Eur J Cardiothorac Surg 2006;30:529-532
© 2006 Elsevier Science NL
Video-assisted thoracic surgery utilizing local anesthesia and sedation
Mark R. Katlic*
Geisinger Wyoming Valley Medical Center, 1000 East Mountain Drive, Wilkes-Barre, PA 18711, USA
Received 6 April 2006;
received in revised form 12 June 2006;
accepted 26 June 2006.
* Corresponding author. Tel.: +1 570 820 6017; fax: +1 570 821 2306. (Email: mrkatlic{at}geisinger.edu).
 |
Abstract
|
|---|
Objective: Video-assisted thoracic surgery (VATS) is usually performed with general anesthesia and double-lumen endotracheal intubation, but minor procedures have been carried out with patients spontaneously breathing and with epidural or regional analgesia. We have broadened our indications for VATS utilizing purely local anesthesia and sedation. Methods: The medical records of all patients undergoing VATS under local anesthesia and sedation at Geisinger Wyoming Valley Medical Center between 7/1/02 and 6/1/06 were reviewed. All procedures were performed in the operating room with patients in full lateral position; no patient had endotracheal intubation or epidural or nerve block analgesia. Results: One hundred and fifteen patients, ranging in age from 21 to 88 years and in size from 40 to 172 kg, underwent 126 video-assisted thoracic operations: pleural biopsy/effusion drainage with or without talc 81, drainage of empyema 21, lung biopsy 18, evacuate hemothorax 3, pericardial window 2, biopsy chest wall mass 1. No patient required intubation or conversion to thoracotomy. Three patients who underwent lung biopsy died of their underlying disease (cytomegalovirus and pneumocystis, primary amyloidosis, metastatic cancer to contra-lateral lung) on postoperative days 18, 14, and 4, respectively. One patient developed transient renal insufficiency attributed to ketorolac. Conclusion: VATS utilizing local anesthesia and sedation is well tolerated, safe, and valuable for an increasing number of indications.
Key Words: Video-assisted thoracic surgery (VATS) • Thoracoscopy • Anesthesia • Pleural effusion • Biopsy
|
1. Introduction
|
|---|
"There is a peculiarly sensitive interrelationship between the lungs, the root of the lungs, and the pleura in the opened human thorax, as if the mystic taboo of primitive man entered the lists against the surgeon. The heart may suddenly cease to beat; respiration may stop without warning. Only general anaesthesia ... can with absolute certainty prevent the nervous reflexes described above from occurring in the course of an operation."
—Ferdinand Sauerbruch [1], regarding surgery prior to 1914
For 80 years thoracoscopy was performed through hollow tubes under local anesthesia [2,3]. The advent of safe general anesthesia, fiberoptic telescopes, and small stapling devices enabled present-day video-assisted thoracic surgery (VATS), including pulmonary lobectomy, esophagectomy, thymectomy, and other procedures. Some operations, however, do not require general anesthesia and endotracheal intubation, and there are risks to such anesthesia.
There have been reports of VATS utilizing less than general anesthesia, often for pleural disease. In 1987 Rusch and Mountain [3] used multiple intercostal blocks and a standard mediastinoscope for diagnosis and treatment of pleural problems in 46 patients. A decade later similar nerve block analgesia was used with modern fiberoptic equipment in patients with malignant effusions [4], and spontaneous pneumothorax [5]; and epidural analgesia has been employed for pulmonary nodules [6] and pneumothorax [7]. Local anesthesia and sedation have been utilized in Italy for pleural disease [8] and tried but abandoned for spontaneous pneumothorax in Switzerland [9].
Encouraged by the results treating pleural disease with VATS under local anesthesia – and success creating an unanticipated pericardial window in a patient undergoing surgery for a malignant pleural effusion – we broadened our indications for this technique.
|
2. Methods
|
|---|
The medical records of all patients undergoing VATS utilizing local anesthesia and sedation at Geisinger Wyoming Valley Medical Center between 7/1/02 and 6/1/06 were retrospectively reviewed. The author performed all procedures. Unsuccessful attempts at this technique were eligible for inclusion but there were none. The Geisinger Health System Institutional Research Review Board approved this research.
|
3. Technique
|
|---|
3.1 Selection criteria
Patients were not selected for this technique if any of the following pertained: hemodynamic instability, patient already intubated and ventilated, anticipated need for decortication, solitary pulmonary nodule, need for mediastinal dissection or biopsy, or pericardial effusion without coexisting large pleural effusion. All other patients with large unilateral pleural effusuin, empyema, and diffuse lung disease were offered local anesthesia and sedation (Table 1
). No patient was excluded based on age or comorbidity.
3.2 General
Patients are sedated with an individualized combination of midazolam, fentanyl, and propofol; a continuous infusion of propofol has been effective (starting at about 120 µg/kg/min and increasing as needed). Supplemental oxygen is administered via face mask and oxygen saturation, electrocardiogram, and blood pressure are monitored. End-tidal carbon dioxide may be monitored via a catheter tucked into an oral airway. Flexible bronchoscopy is carried out when indicated, then the patient is turned into full lateral position. Local anesthesia (1% xylocaine, 10–30 cm3 depending on number of incisions) is infiltrated into skin, then 1–3 two-centimeter incisions are made. Optimally, intercostal muscle and pleura are infiltrated under direct vision or palpation through the skin incision.
Contingency plans for intubation or conversion to thoracotomy (never used) include immediate placement of a chest tube through one incision and occlusive dressings to others, followed by turning the patient supine for intubation. Alternatively, a laryngeal mask airway may be placed with the patient in lateral position depending upon circumstances.
Elective patients are discharged on the same or next day, usually with a Heimlich valve attached to the chest tube. The chest tube is removed in the office as appropriate.
3.3 Pleural disease
One port is employed, with cup biopsy forceps and possible talc insufflation catheter passed along the outside wall of the short trocar (Endopath®, Ethicon). When necessary, e.g., for multiloculated empyema, a second site without trocar allows introduction of other instruments in order to disrupt adhesions.
3.4 Lung biopsy
Three incisions allow introduction of telescope via trocar, grasping ring forceps, and endoscopic stapling device. Finger palpation is performed as needed. Pleural adhesions may be divided bluntly or with scissors or cautery.
3.5 Pericardial window
If a pleural effusion co-exists, and the lung is thereby ‘accustomed’ to being collapsed, two sites will suffice, with grasper being passed alongside the telescope and an anterior site for 15 scalpel blade then endoscopic scissors. If necessary a third anterior-superior site allows the lung to be further retracted superiorly with a grasper or blunt instrument.
|
4. Results
|
|---|
One hundred and fifteen patients ranged in age from 21 to 88 years (mean 68, median 70) and in size from 40 to 172 kg. There were 62 women and 53 men. American Society of Anesthesiologists Physical Status Class were as follows: 1 (none), 2 (11 patients), 3 (72 patients), 4 (43 patients).
Diagnoses (Table 2
) included malignant pleural effusion in 51 patients, benign pleural effusion in 26, empyema in 21, lung disease in 18, mesothelioma in 5, hemothorax in 3, and pericardial effusion in 2.
The 126 procedures (Table 3
) included drainage of pleural effusion/pleural biopsy of 81 (65 with talc insufflation, 16 without talc), drainage of empyema 21, lung biopsy 18, evacuate chronic hemothorax 3, pericardial window 2, and biopsy chest wall mass 1. Mean operating times were as follows: effusion 24 min (range 10–54), empyema 22 min (range 8–60), lung biopsy 34 min (range 14–64), hemothorax 22 min (range 12–40), pericardial effusion 25 min (range 24–25), chest wall mass 33 min.
No patient required intraoperative intubation or epidural or nerve block analgesia. No patient required conversion to thoracotomy. Diagnosis was achieved, without need for additional procedure, in all cases of biopsy. No patient had awareness or memory of the operation. One patient developed transient renal insufficiency attributed to ketorolac. Three lung biopsy patients died of their underlying disease (cytomegalovirus and pneumocystis in an HIV-positive patient; primary amyloidosis; metastatic lung cancer to contra-lateral lung) on postoperative days 18, 14, and 4, respectively.
|
5. Discussion
|
|---|
General anesthesia and endotracheal intubation are a luxury rather than a necessity for many video-assisted thoracic operations, and this luxury is not entirely free. Admittedly, the collapsed quiet lung is easier to palpate (e.g., to find a solitary pulmonary nodule); this also facilitates access to the mediastinum and better overall visualization. Lengthy procedures are possible. However, deep anesthesia – with its hemodynamic consequences and slower recovery – is often necessary for the patient to tolerate an endotracheal tube, particularly a double-lumen tube. Muscle paralysis is usually needed. There is more potential for drying of the airway.
Patients tolerate VATS utilizing local anesthesia, sedation, and spontaneous ventilation. The obligatory unilateral pneumothorax turns out not to be a problem. Many patients are already accustomed to the lung being partially collapsed from effusion or empyema. Also, the ipsilateral lung receives both less ventilation and less perfusion with the patient in lateral position, resulting in less physiologic shunt than would be expected. Even patients with severe generalized interstitial lung disease (Fig. 1
) tolerated lung biopsy procedures.
View larger version (81K):
[in this window]
[in a new window]
|
Fig. 1. Two examples of patients who underwent lung biopsy under VATS with local anesthesia/sedation. (A) Computed tomogram of 46-year-old HIV-positive man; biopsy revealed cytomegalovirus and pneumocystis. (B) Chest radiograph of 70-year-old man; biopsy revealed multifocal lung adenocarcinoma.
|
|
Chhajed et al. [10] has shown that hypoventilation does occur with this technique, with mean 
rising from 13 to 52.3 mmHg (range 37–77 mmHg) and mean fall in oxygen saturation of 4.6% (range 1–14%). However, no complications occurred during procedures ranging from 30 to 68 min in duration. Nezu et al. [5] have shown little decrease in oxygen saturation. Transcutaneous monitoring of carbon dioxide tension will be a welcome addition to these cases.
Newer sedating drugs are wonderful supplements to the local anesthesia and careful manipulation of instruments. It is a rare patient who experiences any discomfort.
These cases require no special skills and are routinely performed by our residents under the authors’ guidance. The average case can be completed in 30 min, though patients will tolerate twice this duration if necessary. Our anesthesiology staff are so comfortable with this approach that they ask before every VATS case and appear disappointed when general anesthesia is requested.
In conclusion, VATS utilizing local anesthesia and sedation is well tolerated, safe, and valuable for an increasing number of indications. It eliminates the deleterious aspects of general anesthesia and endotracheal intubation. Whether it is globally better than general anesthesia for these selected patients will require prospective study.
|
References
|
|---|
- Sauerbruch F. Master Surgeon. New York: Thomas Y. Crowell Company; 1953p. 92.
- Jacobaeus H. The practical importance of thoracoscopy in surgery of the chest. Surg Gynecol Obstet 1922;34:289-296.
- Rusch VW, Mountain C. Thoracoscopy under regional anesthesia for the diagnosis and management of pleural disease. Am J Surg 1987;154(3):274-278.[CrossRef][Medline]
- Danby CA, Adebonojo SA, Moritz DM. Video-assisted talc pleurodesis for malignant pleural effusions utilizing local anesthesia and I.V. sedation. Chest 1998;113(3):739-742.[Abstract/Free Full Text]
- Nezu K, Kushibe K, Tojo T, Takahama M, Kitamura S. Thoracoscopic wedge resection of blebs under local anesthesia with sedation for treatment of a spontaneous pneumothorax. Chest 1997;111(1):230-235.[Abstract/Free Full Text]
- Pompeo E, Mineo D, Rogliani P, Sabato A, Mineo T. Feasibility and results of awake thoracoscopic resection of solitary pulmonary nodules. Ann Thorac Surg 2004;78(5):1761-1768.[Abstract/Free Full Text]
- Mukaida T, Andou A, Date H, Aoe M, Shimizu N. Thoracoscopic operation for secondary pneumothorax under local and epidural anesthesia in high-risk patients. Ann Thorac Surg 1998;65(4):924-926.[Abstract/Free Full Text]
- Migliore M, Giuliano R, Aziz T, Saad R, Sgalambro F. Four-step local anesthesia and sedation for thoracoscopic diagnosis and management of pleural diseases. Chest 2002;121(6):2032-2035.[Abstract/Free Full Text]
- Inderbitzi RG, Leiser A, Furrer M, Althaus U. Three years’ experience in video-assisted thoracic surgery (VATS) for spontaneous pneumothorax. J Thorac Cardiovasc Surg 1994;107(6):1410-1415.[Abstract/Free Full Text]
- Chhajed PN, Kaegi B, Rajasekaran R, Tamm M. Detection of hypoventilation during thoracoscopy: combined cutaneous carbon dioxide tension and oximetry monitoring with a new digital sensor. Chest 2005;127(2):585-588.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
J. E. Heffner and J. S. Klein
Recent Advances in the Diagnosis and Management of Malignant Pleural Effusions
Mayo Clin. Proc.,
February 1, 2008;
83(2):
235 - 250.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
1. Introduction
