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Nonintubated Thoracoscopic Pulmonary Nodule Resection Under Spontaneous Breathing Anesthesia With Laryngeal Mask

Ambrogi, Marcello C. MD, PhD*; Fanucchi, Olivia MD; Korasidis, Stylianos MD*; Davini, Federico MD; Gemignani, Raffaello MD; Guarracino, Fabio MD; Melfi, Franca MD; Mussi, Alfredo MD*

Innovations:Technology and Techniques in Cardiothoracic and Vascular Surgery: July/August 2014 - Volume 9 - Issue 4 - p 276–280
doi: 10.1097/IMI.0000000000000075
Original Articles

Objective During the past 20 years, the use of video-assisted thoracoscopic surgery has increased as an important minimally invasive tool. To further reduce its invasiveness, after a preliminary experience, we decided to use a nonintubated spontaneous breathing general anesthesia, for video-assisted thoracoscopic surgery resection of lung nodule, using a laryngeal mask (LMA). This study aimed to verify the safety and the feasibility of this technique.

Methods Twenty consecutive patients who underwent thoracoscopic wedge of lung nodule under spontaneous breathing general anesthesia with LMA are the subjects of this study. Clinical data, American Society of Anesthesiologists status, Adult Comorbidity Evaluation–27 score, and Revised Cardiac Risk Index score were recorded for each patient. General inhalatory anesthesia (sevoflurane) was given in all cases through an LMA, without muscle relaxants, thus allowing spontaneous breathing. All procedures were performed in the lateral decubitus position. The maximum and minimum values of end-tidal carbon dioxide tension and oxygen saturation were recorded during the procedure. The level of technical feasibility was stratified by the operating surgeon according to four levels: excellent, good, satisfactory, and unsatisfactory.

Results There were 13 men and 7 women (mean age, 57 years). The mean induction anesthesia time was 6 minutes, whereas the mean operative time was 38 minutes. The values of oxygen saturation as well as minimum and maximum end-tidal carbon dioxide tension were 99.1%, 33.6 mm Hg, and 39.1 mm Hg, respectively. No mask displacement occurred. The mean operative time was 38 minutes (range, 25–90 minutes). The level of technical feasibility was defined as excellent in 19 cases and good in 1 case. No mortality occurred. Morbidity consisted of pleural effusion (one case), which was medically resolved. The mean postoperative stay was 3.5 days. Histopathologic results were one squamous cell lung cancer (lung primary), one adenocarcinoma (lung primary), five metastasis from colon cancer, four metastasis from breast cancer, three metastasis from renal cancer, three sarcoidosis, two amartocondroma, and one tuberculosis.

Conclusions Our experience suggests that thoracoscopic wedge resection of lung nodule is safe and feasible under spontaneous breathing anesthesia with LMA. This technique permits a confident manipulation of lung parenchyma and a safe stapler positioning, without cough, pain, or panic attack described for awake epidural anesthesia, avoiding the risks related to tracheal intubation and mechanical ventilation.

From the *Division of Thoracic Surgery, Department of Surgical, Medical, Molecular, and Critical Area Pathology, University of Pisa; †Division of Thoracic Surgery, CardioThoracic and Vascular Department, and ‡Division of Anesthesiology and Intensive Care, Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.

Accepted for publication January 9, 2014.

Presented at the Annual Scientific Meeting of the International Society for Minimally Invasive Cardiothoracic Surgery, June 12–15, 2013, Prague, Czech Republic.

Disclosure: The authors declare no conflicts of interest.

Address correspondence and reprint requests to Olivia Fanucchi, MD, Division of Thoracic Surgery, Department of Surgical, Medical, Molecular, and Critical Area Pathology, via Paradisa 2, 56124 Pisa, Italy. E-mail:

©2014 by the International Society for Minimally Invasive Cardiothoracic Surgery