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Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection

Anesthesia for video-assisted thoracoscopic surgery (VATS) for pulmonary resection
Author:
Sergey Karamnov, MD
Section Editor:
Peter D Slinger, MD, FRCPC
Deputy Editor:
Nancy A Nussmeier, MD, FAHA
Literature review current through: Jan 2024.
This topic last updated: Oct 02, 2023.

INTRODUCTION — The term video-assisted thoracoscopic surgery (VATS) describes minimally invasive thoracic surgical procedures performed with the aid of a video camera to avoid more invasive open thoracotomy. VATS typically involves one small, 4 to 8 cm incision for the camera, plus up to three additional small incisions for insertion of other instruments (figure 1). This approach is used in selected patients to diagnose or treat intrathoracic or chest wall masses and other abnormalities, such as pericardial or pleural effusions. Compared with a thoracotomy, postoperative pain is minimized and other early outcomes may be improved by avoiding use of a rib spreader, severing of the intercostal nerves, or division of muscle tissue [1-3].

This topic will review anesthetic care for patients undergoing VATS for pulmonary resection. Anesthetic management for other VATS procedures (eg, pericardial window, drainage of pleural effusion, esophageal procedures) is similar. Anesthetic considerations for open thoracotomy with pulmonary resection as well as details regarding principles of one lung ventilation (OLV) and lung isolation techniques that are necessary for many VATS procedures are found in other topics:

●(See "Anesthesia for open pulmonary resection".)

●(See "One lung ventilation: General principles".)

●(See "Lung isolation techniques".)

Surgical considerations for VATS procedures are addressed separately. (See "Overview of minimally invasive thoracic surgery".)

PREANESTHESIA PREPARATION

●Consultation – Preanesthetic consultation for VATS is similar to consultation for open resection of a pulmonary or mediastinal mass, since intraoperative conversion to an open procedure may become necessary. (See "Anesthesia for open pulmonary resection", section on 'Preanesthetic consultation' and "Anesthesia for patients with an anterior mediastinal mass", section on 'Preanesthetic assessment'.)

In patients undergoing VATS for pulmonary resection, the American Society of Anesthesiologists physical status assessment tool is a strong predictor of postoperative morbidity including pulmonary, cardiovascular, and other major complications (table 1) [4]. Particular attention is necessary for:

•Chronic obstructive pulmonary disease (COPD) – COPD is common in patients undergoing pulmonary resection. If severe, pulmonary function tests (PFTs) are typically obtained to identify high-risk patients who may not tolerate one lung ventilation (OLV). This is the only absolute contraindication to VATS pulmonary resection [5]. PFTs may be unnecessary for minor VATS procedures that could be performed with very brief periods of either OLV or apnea (eg, pleural biopsy). (See "One lung ventilation: General principles", section on 'Contraindications'.)

•Obstructive sleep apnea (OSA) – For patients with a known diagnosis of OSA, postoperative use of noninvasive continuous positive airway pressure (CPAP) therapy is planned to minimize risk of complications, as discussed separately. (See "Postoperative management of adults with obstructive sleep apnea", section on 'Positive airway pressure therapy'.)

●Preparation – Standard preanesthetic preparations for pulmonary resection via VATS are similar to those for open pulmonary resection, including (see "Anesthesia for open pulmonary resection", section on 'Preanesthetic preparation'):

•Preparation for airway control – (See "Lung isolation techniques".)

•Intravenous (IV) access – At least one large-bore IV catheter is necessary for a VATS procedure, although blood loss is usually minimal. Increased potential for bleeding exists in cases requiring hilar dissection, or if there are adhesions caused by radiation therapy or prior surgery. In such cases, it is prudent to insert two large-bore peripheral IV catheters because bleeding may be difficult to control surgically. Antecubital IV catheters may not flow in the arm on the operative side while it is bent at the elbow in the flexed lateral decubitus position (figure 2). In rare cases, central venous access is employed to ensure adequate vascular access.

•Preparation for hemodynamic monitoring – Although not always necessary, preparations for invasive hemodynamic monitoring may be employed in selected VATS procedures. (See 'Monitoring' below.)

•Regional analgesic technique – Placement of a thoracic epidural or paravertebral block is typically reserved for patients undergoing a nonintubated thoracoscopic VATS procedure, or if conversion to open thoracotomy is considered likely. (See 'Nonintubated thoracoscopic surgery' below and "Anesthesia for open pulmonary resection", section on 'Planning for postoperative analgesia'.)

Regional techniques (eg, intercostal, serratus anterior, or erector spinae blocks) may be useful when postoperative opioids should be avoided or minimized. (See 'Postoperative pain management' below.)

INTRAOPERATIVE ANESTHETIC MANAGEMENT

Monitoring — Standard noninvasive monitoring for patients undergoing VATS is similar to that for open pulmonary resection, and includes electrocardiography (ECG), pulse oximetry (SpO2), capnography, and noninvasive blood pressure (NIBP) cuff measurements. These monitors are secured to prevent displacement during repositioning to a lateral decubitus position (figure 2). (See "Anesthesia for open pulmonary resection", section on 'Monitoring'.)

We employ an intraarterial catheter to continuously monitor blood pressure (BP) in selected patients undergoing lobectomy or more extensive pulmonary resection, or for lesser resections if there is a risk for significant bleeding (eg, hilar involvement or extensive adhesions) or hemodynamic instability (eg, cardiovascular comorbidity). The catheter is also useful for intermittent sampling of arterial blood gases (particularly during one lung ventilation [OLV]). (See "Anesthesia for open pulmonary resection", section on 'Monitoring'.)

Other invasive monitors (eg, central venous catheters or pulmonary artery catheters) are rarely used. Occasionally, intraoperative transesophageal echocardiography (TEE) is urgently employed to rapidly diagnose unanticipated causes of severe hemodynamic instability [6]. (See "Intraoperative rescue transesophageal echocardiography (TEE)".)

Induction and maintenance — General anesthesia is employed for most VATS procedures. Selection of agents and techniques for induction is based on coexisting disease. During the maintenance phase, the patient must remain anesthetized, paralyzed, and mechanically ventilated to provide optimal surgical conditions. Choices of anesthetic agents for patients undergoing pulmonary resection with OLV are discussed separately. (See "One lung ventilation: General principles", section on 'Anesthetic choice' and "Anesthesia for open pulmonary resection", section on 'Induction and maintenance'.)

Rather than general anesthesia, local or regional anesthetic techniques with sedation may be employed for nonintubated thoracoscopic surgery (NITS). (See 'Nonintubated thoracoscopic surgery' below.)

Airway management and surgical bronchoscopy — Surgeons typically perform a fiberoptic bronchoscopic examination while the patient is still in the supine position after induction of general anesthesia. This is done to look for endobronchial lesions that might change the surgical plan, and to remove secretions that might impair oxygenation during OLV. In such cases, a single-lumen endotracheal tube (ETT) is initially inserted to facilitate surgical bronchoscopy. The anesthesiologist observes the bronchoscopy to discover bronchial anatomic factors that may influence lung isolation choices. (See "Anesthesia for adult bronchoscopy".)

After bronchoscopy, the selected device to allow OLV is inserted, and positioning is checked with fiberoptic bronchoscopy. (See "Lung isolation techniques".)

Positioning — The patient is placed and stabilized in a lateral decubitus position with the operative side up. The operating room table is flexed to open the intercostal spaces and potentially reduce the pressure of surgical instruments against intercostal nerves (figure 2). (See 'Causes of pain' below.)

This position change is managed by the anesthesiologist, with care to avoid displacement of airway devices, monitors, and vascular cannulae. Prevention of peripheral nerve damage, vision loss, and other injury requires precise positioning of extremities and padding of pressure points. Prevention of injury in a lateral decubitus or flexed lateral decubitus position is discussed in detail separately. (See "Anesthesia for open pulmonary resection", section on 'Positioning' and "Overview of minimally invasive thoracic surgery", section on 'Patient positioning'.)

The positions of the ETT and lung isolation device are reassessed visually and with fiberoptic bronchoscopy after final patient positioning.

Ventilation — A protective ventilation strategy is employed to minimize acute lung injury during both OLV and two lung ventilation [7]. (See "One lung ventilation: General principles", section on 'Lung-protective ventilation strategies'.)

Communication with the surgeon is necessary to determine initial timing, desired rapidity, and subsequent quality of lung collapse to produce OLV, as well as during specific intraoperative events. (See 'Intraoperative technical considerations' below.)

Hypoxemia (SpO2 <90 percent) may develop during OLV. Management of hypoxemia during VATS is similar to other procedures requiring OLV, except that continuous positive airway pressure (CPAP) is avoided in the nonventilated lung because a VATS procedure is disrupted with even partial inflation of the lung on the operative side. (See "One lung ventilation: General principles", section on 'Management of hypoxemia'.)

Fluid management — For most VATS procedures, barring unusual blood loss, we restrict intraoperative crystalloid administration to <6 mL/kg per hour, or 1 to 2 L total. Such a restrictive fluid strategy is associated with a lower incidence of postoperative pulmonary complications after open or VATS pulmonary resection, compared with more liberal fluid administration [8,9]. (See "Anesthesia for open pulmonary resection", section on 'Fluid and hemodynamic management'.)

Intraoperative technical considerations — The anesthesiologist provides assistance during procedure-specific intraoperative events:

●Localizing the lesion – Surgeons most commonly locate small nodules by examination of preoperative computed tomography (CT) scans and insertion of a finger through a VATS port to palpate the surface of the lung. A Valsalva maneuver to the dependent lung can raise the mediastinum, thereby allowing the surgeon's finger to reach the lung surface. The operative lung should remain fully collapsed for optimal visualization and palpation of small nodules (see below). Other strategies include dye localization and image-guided techniques (see below).

●Image-guided thoracoscopic surgery (iVATS) – The target lesion may be marked using a wire as a fiducial. This is typically accomplished in a hybrid operating suite with the aid of CT guidance and proprietary imaging software [10]. Initially, a temporary lung inflation (ie, breath hold) is achieved in both lungs by briefly clamping both lumens of the double-lumen tube at end-inspiration in order to allow a CT scan of motionless, inflated lungs. Subsequently, the nonoperative lung is ventilated using lung-protective tidal volumes (4 to 6 mL/kg), while the operative lung is held in a prolonged inflation as the fiducial wire is placed in the target lesion of that lung using CT guidance. Following placement of the wire, the operative lung is allowed to collapse, and the VATS procedure is performed while the patient is still in the hybrid suite [10].

●Dye localization – If dye was previously deposited on the target lesion, either percutaneously or via electromagnetic navigational bronchoscopy, the lung is allowed to remain partially inflated when the VATS camera is initially inserted. This facilitates visualization of the dye marking the lesion on the pleural surface.

●Lung collapse – Maximal collapse of the operative lung is required for optimal surgical visualization during completion of pulmonary resection and other VATS procedures. If necessary, lung deflation may be expedited or improved by several maneuvers (see "One lung ventilation: General principles", section on 'Improving deflation of the nonventilated lung'). Also, the surgeon may further facilitate lung collapse with gentle manual compression of lung tissue or by insufflation of carbon dioxide (CO2).

●Vascular ligation – All patient movement is avoided during surgical ligation of a branch of the pulmonary artery (PA) in order to avoid vascular injury.

Right ventricular afterload may be increased after PA branch ligation, but this is well tolerated in most patients because blood flow to the operative lung has been previously reduced by gravity and hypoxic pulmonary vasoconstriction. Since shunted blood volume to the operative lung is decreased after PA branch ligation, oxygenation will typically improve.

●Bronchial ligation – Immediately after the surgical stapling device is closed around a lobar bronchus, but before the staples are fired, the anesthesiologist may be asked to visualize the bronchial stump via fiberoptic bronchoscopy to confirm that the intended bronchial stump is completely closed and appropriately short, and that non-targeted bronchi remain patent.

●Lung re-expansion – When the surgical procedure is complete, re-expansion of the nonventilated lung is necessary to reinflate all atelectatic areas and to allow the surgeon to check for significant air leaks at bronchial staple lines. The VATS monitor is observed to ensure gradual but complete recruitment of residual lung tissue. Details regarding re-expansion techniques are discussed separately. (See "One lung ventilation: General principles", section on 'Re-expanding the nonventilated lung'.)

Final bronchoscopy and emergence — At the end of the procedure, the patient is returned to the supine position. Often, the surgeon performs a final fiberoptic bronchoscopic examination to ensure that the bronchial passageways are patent, to remove residual blood and secretions, and to examine the newly created bronchial stump. If a double-lumen tube (DLT) has been used, the surgeon may perform bronchoscopy via this DLT, or it may be exchanged to a single-lumen tube or a laryngeal mask airway (LMA) if necessary to accommodate a large bronchoscope or surgeon-specific preferences. Strategies to prevent loss of airway control or laryngospasm during this tube exchange are described elsewhere. (See "Anesthesia for open pulmonary resection", section on 'Final bronchoscopy before emergence'.)

Following bronchoscopy, the patient is placed in the semi-Fowler's position (partially sitting with the head of the bed up at a 30 to 45 degree angle) for emergence from anesthesia. When the usual criteria have been satisfied, the patient may be extubated (see "Maintenance of general anesthesia: Overview", section on 'Transition to the emergence phase'). Adequate perioperative pain management including wound infiltration, may decrease the incidence of emergence agitation [11]. (See 'Postoperative pain management' below.)

Complications — Surgical complications of VATS procedures are discussed separately (See "Surgical evaluation of mediastinal lymphadenopathy", section on 'Complications of thoracoscopy'.)

ROBOTIC-ASSISTED THORACOSCOPIC SURGERY — Robotic-assisted thoracic surgery (RATS) is an emerging technology with applications for pulmonary, esophageal, and mediastinal procedures. A few anesthetic considerations for RATS differ from standard VATS procedures:

●Lung isolation techniques – Lung isolation is usually performed with a left double-lumen tube (DLT) because access to the head is limited by the robotic equipment (although this is less problematic with newer robotic equipment). Positioning of a left DLT is easier and the likelihood of displacement is lower compared with a right DLT or bronchial blockers. (See "Lung isolation techniques" and "Lung isolation techniques", section on 'Device choice: General considerations'.)

A DLT with an incorporated video camera may be used. This provides a continuous view of the carina to detect tube malposition without insertion of a bronchoscope. Such monitoring may be more convenient during RATS cases due to limited access to the airway (picture 1), although there are no data demonstrating an outcome advantage.

To facilitate lung collapse, the surgeon may employ carbon dioxide (CO2) insufflation, typically with an insufflation pressure of 8 mmHg.

●Absence of movement – Neuromuscular blockade is carefully monitored with a peripheral nerve stimulator to avoid any patient movement and possible patient injury. The appropriate surgical response to patient movement is immediate withdrawal of the robotic arms from the chest cavity, but this response may be delayed because the surgeon is sequestered at the robotic console and does not have direct tactile sensation to detect movement.

●Emergency responses – Because the surgeon is unable to see the patient or events in the room except for those shown on his camera, situational awareness is reduced and communication is impaired. This may delay recognition of a complication and cause communication errors. Patient safety requires well-established and practiced surgical team responses to emergencies such as cardiac arrest or hemorrhage as soon as they are recognized. Conversion to open resection may be necessary in some patients. (See "Overview of minimally invasive thoracic surgery".)

NONINTUBATED THORACOSCOPIC SURGERY — Selected VATS procedures may be performed without general anesthesia, intubation, or lung isolation in a spontaneously breathing patient [12]. Such nonintubated thoracoscopic surgery (NITS) techniques have been employed (often through a single port) for management of pleural effusions, pneumothorax, empyema, or biopsies of the lung or pleura in patients with severe comorbidities that confer increased risk for general anesthesia [13]. Less commonly, NITS is performed for anatomic lung resection.

Contraindications include hemodynamic instability, morbid obesity, inability to cooperate, extensive pleural adhesions, large centrally located tumors, a difficult airway, or any contraindication to the planned regional anesthetic technique (eg, coagulopathy).

●Anesthetic techniques – Anesthetic management typically includes a local and/or regional technique plus supplemental sedation. Continuous thoracic epidural analgesia (TEA) or paravertebral block (PVB) may be used to provide regional anesthesia during NITS procedures [14-16], and these are the most effective techniques for postthoracotomy analgesia. Choice between a TEA or PVB technique is primarily based on clinician expertise and preference. Other regional techniques have been successfully employed for intraoperative and/or postoperative analgesia. These include intercostal blocks with or without catheters, serratus anterior plane blocks, intrapleural administration of local anesthetics, local wound infiltration, intrathoracic vagal block to attenuate the cough reflex, and combinations of these techniques [12,13,17-19]. (See "Anesthesia for open pulmonary resection", section on 'Post-thoracotomy pain management'.)

During the procedure, regional anesthetic techniques are typically supplemented by sedation with short-acting anesthetic agents, such as continuous infusions of dexmedetomidine, which maintains spontaneous breathing, remifentanil, which decreases the risk of coughing, or propofol administered as intermittent boluses or via continuous infusion to deepen sedation as needed [12,13,20-22]. In general, opioids are used judiciously to minimize the risk of oversedation with loss of airway. Mild permissive hypercapnia is tolerated, particularly in patients with significant pulmonary disease. Some clinicians employ deep sedation, with or without periods of light general anesthesia, using a laryngeal mask airway (LMA) with maintenance of spontaneous ventilation [20,23,24]. (See "Monitored anesthesia care in adults".)

With any of these techniques, the goal is to avoid a need for urgent conversion to general anesthesia with endotracheal intubation.

●Emergency responses – The primary anesthetic risk is difficulty with attempted insertion of an endotracheal tube (ETT) during urgent conversion to general anesthesia while the patient is still in the lateral decubitus position. Emergency conversion to general anesthesia may become necessary because of cardiac arrest, surgical hemorrhage, or oversedation with loss of the airway [12].

Surgical team responses must be well-established and practiced to facilitate rapid conversion and successful resuscitation. (See "Overview of minimally invasive thoracic surgery".)

POSTOPERATIVE PAIN MANAGEMENT — Postoperative pain and inflammatory responses are typically minor after minimally invasive VATS [25,26]. However, many patients have mild to moderate pain requiring treatment, and some report chronic postsurgical pain [27].

Causes of pain

Incisional and local surgical trauma — Pain may be caused by the incisions, crushing of intercostal nerves during angulation of instruments through a porthole incision, rib trauma, costovertebral joint dislocation, tracheobronchial injury, pleural irritation due to thoracostomy tubes, or visceral pain in the lung parenchyma, pericardium, or diaphragm.

Ipsilateral shoulder pain — Ipsilateral shoulder pain (ISP) may occur following pulmonary resection with any technique and may be the dominant complaint in VATS patients whose incisional pain is well controlled by local or regional blocks. Although ISP is less common after VATS compared with open thoracotomy, the incidence may be as high as 53 percent [28-33]. It is described as a dull, stabbing pain of moderate to severe intensity in the region of the deltoid muscle and lateral clavicle, occurring on the side of surgery within two hours after emergence. ISP usually lasts one to three days or until the chest drain is removed. Chronic hyperesthesia, hypoesthesia, dysesthesia, allodynia, and reduced mobility have been attributed to ISP [28].

The etiology of ISP is likely multifactorial. The most frequent cause is thought to be irritation of pleural surfaces of the diaphragm, pericardium, and mediastinum, with afferent nerve conduction via the phrenic nerve [34-36]. Position-related injury to shoulder ligaments with myofascial involvement or transection of a major bronchus may be contributing factors [32].

Management of VATS pain — There is no consensus regarding optimal pain control after VATS. Most clinicians employ a multimodal approach using some combination of the following agents and techniques (see "Nonopioid pharmacotherapy for acute pain in adults", section on 'Nonsteroidal anti-inflammatory drugs' and "Use of opioids for postoperative pain control", section on 'Patient controlled analgesia'):

●Opioids (intraoperative plus postoperative intravenous [IV] patient-controlled analgesia [PCA])

●Regional or neuraxial blocks

●Adjunct IV or oral analgesic agents (eg, non-steroidal antiinflammatory drugs [NSAIDs], selective cyclooxygenase-2 [COX-2] inhibitors, acetaminophen, gabapentinoids, ketamine)

We administer opioids during the intraoperative period and use an opioid-based PCA during the postoperative period. Many patients undergoing VATS procedures may have satisfactory postoperative pain control with PCA used in combination with regional analgesic blocks (eg, intercostal blocks, serratus anterior plane block, erector spinae plane block), bupivacaine or liposomal bupivacaine local infiltration of the wound, and/or adjunct nonopioid analgesic agents [37-40]. Studies of phrenic nerve infiltration of local anesthesia report inconsistent results [33,41]. (See "Thoracic nerve block techniques", section on 'Intercostal nerve block' and "Thoracic nerve block techniques", section on 'Serratus plane block'.)

A 2014 systematic review noted that no one regional analgesic technique was superior for postoperative analgesia after VATS surgery, although this review was limited by small sample sizes and heterogeneity in the 17 included studies [42]. Similarly, a 2018 survey of institutions regarding regional anesthetic techniques used for postoperative pain management after VATS surgery noted variability in clinician preferences [43]. In small randomized trials, erector spinae plane block has provided superior and longer-lasting analgesia after VATS procedures compared serratus plane block [44], or intercostal nerve block [45]. A randomized controlled study demonstrated noninferiority of midpoint transverse process-to-pleura block for postoperative pain control compared with conventional paravertebral block; and since this block allows for more shallow needle insertion, adverse effects may be fewer [46].

We reserve neuraxial blocks (eg, paravertebral block [PVB] [47,48], thoracic epidural analgesia [TEA] [49]) for selected major lung resection such as some lobectomies, or for less invasive resection if opioids or adjunct agents should be avoided or minimized (eg, NSAIDS in patients with renal insufficiency, or opioids in those with severe chronic obstructive pulmonary disease or obstructive sleep apnea). Also, a TEA or PVB technique is typically used when conversion to open thoracotomy is likely. In one randomized study, intraoperative placement of a PVB catheter by the surgeon and initial bolus dosing were accomplished either early (before beginning thoracoscopic lung resection), or late (at the end of the procedure); no pain score differences were noted during the first 24 postoperative hours [47]. Specific analgesic regimens used for TEA or PVB catheter dosing are described in our topic discussing anesthetic management of open pulmonary resection. (See "Anesthesia for open pulmonary resection", section on 'Thoracic epidural analgesia' and "Anesthesia for open pulmonary resection", section on 'Paravertebral block'.)

A 2018 survey noted that TEA was used more frequently than PCA alone, or PCA plus intercostal blocks for patients undergoing lobectomy via a VATS approach, but not for resection of smaller amounts of lung tissue [43]. In a retrospective study, use of TEA reduced opioid consumption during the first 48 hours compared with liposomal bupivacaine wound infiltration, with no differences in analgesic efficacy [50,51]. In a randomized trial, patient-controlled PVB analgesia resulted in lower cumulative intramuscular rescue analgesic doses and fewer adverse side effects (eg, hypotension, nausea/vomiting) compared with intravenous opioid PCA, with no differences in analgesic efficacy [52].

Individual patients responding to a survey after VATS reported high satisfaction scores for various regional techniques and/or opioid and nonopioid analgesics if the selected intervention(s) [53]:

●Achieved acceptable pain levels most of the time

●Ensured ability to sleep

●Included provision of useful information and allowed patient participation in pain management decisions

Enhanced recovery protocols — Enhanced recovery after surgery (ERAS) protocols are used in several centers for patients undergoing VATS procedures [54-59]. Similar to abdominal and other types of surgery, such protocols typically incorporate aspects of preoperative, intraoperative, and postoperative care to reduce morbidity. (See "Anesthetic management for enhanced recovery after major noncardiac surgery (ERAS)".)

SUMMARY AND RECOMMENDATIONS

●Preanesthesia consultation – Video-assisted thoracoscopic surgery (VATS) is a minimally invasive intrathoracic surgical procedure performed with a video camera to avoid more invasive open thoracotomy. Preanesthetic consultation and preparations for VATS procedures are similar to open pulmonary resection. (See "Anesthesia for open pulmonary resection", section on 'Preanesthetic consultation' and "Anesthesia for open pulmonary resection", section on 'Preanesthetic preparation'.)

●Intraoperative anesthetic considerations

•General anesthesia – General anesthesia is employed for most VATS procedures. Choices of anesthetic agents for patients undergoing one lung ventilation (OLV) and/or pulmonary resection are discussed separately. (See "One lung ventilation: General principles", section on 'Anesthetic choice' and "Anesthesia for open pulmonary resection", section on 'Induction and maintenance'.)

•Positioning – The patient is placed in a flexed lateral decubitus position (figure 2 and figure 1), with care to avoid patient injury and prevent displacement of airway devices, monitors, and vascular cannulae. Positioning of the ETT and lung isolation device is reassessed visually and with fiberoptic bronchoscopy. (See 'Positioning' above.)

•Ventilation

-Lung-protective ventilation – We suggest using a protective ventilation strategy to minimize acute lung injury during both OLV and two lung ventilation (Grade 2B). (See "One lung ventilation: General principles", section on 'Lung-protective ventilation strategies'.)

-Use of one lung ventilation – After anesthetic induction, a single-lumen endotracheal tube (ETT) is typically inserted to facilitate surgical bronchoscopy. Subsequently, a device to allow OLV (eg, a double-lumen tube [DLT] or bronchial blocker) is inserted and checked with fiberoptic bronchoscopy. (See 'Airway management and surgical bronchoscopy' above and "Lung isolation techniques".)

Maximal collapse of the operative lung is required for optimal surgical visualization during the procedure. If necessary, lung deflation may be expedited or improved by several maneuvers. (See "One lung ventilation: General principles", section on 'Improving deflation of the nonventilated lung'.)

Management of hypoxemia during VATS is similar to other procedures employing OLV except for avoidance of continuous positive airway pressure (CPAP) in the nonventilated lung, because partial inflation of the operative lung disrupts surgery. (See "One lung ventilation: General principles", section on 'Management of hypoxemia'.)

•Fluid management – We suggest restricting intraoperative crystalloid fluid administration to 1 to 2 L (<6 mL/kg/hour), which may reduce pulmonary complications (Grade 2C). (See 'Fluid management' above.)

•Emergence – After completion of the VATS procedure, the patient is typically returned to the supine position for final bronchoscopy via the DLT or after exchange to a single-lumen ETT or a laryngeal mask airway (LMA). Following bronchoscopy, the patient is placed in the semi-Fowler's position for emergence and extubation. (See 'Final bronchoscopy and emergence' above.)

●Robotic-assisted thoracoscopic surgery (RATS) – RATS is a variation of VATS that imposes limitations for access to the head. Typically, a left DLT is employed for OLV due to ease of positioning and low likelihood of displacement since access to the airway is limited (picture 1). Neuromuscular blockade is monitored to avoid all patient movement. (See 'Robotic-assisted thoracoscopic surgery' above.)

●Nonintubated thoracoscopic surgery (NITS) – NITS is a variation of VATS performed in a spontaneously breathing patient without general anesthesia, intubation, or lung isolation. Regional anesthetic techniques are typically employed, supplemented by sedation with short-acting anesthetic agents. Opioids are used judiciously, and mild permissive hypercapnia is tolerated to minimize risk of urgent endotracheal intubation of a patient in the lateral decubitus position. (See 'Nonintubated thoracoscopic surgery' above.)

●Postoperative pain management – For most patients undergoing VATS, we use an intravenous (IV) opioid administered by patient-controlled analgesia (PCA), combined with IV and/or oral nonsteroidal antiinflammatory drugs (NSAIDs) to control postoperative incisional pain and to prevent ipsilateral shoulder pain (ISP). Other adjunct IV or oral agents or a regional analgesic technique (eg, intercostal, serratus anterior, or erector spinae blocks) may be added to supplement postoperative pain control. We typically reserve thoracic epidural analgesia (TEA) or paravertebral block (PVB) neuraxial techniques for selected major lung resection (eg, lobectomy), or for less invasive resection if opioids or adjunct agents should be avoided or minimized. (See 'Postoperative pain management' above.)

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  22. Gallego-Ligorit L, Vives M, Vallés-Torres J, et al. Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia. J Cardiothorac Vasc Anesth 2018; 32:1426.
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  27. Wang S, Li Y, Fei M, et al. Clinical Analysis of the Effects of Different Anesthesia and Analgesia Methods on Chronic Postsurgical Pain in Patients With Uniportal Video-Assisted Lung Surgery. J Cardiothorac Vasc Anesth 2020; 34:987.
  28. Misiołek H, Karpe J, Copik M, et al. Ipsilateral shoulder pain after thoracic surgery procedures under general and regional anesthesia - a retrospective observational study. Kardiochir Torakochirurgia Pol 2014; 11:44.
  29. Burgess FW, Anderson DM, Colonna D, et al. Ipsilateral shoulder pain following thoracic surgery. Anesthesiology 1993; 78:365.
  30. Pennefather SH, Akrofi ME, Kendall JB, et al. Double-blind comparison of intrapleural saline and 0.25% bupivacaine for ipsilateral shoulder pain after thoracotomy in patients receiving thoracic epidural analgesia. Br J Anaesth 2005; 94:234.
  31. Bunchungmongkol N, Pipanmekaporn T, Paiboonworachat S, et al. Incidence and risk factors associated with ipsilateral shoulder pain after thoracic surgery. J Cardiothorac Vasc Anesth 2014; 28:979.
  32. Ohmori A, Iranami H, Fujii K, et al. Myofascial involvement of supra- and infraspinatus muscles contributes to ipsilateral shoulder pain after muscle-sparing thoracotomy and video-assisted thoracic surgery. J Cardiothorac Vasc Anesth 2013; 27:1310.
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  34. Scawn ND, Pennefather SH, Soorae A, et al. Ipsilateral shoulder pain after thoracotomy with epidural analgesia: the influence of phrenic nerve infiltration with lidocaine. Anesth Analg 2001; 93:260.
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  39. Hu B, Zhou H, Zou X. The erector spinae plane block (ESPB) for non-intubated video-assisted thoracoscopic surgery. J Clin Anesth 2019; 54:50.
  40. Parascandola SA, Ibañez J, Keir G, et al. Liposomal bupivacaine versus bupivacaine/epinephrine after video-assisted thoracoscopic wedge resection†. Interact Cardiovasc Thorac Surg 2017; 24:925.
  41. Kimura Kuroiwa K, Shiko Y, Kawasaki Y, et al. Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial. Anesth Analg 2021; 132:1594.
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  44. Gaballah KM, Soltan WA, Bahgat NM. Ultrasound-Guided Serratus Plane Block Versus Erector Spinae Block for Postoperative Analgesia After Video-Assisted Thoracoscopy: A Pilot Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2019; 33:1946.
  45. Fiorelli S, Leopizzi G, Menna C, et al. Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2020; 34:2421.
  46. Chen X, Yang J, Xia M, et al. Single-Injection Midpoint Transverse Process-to- Pleura Block Versus Thoracic Paravertebral Block for Postoperative Analgesia After Uniportal Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial. J Cardiothorac Vasc Anesth 2022; 36:2432.
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  49. Yeap YL, Wolfe JW, Backfish-White KM, et al. Randomized Prospective Study Evaluating Single-Injection Paravertebral Block, Paravertebral Catheter, and Thoracic Epidural Catheter for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery. J Cardiothorac Vasc Anesth 2020; 34:1870.
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  56. Teeter EG, Kolarczyk LM, Popescu WM. Examination of the enhanced recovery guidelines in thoracic surgery. Curr Opin Anaesthesiol 2019; 32:10.
  57. Batchelor TJP, Ljungqvist O. A surgical perspective of ERAS guidelines in thoracic surgery. Curr Opin Anaesthesiol 2019; 32:17.
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  59. Raft J, Richebé P. Anesthesia for thoracic ambulatory surgery. Curr Opin Anaesthesiol 2019; 32:735.
Topic 94263 Version 22.0

References

1 : The variability of practice in minimally invasive thoracic surgery for pulmonary resections.

2 : The variability of practice in minimally invasive thoracic surgery for pulmonary resections.

3 : Thoracoscopic lobectomy has increasing benefit in patients with poor pulmonary function: a Society of Thoracic Surgeons Database analysis.

4 : American Society of Anesthesiologists physical status facilitates risk stratification of elderly patients undergoing thoracoscopic lobectomy.

5 : Lung resection in patients with marginal pulmonary function.

6 : Cardiovascular collapse and hypoxemia in a man with a right-sided mediastinal mass, undiagnosed atrial septal defect, and right-to-left shunt.

7 : Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung.

8 : Effect of the amount of intraoperative fluid administration on postoperative pulmonary complications following anatomic lung resections.

9 : Risk factors for post-operative pulmonary complications in lung cancer patients after video-assisted thoracoscopic lung resection: Results of the German Thorax Registry.

10 : Image-guided video assisted thoracoscopic surgery (iVATS) - phase I-II clinical trial.

11 : Risk Factors for Emergence Agitation in Adults Undergoing Thoracoscopic Lung Surgery: A Case-Control Study of 1,950 Patients.

12 : Anesthesia for nonintubated video-assisted thoracic surgery.

13 : Five Hundred Seventy-Six Cases of Video-Assisted Thoracic Surgery Using Local Anesthesia and Sedation: Lessons Learned.

14 : Is there any benefit in using awake anesthesia with thoracic epidural in thoracoscopic talc pleurodesis?

15 : Thoracic epidural anaesthesia for awake thoracic surgery in severely dyspnoeic patients excluded from general anaesthesia.

16 : Thoracic paravertebral anaesthesia for awake video-assisted thoracoscopic surgery daily.

17 : Non-intubated anesthesia in thoracic surgery-technical issues.

18 : Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.

19 : Nonintubated thoracoscopic surgery using regional anesthesia and vagal block and targeted sedation.

20 : Nonintubated video-assisted thoracoscopic surgery under epidural anesthesia compared with conventional anesthetic option: a randomized control study.

21 : Anesthetic management of nonintubated video-assisted thoracoscopic surgery using epidural anesthesia and dexmedetomidine in three patients with severe respiratory dysfunction.

22 : Use of Dexmedetomidine in Cardiothoracic and Vascular Anesthesia.

23 : Spontaneous ventilation anaesthesia: total intravenous anaesthesia with local anaesthesia or thoracic epidural anaesthesia for thoracoscopic bullectomy.

24 : Intubated Versus Nonintubated General Anesthesia for Video-Assisted Thoracoscopic Surgery-A Case-Control Study.

25 : Video-assisted thoracic surgery lobectomy: experience with 1,100 cases.

26 : Pulmonary function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure.

27 : Clinical Analysis of the Effects of Different Anesthesia and Analgesia Methods on Chronic Postsurgical Pain in Patients With Uniportal Video-Assisted Lung Surgery.

28 : Ipsilateral shoulder pain after thoracic surgery procedures under general and regional anesthesia - a retrospective observational study.

29 : Ipsilateral shoulder pain following thoracic surgery.

30 : Double-blind comparison of intrapleural saline and 0.25% bupivacaine for ipsilateral shoulder pain after thoracotomy in patients receiving thoracic epidural analgesia.

31 : Incidence and risk factors associated with ipsilateral shoulder pain after thoracic surgery.

32 : Myofascial involvement of supra- and infraspinatus muscles contributes to ipsilateral shoulder pain after muscle-sparing thoracotomy and video-assisted thoracic surgery.

33 : Postoperative Pain Management and the Incidence of Ipsilateral Shoulder Pain After Thoracic Surgery at an Australian Tertiary-Care Hospital: A Prospective Audit.

34 : Ipsilateral shoulder pain after thoracotomy with epidural analgesia: the influence of phrenic nerve infiltration with lidocaine.

35 : Ipsilateral shoulder pain after thoracotomy surgery: a prospective, randomized, double-blind, placebo-controlled evaluation of the efficacy of infiltrating the phrenic nerve with 0.2%wt/vol ropivacaine.

36 : Randomized double-blind comparison of phrenic nerve infiltration and suprascapular nerve block for ipsilateral shoulder pain after thoracic surgery.

37 : Anesthesia and fast-track in video-assisted thoracic surgery (VATS): from evidence to practice.

38 : A randomised trial of serratus anterior plane block for analgesia after thoracoscopic surgery.

39 : The erector spinae plane block (ESPB) for non-intubated video-assisted thoracoscopic surgery.

40 : Liposomal bupivacaine versus bupivacaine/epinephrine after video-assisted thoracoscopic wedge resection†.

41 : Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

42 : Regional analgesia for video-assisted thoracic surgery: a systematic review.

43 : Survey of Postoperative Regional Analgesia for Thoracoscopic Surgeries in Canada.

44 : Ultrasound-Guided Serratus Plane Block Versus Erector Spinae Block for Postoperative Analgesia After Video-Assisted Thoracoscopy: A Pilot Randomized Controlled Trial.

45 : Ultrasound-Guided Erector Spinae Plane Block Versus Intercostal Nerve Block for Post-Minithoracotomy Acute Pain Management: A Randomized Controlled Trial.

46 : Single-Injection Midpoint Transverse Process-to- Pleura Block Versus Thoracic Paravertebral Block for Postoperative Analgesia After Uniportal Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.

47 : Early Versus Late Paravertebral Block for Analgesia in Video-Assisted Thoracoscopic Lung Resection. A Double-Blind, Randomized, Placebo-Controlled Trial.

48 : The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: A randomized, double-blinded, clinical trial.

49 : Randomized Prospective Study Evaluating Single-Injection Paravertebral Block, Paravertebral Catheter, and Thoracic Epidural Catheter for Postoperative Regional Analgesia After Video-Assisted Thoracoscopic Surgery.

50 : Thoracic Epidurals are Associated With Decreased Opioid Consumption Compared to Surgical Infiltration of Liposomal Bupivacaine Following Video-Assisted Thoracoscopic Surgery for Lobectomy: A Retrospective Cohort Analysis.

51 : Does the Amount of Opioid Consumption Really Matter in Video-Assisted Thoracoscopic Lobectomy-Thoracic Epidural Analgesia Versus Liposomal Bupivacaine.

52 : Patient-Controlled Paravertebral Block for Video-Assisted Thoracic Surgery: A Randomized Trial.

53 : Evaluation of the Determinants of Satisfaction With Postoperative Pain Control After Thoracoscopic Surgery: A Single-Center, Survey-Based Study.

54 : Guidelines for enhanced recovery after lung surgery: recommendations of the Enhanced Recovery After Surgery (ERAS®) Society and the European Society of Thoracic Surgeons (ESTS).

55 : Preoperative rehabilitation for thoracic surgery.

56 : Examination of the enhanced recovery guidelines in thoracic surgery.

57 : A surgical perspective of ERAS guidelines in thoracic surgery.

58 : Precise anesthesia in thoracoscopic operations.

59 : Anesthesia for thoracic ambulatory surgery.

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