Awake Single-Access (Uniportal) Video-Assisted Thoracoscopic Surgery for Peripheral Pulmonary Nodules in a Complete Ambulatory Setting

Purpose: Traditional 3-port video-assisted thoracoscopic surgery (VATS) in a patient who is awake has been proposed as a breakthrough in the direction of fast tracking patients through routine thoracic surgical procedures. We wanted to explore the possibility of further reducing surgical invasiveness by resecting a peripheral pulmonary nodule with single-access (uniportal) VATS in an awake, nonintubated, nonventilated patient, with selective occlusion of the tributary lobar bronchus. Description: A 47-year-old woman with bilateral peripheral nodules underwent uniportal VATS wedge resection of an undetermined nodule in the right middle lobe. The patient was awake and under mild sedation for the entire procedure. Single-shot epidural regional anesthesia was administered. Under guidance provided by a reusable, portable flexible bronchoscope, a Fogarty balloon was positioned to occlude the right middle lobe bronchus to facilitate collapse of the targeted parenchyma. At the end of the procedure, the chest drain was connected to a portable vacuum system delivering autonomous suction. Evaluation: Awake uniportal VATS resection of peripheral nodules in selected patients is feasible and appears to be safe. Available technology may enable further reduction of costs related to length of hospitalization. Conclusions: The concept of ambulatory thoracic surgery may further evolve by utilizing uniportal VATS in an awake patient to solve the often-challenging diagnostic dilemmas represented by undetermined lung lesions.