Non-intubated uniportal video-assisted thoracoscopic lobectomy: expanding the boundaries of minimally invasive surgery while mindful of patient safety

Non-intubated uniportal video-assisted thoracoscopic lobectomy: expanding the boundaries of minimally invasive surgery while mindful of patient safety

Rafael Ribeiro Barcelos, Paula Ugalde Figueroa

Division of Thoracic and Cardiac Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA

Correspondence to: Paula Ugalde Figueroa, MD. Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham & Women’s Hospital, 75 Francis St., Boston, MA 02115, USA. Email:

Comment on: Wang H, Li J, Liu Y, et al. Non-intubated uniportal video-assisted thoracoscopic surgery: lobectomy and systemic lymph node dissection. J Thorac Dis 2020;12:6039-41.

Keywords: Non-intubated; uniportal video-assisted thoracoscopic surgery (uniportal VATS); lobectomy; lung cancer

Submitted Feb 13, 2023. Accepted for publication Feb 24, 2023. Published online Mar 30, 2023.

doi: 10.21037/jtd-23-218

The rapid evolution of surgical instrumentation and high-resolution video technology over the last two decades created a special momentum that allowed the refinement of video-assisted thoracoscopic surgery (VATS) lobectomy to a universal, feasible, and safer procedure that is widely used (1). In fact, minimally invasive surgery became the preferred approach for curative treatment of early-stage lung cancer and may be considered the gold standard when performed at an experienced center (2-4). Minimally invasive surgery has resulted in major improvements in postoperative pain control and decreased morbidity and mortality with faster recovery (5-7).

Although VATS lobectomy is usually performed through multiple ports, the first single-port VATS lobectomy [uniportal VATS (U-VATS)] was described in 2011 as a natural evolution of VATS techniques to reduce the number of thoracic incisions (8-10). The rapid adoption of U-VATS lobectomy in Asia and Europe has been primarily based on the potential benefits of shortened recovery as compared with multiport VATS techniques (11). The success of minimally invasive surgery has led to increased interest in even less invasive surgical methods, such as non-intubated VATS. The goal of non-intubated VATS is to avoid the adverse effects associated with general anesthesia and single-lung ventilation, such as ventilation-induced lung injury, intubation-related airway damage, nausea, and vomiting (12-14).

Thoracic operations without general anesthesia are not a novelty. In the 1950s, Buckingham and colleagues reported 617 major thoracic procedures (397 thoracoplasties, 64 pneumonectomies, 58 lobectomies, and 98 others) performed under epidural anesthesia and sedation (15). Unfortunately, this paper does not describe surgical outcomes in these patients, and all these surgeries occurred prior to the advent of the single-lung ventilation technique. Non-intubated VATS emerged in 1997 with a retrospective study of lung resections performed under local anesthesia. In this study, 34 patients with spontaneous pneumothorax underwent wedge resection of blebs, with 2 patients requiring conversion to general anesthesia and thoracotomy due to the development of empyema and intraoperative dyspnea. When compared with 38 patients placed under general anesthesia, the results favored surgery with local anesthesia, because local anesthesia was associated with a shorter hospital stay (mean 4.5 vs. 5.8 days, P<0.05) (16).

The first non-intubated U-VATS lobectomy was reported in 2014. The patient underwent a right middle lobectomy for a 1.5-cm nodule. A laryngeal mask was used to control the airway, and no epidural anesthesia was used. Pain management in the skin and intercostal space that was satisfactory for surgery was achieved by infiltration of levobupivacaine. The surgical procedure was successful, and the patient was discharged 36 hours after the surgery (17).

Numerous studies have demonstrated that non-intubated VATS procedures have positive short-term outcomes, including reduced postoperative fasting times, shorter hospital stays, and lower complication rates (18,19). However, the potential long-term impacts must be considered, as these procedures pose a greater challenge to an oncologically sound resection due to spontaneous ventilation during lung resection and lymph node dissection. Further research is needed through multi-center randomized clinical trials with extended follow-up periods to confirm the long-term efficacy of this approach (20,21).

In 2020, Wang and colleagues published a surgical technique description and video of non-intubated uniportal VATS left lower lobectomy and systemic lymph node dissection in the Journal of Thoracic Disease (22). The publication detailed the clinical case of a 37-year-old woman with a 4-cm tumor and no suspicion of hilar or mediastinal disease in a computed tomography (CT) scan. The airway was controlled with ventilation through a laryngeal mask. According to the authors, a key element to achieving adequate exposure and making the procedure safe is performing selective intercostal nerve blocking and spraying local anesthetic on the surface of the pleura to abolish the cough reflex. They present a nice video of lung resection with lymph node dissection, demonstrating how feasible the technique is in the hands of experienced surgeons and anesthetists (22).

The adoption of emerging techniques, such as non-intubated U-VATS lobectomy, by surgeons at academic centers is generally planned, with a strategy to implement the new procedure with all outcomes measured and controlled. Patient safety is of paramount importance when developing new surgical techniques, and a step-wise plan helps ensure safe implementation. To achieve proficiency, where the highest safety parameters are met and sound surgical principles are maintained according to international guidelines, an apprenticeship period must be surpassed.

Because patient safety is an essential consideration during surgery, it is imperative to develop an emergency intubation plan before starting non-intubated thoracic surgery. To minimize the patient’s risk, the team must develop alternative strategies for the surgery and anesthesia in case of any complications or surgical difficulties, and should not hesitate to change to general anesthesia if necessary (22). Contraindications for non-intubated major pulmonary resection using VATS can vary among medical teams. Some common contraindications, based on the experience of Gonzalez-Rivas and colleagues, include anticipated difficulty with airway management as evaluated by anesthesiologists, body mass index (BMI) greater than 30, an inexperienced surgical team, persistent coughing, extensive pleural adhesions or prior pulmonary resections, hypoxemia [partial pressure of oxygen (PaO2) <60 mmHg] or hypercarbia [partial pressure of carbon dioxide (PCO2) >50 mmHg], and procedures requiring isolation of the contralateral lung (12).

The publication of Wang and colleagues provides a valuable description of a surgical technique to perform a non-intubated uniportal VATS for a lobectomy and lymph node dissection that will help surgeons improve their outcomes and benefit patients. We appreciate the invitation to comment on this technical report and congratulate the authors for their work thus far. We hope their publication will stimulate more robust studies on this subject, which are vital for patients undergoing surgery for lung cancer.


Funding: None.


Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Thoracic Disease. The article did not undergo external peer review.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

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  1. Swanson SJ, Herndon JE 2nd, D'Amico TA, et al. Video-assisted thoracic surgery lobectomy: report of CALGB 39802--a prospective, multi-institution feasibility study. J Clin Oncol 2007;25:4993-7. [Crossref] [PubMed]
  2. National Comprehensive Cancer Network. Non-small cell lung cancer NCCN guidelines version 3. 2019. Available online:
  3. Howington JA, Blum MG, Chang AC, et al. Treatment of stage I and II non-small cell lung cancer: Diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2013;143:e278S-313S.
  4. Lim E, Batchelor TJP, Dunning J, et al. Video-assisted thoracoscopic or open lobectomy in early-stage lung cancer. NEJM Evid 2022;1: [Crossref]
  5. Stephens N, Rice D, Correa A, et al. Thoracoscopic lobectomy is associated with improved short-term and equivalent oncological outcomes compared with open lobectomy for clinical Stage I non-small-cell lung cancer: a propensity-matched analysis of 963 cases. Eur J Cardiothorac Surg 2014;46:607-13. [Crossref] [PubMed]
  6. Yang CJ, Kumar A, Klapper JA, et al. A National Analysis of Long-term Survival Following Thoracoscopic Versus Open Lobectomy for Stage I Non-small-cell Lung Cancer. Ann Surg 2019;269:163-71. [Crossref] [PubMed]
  7. Boffa DJ, Kosinski AS, Furnary AP, et al. Minimally Invasive Lung Cancer Surgery Performed by Thoracic Surgeons as Effective as Thoracotomy. J Clin Oncol 2018;36:2378-85. [Crossref] [PubMed]
  8. McKenna RJ Jr. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. J Thorac Cardiovasc Surg 1994;107:879-81; discussion 881-2. [Crossref] [PubMed]
  9. Burfeind WR, D’Amico TA. Thoracoscopic lobectomy. Oper Tech Thorac Cardiovasc Surg 2004;9:98-114. [Crossref]
  10. Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12:514-5. [Crossref] [PubMed]
  11. Harris CG, James RS, Tian DH, et al. Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer. Ann Cardiothorac Surg 2016;5:76-84. [Crossref] [PubMed]
  12. Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated video-assisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2016;49:721-31. [Crossref] [PubMed]
  13. Gothard J. Lung injury after thoracic surgery and one-lung ventilation. Curr Opin Anaesthesiol 2006;19:5-10. [Crossref] [PubMed]
  14. Schilling T, Kozian A, Huth C, et al. The pulmonary immune effects of mechanical ventilation in patients undergoing thoracic surgery. Anesth Analg 2005;101:957-65. [Crossref] [PubMed]
  15. Buckingham WW, Beatty AJ, Brasher CA, et al. The technique of administering epidural anesthesia in thoracic surgery. Dis Chest 1950;17:561-8. [Crossref] [PubMed]
  16. Nezu K, Kushibe K, Tojo T, et al. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111:230-5. [Crossref] [PubMed]
  17. Gonzalez-Rivas D, Fernandez R, de la Torre M, et al. Single-port thoracoscopic lobectomy in a nonintubated patient: the least invasive procedure for major lung resection? Interact Cardiovasc Thorac Surg 2014;19:552-5. [Crossref] [PubMed]
  18. Liu J, Cui F, Li S, et al. Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study. Surg Innov 2015;22:123-30. [Crossref] [PubMed]
  19. Wen Y, Liang H, Qiu G, et al. Non-intubated spontaneous ventilation in video-assisted thoracoscopic surgery: a meta-analysis. Eur J Cardiothorac Surg 2020;57:428-37. [PubMed]
  20. Prisciandaro E, Bertolaccini L, Sedda G, et al. Non-intubated thoracoscopic lobectomies for lung cancer: an exploratory systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2020;31:499-506. [Crossref] [PubMed]
  21. Deng HY, Zhu ZJ, Wang YC, et al. Non-intubated video-assisted thoracoscopic surgery under loco-regional anaesthesia for thoracic surgery: a meta-analysis. Interact Cardiovasc Thorac Surg 2016;23:31-40. [Crossref] [PubMed]
  22. Wang H, Li J, Liu Y, et al. Non-intubated uniportal video-assisted thoracoscopic surgery: lobectomy and systemic lymph node dissection. J Thorac Dis 2020;12:6039-41. [Crossref] [PubMed]
Cite this article as: Barcelos RR, Figueroa PU. Non-intubated uniportal video-assisted thoracoscopic lobectomy: expanding the boundaries of minimally invasive surgery while mindful of patient safety. J Thorac Dis 2023;15(4):1536-1538. doi: 10.21037/jtd-23-218

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