Introduction

Video-assisted thoracoscopic surgery (VATS) has been reported to offer substantial clinical advantages compared to open surgery for many clinical conditions (1). Regarding primary spontaneous pneumothorax (PSP), several studies have shown that the VATS procedure is as effective as thoracotomy in terms of recurrence and complication rate (2).

In the context of minimally invasive thoracic surgery, uniportal VATS represents one of the most recent evolutions. With the aim of further reducing the invasiveness of VATS, Rocco and colleagues demonstrated that treatment of PSP using uniportal VATS was feasible and, compared with the conventional (3-portal) VATS, resulted in less postoperative pain, paraesthesia, postoperative drainage duration, postoperative stay, and hospital costs (3).

Currently, general anaesthesia with one-lung intubated ventilation is the standard anaesthesia in thoracic surgery. Intubated anaesthesia is often associated, however, with postoperative throat discomfort, including irritating cough, as well as throat pain in some patients. Nonintubated anaesthesia can reduce general anaesthesia-related complications; therefore, many investigators have begun to explore its application in general thoracic surgery (4). Two examples of such groups are Dong et al. who reported that thoracoscopic wedge resection under nonintubated anaesthesia was both feasible and safe (5), and Chen et al., who reported the safety and feasibility of thoracoscopic resection under nonintubated anaesthesia in 285 patients (6).

The combination of uniportal VATS and nonintubated anaesthesia is potentially a less invasive operation in the management of PSP. This is the first report to include a large number of records on the use of a nonintubated uniportal technique in VATS for PSP.

Materials and methods

Patients

This study was reviewed and approved by the First Affiliated Hospital of Guangzhou Medical University Research Ethics Committee. From November 2011 to June 2013, VATS was performed for PSP in our department using a single-incision and non-rib-spreading approach. The same group of thoracic surgeons and anaesthesiology team performed all of the operations. Data from 32 consecutive patients (28 males and 4 females) who received this operation were analysed (Table 1).

Table 1 Patient characteristics
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Patients were eligible for the procedure if their CT scan demonstrated unilateral apical bullae, if they had an American Society of Anesthesiologists (ASA) grade of I-II and a body mass index (BMI) <25, and had no evident airway secretions or contraindications for epidural puncture in the preoperative anaesthesia assessment.

Surgical technique

Administration of anaesthesia

After establishing intravenous rehydration, an epidural catheter was inserted in the thoracic T6-7 space. With the patient in the supine position, 2 mL of 2% lidocaine was injected through the epidural catheter. If signs of spinal anaesthesia were not present within 5 min, fractionated injection of 12 mL 0.375% ropivacaine was performed. Prior to surgery, an anaesthesia level between T2 and T10 had to be achieved. Propofol and remifentanil were infused for sedation and anaesthesia during surgery, and bispectral index values were maintained between 40 and 60. During the surgery, masked and nasopharyngeal airway assisted ventilation were provided with a fraction of inspired oxygen (FiO₂) concentration of 0.33. The hilum and waist were padded to widen the intercostal space further. To reduce coughing induced by pulling on the lung tissue, and to ensure a steady surgical environment, 6 mL of 2% lidocaine was sprayed on the surface of the lung under thoracoscopic guidance in the chest cavity. The use of lidocaine on the lung surface eliminated the need for blocking of the vagus nerve.

Surgical management

All video-assisted thoracic operations were performed using a Stryker 1288 HD 3-Chip Camera/1288 (Stryker, USA) with a three-chip HD camera system, in addition to endoscopic instruments specially designed by our department. We created a 2 cm incision at the level of the 6^th intercostal space in the median axillary line, after which a soft incision protector was placed into the space as the surgical operation channel. A 5 mm 30° video thoracoscope and two laparoscopic instruments (Roticulator™ and Endo Grasp™, USSC-Tyco Healthcare and Endo GIA Universal, Johnson & Johnson, USA) were introduced through this channel.

By deploying the articulating arm, the target bullae were identified and resected with 2-3 firings of blue cartridges. For all procedures, the video thoracoscope lay between the operative instruments, but shifts may have occurred during the procedure. Thus, the relative position was best determined by a geometric approach to the target area. The specimen was usually extracted through an endobag, after which the incision protector was removed, and an 18 Fr chest tube was introduced under direct camera visualization, and placed in the pleural apex. The chest tube was removed after air leak stopped, and an X-ray of the chest demonstrated a well-expanded lung. The patients were observed overnight, and discharged the following morning.

Results

During a telephone interview, all patients provided answers to a questionnaire regarding pain and satisfaction scores. The mean postoperative follow-up time was 14.5 months with a minimum follow-up of 10 months (range, 10-19 months). Neither the signs nor the symptoms of recurrent pneumothorax were observed in any patients.

The median operative time was 49.0 min (range, 33-65 min). The necessity to convert the uniportal VATS procedure to a standard 3-port VATS procedure or a thoracotomy was not encountered. Further, no major complications were observed, and the administration of opiates was not required. The postoperative feeding time was 6 h. The median chest drainage time was 19.3 h (range, 15-26 h). All patients were discharged after a median hospital stay of 41.6 h (range, 26-47 h). Variables contained in the prospective dataset included operation length, intraoperative blood loss, postoperative feeding time, drainage volume, drainage time, postoperative hospital stay, and pain scores (Table 2).

Table 2 Intra- and post-operative conditions of uniportal VATS
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Discussion

Currently, VATS is reported to be as effective as thoracotomy, and entails less associated morbidity. In an attempt to reduce complications, conventional VATS has developed to include either smaller working ports and instrumentation, or fewer incisions. Rocco and colleagues first described the uniportal VATS technique as an effective approach to the safe performance of wedge resections for pulmonary lesions (7).

Compared with general anaesthesia performed in a traditional thoracic surgery, nonintubated anaesthesia reduces intubation-related complications, and facilitates timely patient mobility (8). With nonintubated anaesthesia, coughing induced by postoperative throat discomfort is significantly reduced (9). Further, coughing may worsen wound pain, which in turn suppresses the cough reflex, making pulmonary secretions difficult to discharge after surgery. Additionally, nonintubated endoscopic resection may reduce the required dose of intraoperative anaesthetic drugs, which may help protect breathing and digestive functions.

In 4-6 h after non-intubated segmental resection, patients could start eating, drinking, and could get out of bed. The absence of general anaesthesia and double-lung ventilation, in combination with the reduction of postoperative hospital days, could decisively shift the balance in the management of PSP toward uniportal VATS.

At present, nonintubated anaesthesia, combined with uniportal VATS bullectomy, is one of the most minimally invasive surgeries, but only a limited number of reports have been published regarding this procedure. According to the literature (10-15), most previous uniportal VATS were performed under general anaesthesia. Only one procedure, conducted by Rocco et al., was performed while the patient was conscious (16). The procedure described by Rocco et al. was performed using a 5 mm 0° thoracoscope, an endostapler, and grip forceps, with which they resected blebs or bullae in the lung apex. In a separate study, Gigirey et al. reported some disadvantages including quality of vision; however, problems related to quality of vision are not an issue if a 30° thoracoscope and an incision protector are used (17). Additionally, the absence of any protected channels for introducing the material into the cavity can lead to intercostal nerve injury, as well as increase the need to clean the optical lenses and consequently delay the operative time.

Tsai et al. (18) performed a vagus nerve block during nonintubated VATS. In the current study, however, it was not necessary for us to perform this procedure, which raises the risks of damage to adjacent vessels. Instead, we sprayed approximately 6 mL of 2% lidocaine onto the surface of lung. Using the latter method, we found that the cough reflex could be effectively abolished without affecting the heart rate, breathing rate, or blood pressure. Further, we believe that this novel technique is safer than performing a vagus nerve block.

Reports from eight different authors regarding patients who received bullectomy for PSP, including the present report, were divided into four different groups (A-D) for a comparison of duration of chest drainage, postoperative feeding time, and postoperative hospital stay (Table 3). Patients in group A received conventional (3-port) VATS under general anaesthesia, and had the longest duration of chest drainage, postoperative feeding time, and postoperative hospital stay of the four groups. Group B patients also received conventional (3-port) VATS, but under nonintubated anaesthesia. Data from group B was similar to that of group A, except for postoperative feeding time, which was significantly reduced and similar to group D patients, who also underwent nonintubated anaesthesia. Group C received uniportal VATS under general anaesthesia. Postoperative feeding time was similar to that of group A, while duration of chest drainage was the same as group D. The postoperative hospital stay of group C patients was also slightly less when compared to group A.

Table 3 Comparison of intraoperative and postoperative variables between bullectomy groups
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Finally, group D patients underwent a combination of uniportal VATS under nonintubated anaesthesia, Rocco et al. reported only one case, and did not use an incision protector. In contrast, we have reported 32 cases, each of which involved the use of a soft incision protector. The mean operative time of group D was comparable to all other groups; however, the combination of the other scores was less than values observed in the other three groups. Specifically, both the postoperative feeding time and hospital stay were less in group D patients than in group A and C subjects, while both duration of chest drainage and postoperative hospital stay were less in group D than in groups A and B.

Passlick et al. (21) demonstrated that about a third of all patients who underwent minimally invasive surgery experienced chronic pain. Sihoe et al. (22) found that over 50% of patients who underwent VATS for PSP complained of distinct paraesthesia resulting from wound pain. In each of our 32 cases, we chose the use of a soft incision protector instead of a trocar to safeguard the surgical operation channel. We observed moderate chest wall pain in two patients (6.25%), which was a lower rate than previously reported (35%) for the uniportal no-trocar technique (12). It is possible that the use of an incision protector in VATS procedures shields the intercostal nerves from compression due to torqueing of the camera or instruments, and therefore reduces the rate of residual chest wall paraesthesia. It is our opinion that using a smaller soft incision protector could further reduce the intensity of postoperative pain. The incidence of chronic postoperative pain in our uniportal group was less than that of the 3-port group (3). We believe this to be an effect of the potential advantages of using only one intercostal space, as well as a soft incision protector. By reducing the number of ports and using smaller instruments without trocars, the risk of traumatizing the intercostal nerves was decreased. Further, the potential reduction in intercostal nerve trauma was apparent by the fact that the administration of opiates was not necessary during the performance of procedures in the current study, and patients did not require any painkillers after surgery.

We acknowledge that the study was limited by the lack of a control group. Further studies and follow-up are needed to verify the benefits of nonintubated uniportal VATS for PSP. Nevertheless, our initial results indicate that nonintubated uniportal VATS is technically feasible, and may be a safe and less invasive alternative for the management of PSP.

Acknowledgements

The authors are grateful for Professor Guangqiao Zeng (State Key Laboratory of Respiratory Disease and National Clinical Center for Respiratory Disease, China) for his assistance in preparing this paper.

Disclosure: The authors declare no conflict of interest.

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