Prof. Javier Gallego

Cardiothoracic Surgeon

Prof. Diego Gonzalez-Rivas

Cardiothoracic Surgeon

Tubeless Thoracic Surgery

HPA Magazine 14

The main advantage of non-intubated surgery is to avoid the perioperative morbidity derived from the deleterious effect of general anaesthesia and one-lung ventilation, in addition to the beneficial effects of spontaneous ventilation in a non-intubated patient.
Inclusion criteria for a non-intubated uniportal procedure includes all selected patients for whom the avoidance of morbidity of conventional thoracotomy and the risk of intubated general anesthesia could be reduced 



The choice of a single incision technique in an awake or non-intubated patient could minimize even more the invasiveness of the surgery and anesthesia. We call these Uniportal procedures “Tubeless VATS”: single 3 cm incision, no endotracheal tube, no urinary catheter, no central vein and no epidural.
We consider it very important in high risk patients for general intubated anaesthesia such as elderly patients or those with poor pulmonary function. It is advisable to perform a careful selection of the patients, especially during the learning curve. The contraindications for awake major resections are patients with an expected difficult airway management, obesity (body mass index>30), dense and extensive pleural adhesions, hemodynamically unstable patients, ASA>II and big tumours (>6 cm). 
Thanks to the avoidance of intubation, mechanical ventilation and muscle relaxants the anaesthetic side effects are minimal allowing to most of the patients to be included in a fast protocol avoiding the stay in an intensive care unit. Moreover, the perioperative surgical stress response could be attenuated in non-intubated patients undergoing uniportal VATS as a result of the reduced postoperative stress hormones and pro-inflammatory mediators related to mechanical ventilation. Oxygen (6-9 l/min) is supplied via nasal cannulae or facial mask. The pharmacological mana-
gement is based on a target-controlled infusion of remifentanyl and propofol, with a premedication of midazolam (0.15-0.25 mg/kg) and atropine (0.01 mg/kg) 15 minutes before anesthesia, adjusting real-time rate of infusion with the aggressiveness of each period during the surgery. The use of an intraoperative vagus blockade is recommended to suppress coughing that could be troublesome when performing lung traction and hiliar manipulation during dissection. 

During an uniportal approach in a non-intubated patient, is recomended to perform a paravertebral blockade or an intercostal infiltration under thoracoscopic view. The importance of avoiding epidural thoracic blockade (avoiding opioids) will result in faster recovery and return to daily activities. 
The non-intubated VATS major pulmonary resections must only be performed by experienced anaesthesiologists and uniportal thoracoscopic surgeons (preferably skilled and experienced with complex or advanced cases as well as bleeding control through VATS). In some unpredictable difficult cases, intraoperative conversion to general anaesthesia is sometimes necessary. The anaesthesiologist must be skilled in bronchoscopic intubation, placing a double-lumen tube or an endobronchial blocker in a lateral decubitus position. 
Tubeless thoracic surgery is currently evolving, challenging former exclusion criteria and expanding indications to major lung resections or even tracheal and carinal resections to provide better intraoperative status and promote minimal need for recovery.


Two international cardiothoracic surgery specialists joined forces in May and June to share their knowhow and innovation, but above all, to provide additional health and quality of life to patients operated by this duo - Prof. Javier Gallego and Prof. Diego Gonzalez Rivas. 
Prof. Javier Gallego is Coordinator of the Specialty of the HPA Health Group in the Algarve and has gained extensive experience in both cardiac surgery, in pathologies such as aortic stenosis, and in thoracic surgery, in situations such as lung cancer, chest deformities (pectus excavatum and carinatum) and hyperhidrosis (an exaggerated increase in sweating that especially affects the hands, armpits and feet).
Most of these surgeries are performed using minimally invasive techniques, namely by percutaneous single-port video-assisted thoracoscopy. For the patient the results are substantially superior as far as safety and comfort are concerned.
In fact, these techniques have revolutionized thoracic surgery. Prof. González Rivas, one of the most eminent cardiothoracic surgeons in the world is forerunner in this area. 
In 2010 González Rivas was a pioneer in performing unilateral anatomical resection by video-assisted thoracoscopy (with only one incision), having in 2014 performed the first lung surgeries, also with a single incision in patients without intubation and in spontaneous breathing. He was also pioneer in performing uniport resections using an articulated robotic arm, without the need for an assistant surgeon (first case in 2016).
Prof. González Rivas is the founder and current director of the single-port video-assisted thoracoscopy training program, at the Shanghai Lung Hospital, the largest thoracic surgery centre in the world (in 2019, he performed 17,440 major lung resections). 
With the recent and extraordinary contribution of the team at the Hospital Particular da Madeira (see pages 21 and 38). The Cardiothoracic Surgery Unit of the HPA Health Group has all the conditions to be a Centre of Excellence.