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Elkhayat et al. Mini-invasive Surg 2020;4:85 I http://dx.doi.org/10.20517/2574-1225.2020.76 Page 3 of 5

AWAKE VATS: WHAT CAN BE OFFERED
Surprisingly, awake thoracic surgery is not a brand-new intervention. The idea dated back to 1923 to
[13]
Eloesser who, in his report in California State Journal of Medicine, stated that, “…almost all operations
upon the bony thorax should be done under local and regional anesthesia…” With the improvements
[14]
in general anesthesia and tracheal intubation, regional and local anesthesia vanished gradually till
the evolution of VATS in the early 1990s when more surgeons showed increased interest in keeping the
patients breathing spontaneously with some degree of awareness to avoid the problems associated with
[15]
general anesthesia and double lumen endotracheal intubation . Later, surgeons started to look for the
postoperative lymphocyte responses and other immune responses in cases of awake versus conventional
general anesthesia, and they demonstrated attenuated stress response after awake VATS in comparison to
an equivalent procedure performed under general anesthesia and one-lung ventilation [16,17] . This in turn
attracted more surgeons to adopt this technique in cancer surgery as lower immune system responses are
[18]
highly desirable in those patients. In 2014, Gonzalez-Rivas published the first report of awake uniportal
VATS lobectomy. Two years later, the Tor Vergata group published the first series of 1000 patients operated
using awake uniportal VATS . Moreover, the development of uniportal VATS in conjunction with awake
[19]
[20]
surgery helped to perform some operations in the outpatient setting . Non-intubated VATS can be non-
intubated with deep sedation in which patients are relaxed with good airway control via facemask, nasal
cannula, or even laryngeal masks. This type awake VATS is suitable for major resections with longer
operative time. The second type is loco-regional anesthesia in awake patients and this is commonly used
for diagnostic VATS and minor resections [21,22] .

FUTURE PROSPECTIVE
This contentious effort drove more surgeons to use this technique in more frail and high risk surgery
[3]
patients. Wang et al. , in Taiwan, retrospectively investigated the results of 28 patients with impaired
lung function (preoperative forced expiratory volume in 1 second < 70% of the predicted value) who
underwent non-intubated VATS. Only eighteen patients in this series had primary lung cancers, of those
patients, lobectomy was performed in 4, segmentectomy in 3, and wedge resection in 11, with lymph node
sampling adequate for staging. Wang et al. reported no mortalities after 30 days; however, conversion
[3]
to tracheal intubation and one-lung ventilation was required in one patient, an 80-year-old man, because
of persistent intraoperative wheezing and labored breathing. The intubation was performed smoothly in
the lateral position. He required ventilator support postoperatively but was weaned off the next morning.
No patients required conversion to a thoracotomy or blood component therapy. This report gives hope
that some patients, previously categorized with impaired pulmonary function and medically inoperable
patients, can now safely be offered a curative surgery. Yet, sharp cardiac and pulmonary indications for
awake non-intubated surgery have not been fully investigated and are still under trials to determine the
exact cut-off values. The most accepted contraindications so far for awake or non-intubated uniportal
VATS can be categorized into: (1) patient related (i.e., obesity, neurological conditions, uncontrolled
gastroesophageal regurgitation, central hypoventilation syndrome, persistent cough or mucus retention,
and hemodynamically instable or severely hypoxia/hypercapnia); (2) anesthesiologist-related (i.e., difficult
intubation, technical contraindications to general anesthesia, need to protect the contralateral lung from
spillage of endobronchial contents, and inexperienced or non-cooperative team); and (3) surgeon-related
(i.e., uniportal VATS experience and previous operations with adhesions) .
[23]
Khorfan et al. retrospectively investigate records from 2004 to 2016 of patients who were fit for surgery,
[2]
but refused to have surgery and preferred SBRT. From 138,143 patients who met our inclusion criteria, they
found that 1359 patients (0.98%) refused recommended surgery and elected SBRT. Numbers are increasing
every year. Propensity matching resulted in 1,315 well-balanced pairs. Surgery was associated with higher
median survival (74 months vs. 47 months; P < 0.01) in the matched cohort. Survival benefit persisted