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Page 2 of 5 Elkhayat et al. Mini-invasive Surg 2020;4:85 I http://dx.doi.org/10.20517/2574-1225.2020.76

that every operable patient considering primary SBRT should be educated regarding this difference
[2]
in survival . Even though this was a retrospective study, it makes a real clinical trial to compare both
maneuvers very difficult. Such a trial that will contain two very different patient populations, one group
will be fit for surgery and the other one is unfit, with a significant bias regarding long-term outcomes and
[3]
overall survival. Surgery still offers the best option for patients that can tolerate it . With the increase in
minimally invasive approaches, more patients can be offered surgery and achieve better overall survival.
Awake non-intubated video assisted thoracic surgery (VATS) resection is one of the most recent technique
that we believe to be a game changer in this spectrum of patients who were previously classified as
medically inoperable.

CHALLENGES WITH EARLY STAGE LUNG CANCER
As more screening programs become readily available for lung cancer, more patients are diagnosed with
[4]
early stage lung cancer . Most of these patients have very mild or no symptoms, making it troublesome
for physicians to ask them to consider high risk or very complex interventions. However, at the same
time, these patients mostly have comorbidities that increase with age such as cardiovascular problems and
limited pulmonary reserves, and even if we can offer them curative surgery, a large percentage of them
are medically inoperable. There was no specific definition of such inoperability. With an average age of
[5]
diagnosis of 70 years , lung cancer patients often have a level of baseline frailty, along with concomitant
comorbid conditions, especially those associated with risk factors for non-small cell lung cancer such as
heart disease, chronic obstructive pulmonary disease, and loss of pulmonary parenchyma. Age is not the
sole factor to determine medical operability, several factors such as performance status, presence of medical
comorbidities, and pulmonary function tests, contribute to overall risk assessment.

With this above-mentioned status, surgeons try to improve the overall perioperative experience and
facilitate surgery for more lung cancer patients by moving from open surgery to less invasive surgery. In
thoracic surgery, there was a rapid pace of change from open thoracotomy to multiport VATS, uniportal
VATS, and subxiphoid VATS, all aiming at decreasing the surgical burden on the patients by decreasing
the incision and limited access surgery. Yet, there was another important factor that attributed to mortality
and morbidity and that was anesthesia. Since the development of minimally invasive lung resection,
almost all cases were operated under general anesthesia with double lumen endotracheal intubation.
[6-8]
[9]
Tracheobronchial injuries , prolonged effect of neuromuscular blockers , and pulmonary complications
[10]
postoperatively are all possible complications of general anesthesia and double lumen endotracheal
intubation. This drove surgeons to think of non-intubated VATS as a way to avoid these complications and
improve the patients’ overall experience. This seems to have an extra advantage in patients with impaired
pulmonary function who are usually unfit for general anesthesia and will typically be deferred to another
therapeutic option inferior to radical curative surgery.

Another challenge appears on the surface is the ground glass opacities (GGOs) which become more
detected nowadays thanks to screening programs. Incidence of cancer in GGO has been reported as high as
63% so most surgeons prefer to get a biopsy before resection, but some prefer direct surgical resection. This
can be possible for peripheral lesions, but for central GGOs it is very challenging to obtain a preoperative
pathology. Hence, a minimally invasive approach can offer both diagnostic and therapeutic solutions that
cannot be done with the SBRT approach . Even in peripheral GGOs, localization in non-collapsed lung
[11]
or emphysematous patients is limited especially with coughing and movements of the diaphragm and
the mediastinum in case of awake VATS. This can be overcome by intrathoracic vagal and phrenic nerve
blocks or administration of aerosolized lidocaine. For nodules and GGOs not amenable to finger palpation,
preoperative CT guided hook wire insertion or a preoperative CT-guided dye localization can improve the
[12]
intraoperative localization and shortened the operative time and manipulation .