Non-intubated video-assisted thoracoscopic surgery for pleural biopsy: a narrative review

Video-assisted thoracoscopic surgery (VATS) has significantly improved patient care by reducing pain, complications, and recovery time, but it still carries risks related to general anesthesia especially in frail patients. To address this problem, awake VATS is gaining popularity worldwide. The most common procedures performed with this technique are pleural biopsies and pleurodesis for malignant pleural effusions. Available data suggest that, in experienced centers, awake VATS is safe and has a similar efficacy in treating pleural effusions compared to intubated VATS, with very few contraindications. Patients with multiple comorbidities, elderly patients, and those with poor pulmonary function, who are at higher risk during general anesthesia, are the ideal candidates for awake VATS. A narrative review was conducted in order to help surgeons approaching this technique make meaningful improvements in their quality of practice, in a way that is safe for the patient. This article provides a detailed overview of indications, surgical technique, advantages and disadvantages of non-intubated VATS in comparison with medical thoracoscopy and intubated VATS.