身麻醉、肌肉松弛和插管的传统观念已被重新评估，在我们的实践中，通过实施非插管胸腔镜手术（NITS-VATS），自主呼吸发挥着核心作用。
我们对医学文献（PubMed、谷歌学术、Scopus）进行了计算机检索，以使用以下术语[(非插管)或(非插管)或(清醒)或(无管)或(区域麻醉)]以及[(VATS)或(NIVATS)]及其医学主题词（MeSH）术语来识别非插管胸腔镜手术中的相关文章。
根据综述文献的结果和我们的实践，似乎通过适当的手术和麻醉管理可以克服病理生理方面的问题。所有风险都由有利于患者预后的生理变化所补偿。通过维持自主呼吸，可以降低机械通气潜在不良反应的发生率，如呼吸机诱导的肺损伤及随之而来的术后肺部并发症。避免使用肌肉松弛剂还能维持依赖侧半膈肌的收缩和较低的气道压力水平，这可能导致更好的通气-灌注匹配。这些技术对外科医生和麻醉医生来说都具有挑战性；因此，充分了解生理和病理生理变化、明确的纳入和排除标准以及术中转换标准，以及团队成员之间良好的沟通至关重要。
NITS-VATS似乎是一种在特定患者中可行且安全的方法，作为微创外科和麻醉理念的一部分，其重要性不断增加，并且在减少围手术期并发症方面发挥着作用，这在胸外科患者群体中至关重要。
