LAUSR

The first reported thoracoscopic procedure was performed in 1865 by Francis Richards Cruise, using a binocular cystoscope on an 11-year-old patient with an empyema. Hans Jacobaeus advanced the technique and is considered the forefather of modern thoracoscopy. The first thoracoscopies were performed under local anesthesia with sedation. With the advent of improved double-lumen endobronchial tubes allowing for more reliable single-lung ventilation and the development of video-assisted minimally invasive techniques allowing for more extensive procedures to be performed, the majority of thoracoscopies were thought to require general anesthesia. Interest in non-intubated thoracoscopy was awakened when Mukaida et al used the technique on 4 high-risk patients who had good outcomes. The advantages of non-intubated thoracoscopy include the avoidance of general anesthesia and the adverse effects of tracheal intubation, mechanical ventilation, and muscle relaxants. The use of muscle relaxants can be associated with postoperative respiratory muscle weakness, hypoxia, hypercapnia, and upper respiratory obstruction, increasing the risk for aspiration. Other advantages of awake thoracoscopy under thoracic epidural anesthesia (TEA) or paravertebral blocks include improved respiratory function, attenuated stress response, and inflammation as measured by lower postoperative white blood cell counts, tumor necrosis factor-α, and C-reactive protein levels, improved analgesia, reduced chest drainage, early oral intake, early ambulation, and shortened recovery time. Reported drawbacks of non-intubated thoracoscopies include TEA-associated cough reflex, inadequate analgesia, panic attacks, respiratory movement of the lung and mediastinum, hypoxia, hypercapnia, and the conversion to general anesthesia. The cough reflex is due to a combination of surgical manipulation of the lung and bronchi and by increased airway hyper-reactivity as a result of TEA-induced sympathectomy and may interfere with hilar dissection and lymph node dissection. This reflex can be abolished using topical anesthesia placed directly onto the surface of the lung as well as intrathoracic vagal blockade.