Dr. Hung, Dr. Chen and nonintubated and awake thoracic surgery

Dr. Ming-Hui Hung & Dr. Jin-Shing Chen at National Taiwan University Hospital talk about their work in nonintubated and awake thoracic surgery.

After attending multiple recent thoracic surgery conferences, where the topic of nonintubated thoracic surgery sparked murmurs and outspoken criticism, thoracics.org conducted a brief review of the literature to attempt to discern if this criticism and skepticism was warranted.  As part of this review, we reached out to several of the leaders in the field, including Dr. Ming-Hui Hung, a well-respected Taiwanese anesthesiologist and widely acknowledged expert on this topic.

Thoracics.org asked for Dr. Hung’s commentary as well as his response to several specific questions on nonintubated thoracic surgery.  Here is his response in it’s entirety (re-formatted to fit the Question and Answer format posed by our correspondence).

Question:  Would you tell me more about your initial research in this area.   What lessons have you learned (overall) in patient selection for non-intubated thoracic surgery?  What additional tips or advice would you offer interested thoracic surgeons/ members of anesthesia?

As we had discussed in our publications, we are facing more and more aging and frail patients with minor thoracic procedures. As surgical approach evolves toward a minimally invasive thoracoscopic technique, we expect that there would be a need for less invasive anesthetic management (i.e. nonintubated VATS) as well. Traditional intubated one-lung ventilation does offer a safe and quiet surgical environment for surgery; however, we still suffer occasionally to have patients complicated with intubation-related adverse effects, not to mention the consuming procedures for successful one-lung ventilation. Actually, there was a short-stature elderly lady complicated with pneumo-mediastinum because of tracheobronchial laceration after a double-lumen tracheal intubation. We was driven by this case we suffered to find a solution and whereas we developed our nonintubated techniques since 2009. As you noted, now nonintubated VATS is a routine part of our armamentarium for thoracic surgery.

To summarize, there are important steps that we learned from our experiences:

  1. Thoracic epidural anesthesia (TEA) vs internal intercostal nerve blocks (INB)

In the beginning, we applied TEA. It does provide satisfying analgesia but it is time-consuming and carries more risks for neurological complications. Once again, we had a nonintubated case coincidentally complicated with acute transverse myelitis after surgery. Although we excluded the epidural procedure per se, to be the direct cause of the regretful complication, we were still bothered by a legal suit against us. Then we learned that internal INB is equally effective as a thoracic epidural catheter. It saves time and risk free to do it as we do it under a direct vision by scope, and no touching on any spinal structures. Now INB is our routine part of nonintubated VATS. TEA is considered for those doing a bilateral VATS. We think this is important because it makes nonintubated VATS more safe and even more less invasive, for which our patients would accept this approach more. We Taiwanese are mostly reluctant to have someone doing anything on our spines, as we usually call them the “dragon bones”, the most important part of our bodies.

  1. Intrathoracic vagal block

Since cough reflex is a visceral part of autonomic nerve, which is not blocked by TEA or INB, unpredictable cough reflex during surgery could quietly bothering and even dangerous. We soon learned that we could block the cough reflex via intrathoracic vagal nerves. It really works. It alleviates the tension upon surgeons who working on a spontaneously breathing lung and enable them more manipularity of lung parenchyma and hilar structures. Surgeons are still needed to be as gentle as possible for that excessive traction still can trigger cough reflex from the dependent side where vagal nerve function is intact.

  1. Sedation and titration of its depth

We know there is an “awake, or not awake” issue on nonintubated VATS. We prefer to sedate our patients just because our patients do not want to be awake during surgery. Lateral decubitus position is not a confortable position. Most of our patients undergo surgery because of lung cancer or potential lung cancer. It usually takes 1-2 hours to have a diagnosis first and complete the definite treatment upon the final pathological result. We believe no one would like to be anxiously awake for the result with an open chest in an awkward position. In addition, the initial phase of iatrogenic pneumothorax would cause the patient dyspneic and tachypneic for a while, giving patient sedated with supplemental opioid is useful to alleviate the respiratory disturbances and accelerate the operated lung to collapse. By applying bispectral index EEG monitor, we can observe the BIS index increasing during the initial phase of open pneumothorax, it could be caused by inadequate analgesia, or just because of a dyspneic response. We may give the patients some more anesthetic and it usually recovered after effective vagal block. Carefully observe the respiratory pattern (from the video, or using an noninvasive end-tidal capnography) is of importance. Anesthesiologists should keep vigilant on the respiratory pattern and airway patency of the nonintubated patients, including a plan B for intubation conversion.

  1. Patient selection

We operate on spontaneous breathing lungs (most of the time, the operated lung collapses well because of positive pressure introduced into the chest cavity). The remaining opposite lung is sufficient to maintain satisfactory oxygen saturation, despite unavoidable hypoventilation. However, a vigorous diaphragm would jeopardize the balance. For surgery, it causes excessive movement of the operated lung and makes hilar manipulation dangerous or even impossible. For respiration, COrebreathing (an to-and-fro phenomenon between the dependent and the non-dependent lung) would further exacerbate the breathing pattern and decrease the alveolar oxygen fraction of the nondependent lung, leading to oxygenation desaturation. It is the most common scenario of our difficult cases and we changed to intubation conversion in some of them, especially in major resections (i.e. lobectomy) for lung cancer. We learned that obese patients tend to be an abdominal breather because of an elevated diaphragm and they are usually associated with excessive diaphragmatic movement during nonintubated surgery. Other contraindications for nonintubated VATS are also listed on the literature. We suggest that are mostly at the discretions of the caring surgeon and anesthesiologist as their good clinical practice routines.

Question:  How have your findings of your work been received internationally?  At several recent conferences, there has been a lukewarm or even critical response towards nonintubated thoracic surgery.  Is this a frequent response? 

A typical unfriendly tone from other colleagues is “just because it can be done, should it be done?” We have the same feelings as you experienced in those meeting. Nonetheless, our findings are relevant and robust that nonintubated VATS is feasible and safe in selected patients with a variety of thoracic procedures. They were published in well-known surgical journals in cardiothoracic field, including Annals of Surgery, Journal of Thoracic and Cardiovascular Surgery, Annals of Thoracic Surgery and the European Journal of Cardio-Thoracic Surgery. Still, there are surgeons and anesthesiologists enthusiastic about less invasive alternative for their caring patients visiting our hospital for nonintubated VATS, including Korea, China, Switzerland internationally and other hospitals nationally.

We believe it is human nature being anxious and doubtful to do something you do not get familiar with, especially when intubated one-lung ventilation is nearly an unbreakable only golden standard for thoracic surgery for decades, and almost all thoracic surgeons in current generations would request a fully collapsed lung to operate upon. But at this time, we are approaching a 1000 nonintubated VATS case volume, and all thoracic anesthesiologists and thoracic surgeons in our hospital are dealing with nonintubated VATS if this is appropriate for their patients. We think it is quiet a milestone in our program.

Five years ago, I asked one of my colleagues, a nursing anesthetist [emphasis mine] whether she would choose nonintubated technique if she needs a VATS procedure.

She said, “Well, I need to think about it. You better give me an double lumen even though I know how big it is.”

One year later, her answer to the same question is a “Yes, please, no tube.”

Question: Are there any other obstacles for researchers in this area?  Do you have other on-going research programs at your facility?

Obviously, nonintubated patients recover from surgery fast. They can shift to the gurney on their own from the surgical table. They experience less pain and less PONV in PACU, which enables them to recover oral intake sooner with oral analgesics and early ambulation, not to mention those common adverse effects after double lumen intubations, such as a sore throat and a change of voice quality. Currently, we are drafting our manuscripts about nonintubated VATS pulmonary resection in patients with compromised lung function. Meanwhile, a randomized trial is under investigation to compare the recovery differences of nonintubated VATS vs. intubated VATS.   There are also several more nonintubated trials in Clinicaltrial.org in different countries.

Question: Do you know of any programs that have adopted your techniques and protocols?

To our knowledge, Dr. Jianxing He from the First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China, is also an enthusiastic advocator and pioneer in nonintubated VATS. He is also leading journals such as Journal of Thoracic Disease andAnnals of Translational Medicine as an open forum to accelerate the impact of nonintubated VATS. He is going to publish a state-of-the-art monograph dedicated to nonintubated VATS in the near future. We believe you can get useful information regarding nonintubated VATS in China and different perspectives from him.

As always, we keep doing our best to satisfy our patients’ need during their curing and recovery processes, just because “our patients, first.”

Ming-Hui Hung, MD, MS

Anesthesiologist, Department of Anesthesiology

Jin-Shing Chen, MD, PhD

Professor, Department of Surgery

National Taiwan University Hospital

Thoracics.org would like to thank Dr. Hung and his colleagues for their continued work in this area.  Thoracics.org would also like to thank Dr. Hung for his willingness and frank candor in addressing some of the other issues in this area.

Additional References and Resources

Ke-Cheng Chen1,3, Ya-Jung Cheng2, Ming-Hui Hung2, Yu-Ding Tseng3, Jin-Shing Chen (2012).  Nonintubated thoracoscopic lung resection: a 3-year experience with 285 cases in a single institution.  Journal of Thoracic Disease, Aug 2012, 4(4).

Hung MH, Hsu HH, Cheng YJ, Chen JS. (2014).  Nonintubated thoracoscopic surgery: state of the art and future directions. J Thorac Dis. 2014 Jan;6(1):2-9. doi: 10.3978/j.issn.2072-1439.2014.01.16. Review. (Best read in pdf form).

Liu YJ, Hung MH, Hsu HH, Chen JS, Cheng YJ. (2015).  Effects on respiration of nonintubated anesthesia in thoracoscopic surgery under spontaneous ventilation.  Ann Transl Med. 2015 May;3(8):107. doi: 10.3978/j.issn.2305-5839.2015.04.15. Review

Fast track thoracic surgery: nonintubated minimally invasive surgery for complex procedures.  October 4, 2015.

Readers: Thoracics.org has highlighted a key phrase in Dr. Hung’s response that also, unintentionally but directly addresses one of the criticisms recently advanced by a noted American thoracic surgeon who challenged Dr. Martinez as to whether he would ever delegate the care of a nonintubated patient to a nurse anesthetist.  When Dr. Martinez hesitated in his response, the surgeon claimed victory, stating, “See?  That would never work in American hospitals, [where certified nurse anesthetists oversee the majority of cases]”.  This was his rationale for dismissing this technique, even when it might make otherwise inoperable patients eligible for life-saving surgery.  That dismissal of both his American colleagues and the needs of the more fragile subset of our thoracic surgery population demonstrates some of the limitations in our so-called “masters” or “giants” of thoracic surgery.  While great, and influential surgeons, they are not infallible.  Their experiences carry wisdom, but their opinions shouldn’t carry more weight than any other published study.

Thoracics.org is committed to giving a voice and forum to all specialties and members of the thoracic surgery community.       

Case Report: Repair of diaphragm defect in Hepatic Hydrothorax

Case report with video of SITS (single incision thoracoscopic surgery) repair of diaphragm defect in a case of hepatic hydrothorax resulting from liver cirrhosis with Dr. Chih-Hao Chen, MAckay Memorial Hospital, Taiwan

Case Report: Single incision thoracoscopic repair of diaphragmatic defect in a patient with hepatic hydrothorax

Dr. Chih-Hao Chen, Thoracic Surgeon
MAckay Memorial Hospital, Taiwan

Dr. Chen, Thoracic Surgeon
Dr. Chen, Thoracic Surgeon

Clinical History:

Patient is an elderly woman who was admitted after a motor-vehicle accident  with a traumatic fracture of the humerus and femoral neck. She was brought to our ED immediately and was intubated due to acute respiratory failure.

Subsequent Chest radiograph showed diffuse opacity in right hemithorax and concomitant fracture in left side humerus and femoral neck. Attempt for tapping of the pleural effusion showed clear in nature.

According to previous medical records, she had no relevant history. She was admitted to ICU for further evaluation and management.

Fluid analysis in emergency department showed transudate.

Relevant Diagnostics: 

The initial effusion analysis :

Pleural Fluid Analysis

Color                    Yellow

Appearance               clear

Specific Gravity         1.009

Rivalta                  Negative

RBC                      274       /cmm

WBC                      27        /cmm


L                    2

N                    18

Other cells          7


P-glucose                134       mg/dL

P-protein                0.872     g/dL

P-LDH                    46        IU/L

Additional Labs:

Coags:  14.1 sec.  INR 1.41 APTT:  38.9 sec.

CBC: Hb 10.0 g/dL HCT  30.1 %  RBC 3.00  MCV  100.3 fL  WBC 5.80 10^3/uL  Platelet 57

LFTS: Total Bilirubin  2.7 mg/dL  AST 116 ALT 68 Albumin 2.3 g/dL Direct Bilirubin H 1.1 mg/dL

Chem panel: BUN 83 mg/dL Creatinine 1.6 mg/dL  K 3.2 mEq/L Na 144 mEq/L

Chest radiograph on admission showed a massive right-sided pleural effusion.

Chest radiograph on admission
Chest radiograph on admission

For symptomatic control, the physician performed intermittent thoracentesis. Because the traumatic site is left aspect of the trunk ( fracture in left side humerus and left side femoral neck ) and right side effusion was very clear.

Hepatic hydrothorax was suspected. Later peritoneal scan confirmed the diagnosis.

Peritoneal scan
Peritoneal scan

The scan showed left side pleural space was sparring from radioisotope. Direct communication between right side pleural cavity and the abdomen. The diagnosis is confirmed with such findings.

CT scans are not diagnostic for this condition, and were not indicated for her other injuries. Therefore, we did not arrange CT scan of the chest / abdomen.

Abdominal ultrasound showed moderate to massive ascites. Along with hepatic encephalopathy, moderate to massive ascites, prolonged PT/PTT, low albumin, higher bilirubin, the extent of cirrhosis is Child’s class C.

Operative Procedure:  Single incision thoracoscopic repair of a diaphragmatic defect.  Theoretically, with SITS, the wound can be very tiny. However, in our experience (fifteen total cases to date), diaphragm surgery through single port may be a bit difficult because we did not know where the defect is. We have to inspect very carefully and to search for the defect where the fluid came out. In this case, we made one small wound around 2 cm in length at the 6th ICS along the anterior axillary line.

Repair of the diaphragmatic defect was performed using silk suture similar to that used to repair inguinal hernias. Intra-operatively, the defect was 2 -3 mm in diameter.

At the conclusion of the procedure, using the original incision, we placed one Fr.24 chest tube to monitor the drainage and may consider chemical pleurodesis if the drainage persists.  The operative procedure was accomplished within 30 minutes.


Post-operative Chest Radiograph


Post-operative condition of the chest film showed near complete resolution of the effusion and lung re-expansion was complete.

Pathology/ Fluid Cytology: fluid analysis and peritoneal scan showed communication between peritoneal space and right side pleural space confirming pre-operative diagnosis.  No tissue specimens were taken during this procedure.


Hepatic hydrothorax is the development of a pleural effusion in a patient with liver disease in the absence of cardiopulmonary pathology, making it a diagnosis of exclusion in many cases.  It can occur in patients with and without ascites and may be the first presenting symptom in patients with undiagnosed liver disease.  Similar to catamenial pneumothorax; hepatic hydrothorax is predominantly a right-sided disease.  This is due to an anatomic gutter or diaphragmatic defect that occurs, and allows the passage of material or fluid from the abdominal cavity into the pleural space.  This can be seen and identified on peritoneal studies(Peritoneal scan) like the study showed in our case study above.  (Similar pathologies can occur in related conditions such as renal failure related hydrothorax due to this defect). Such defect is usually identified in the tendon part of the diaphragm. Peritoneal scan can confirm there is communication between the abdominal cavity and the pleural space. However, the definite location, size and number of defects can not been identified by the scan alone. Thoracoscopic inspection is the only method to search for such defect(s).

Video-assisted thoracoscopic surgery (VATS) has been shown to be a safe and effective method of treating this condition, by allowing surgeons to correct the defect, and thus prevent recurrence (Saito et al. 2012). The cure rate varied greatly in the literature. The key is whether the defect can be repaired. For one to two obvious defects, direct suture repair usually cured the disease. (the cure rate more than 80%) However, for some undetectable defects or defects with fenestration type, the cure rate is very low, ( around 30-50% ).  Alternative strategies have to be considered in such condition, such as tissue glue, abrasion pleurodesis, mesh interposition and  using sclerosing agents(OK432, bleomycin, Minocin, talc, etc).  This is in distinct contrast to the numerous non-surgical drainage procedures such as thoracentesis, which removes accumulated fluid but does not correct the underlying pathology.  However, the hallmark of this condition, liver failure predisposes patients to complications such as bleeding, infection and poor wound healing.  These risks are one of the primary reasons treatment was often limited to drainage procedures prior to the popularization of lower risk VATS procedures. In the past, patients with Child’s class C liver cirrhosis are basically not proper surgical candidates because of extremely high mortality/morbidity rate. In recent experience of single-port approach, some patients with Child B and C are still safe with minimal postoperative complications. The advance of these minimally invasive technologies such as uni-port thoracoscopy permits fewer and more limited incisions which is believed to further reduce these risks while providing patients with definitive treatment options.  More case studies such as this one, along with larger studies are needed to demonstrate the benefits of this technique for hepatic hydrothorax.


Doraiswamy V, Riar S, Shrestha P, Pi J, Alsumrain M, Bennet-Venner A, Kam J, Klukowicz A, Miller R. (2011).  Hepatic hydrothorax without any evidence of ascites.  ScientificWorldJournal. 2011 Mar 7;11:587-91. doi: 10.1100/tsw.2011.68  Case study.

Gurung P, Goldblatt M, Huggins JT, Doelken P, Nietert PJ, Sahn SA (2011).   Pleural fluid analysis and radiographic, sonographic, and echocardiographic characteristics of hepatic hydrothorax. Chest. 2011 Aug;140(2):448-53. doi: 10.1378/chest.10-2134. Epub 2011 Jan 27.

Kim YS, Susanto I, Lazar CA, Zarrinpar A, Eshaghian P, Smith MI, Busuttil R, Wang TS. (2012). Ex-vacuo or “trapped lung” in the setting of hepatic hydrothorax.. BMC Pulm Med. 2012 Dec 17;12(1):78.

Lee WJ, Kim HJ, Park JH, Park DI, Cho YK, Sohn CI, Jeon WK, Kim BI. (2011).  Chemical pleurodesis for the management of refractory hepatic hydrothorax in patients with decompensated liver cirrhosis.  Korean J Hepatol. 2011 Dec;17(4):292-8. doi: 0.3350/kjhep.2011.17.4.292.  Eleven patient Korean study looking at the effectiveness of pleurodesis in patients with hepatic hydrothorax.  While the procedure was successful in 8 patients, the authors noted a high rate of procedural-associated complications. (Notably, the researchers used several different agents for chemical pleurodesis.)

Luh SP, Chen CY. (2009).  Video-assisted thoracoscopic surgery (VATS) for the treatment of hepatic hydrothorax: report of twelve cases. J Zhejiang Univ Sci B. 2009 Jul;10(7):547-51. doi: 10.1631/jzus.B0820374

Nishina M, Iwazaki M, Koizumi M, Masuda R, Kakuta T, Endoh M, Fukagawa M, Takagi A. (2012). Case of peritoneal dialysis-related acute hydrothorax, which was successfully treated by thoracoscopic surgery, using collagen fleece.  Tokai J Exp Clin Med. 2011 Dec 20;36(4):91-4.

Saito M, Nakagawa T, Tokunaga Y, Kondo T. (2012).  Thoracoscopic surgical treatment for pleuroperitoneal communication.  Interact Cardiovasc Thorac Surg. 2012 Oct;15(4):788-9. Epub 2012 Jun 29

Sawant P, Vashishtha C, Nasa M. (2011).  Management of cardiopulmonary complications of cirrhosis.  Int J Hepatol. 2011;2011:280569. doi: 10.4061/2011/280569. Epub 2011 Jul 19.  Article discussing complications of cirrhosis including hydrothorax.

Sen S, Senturk E. (2010).  Diaphragmoplasty with patch on the hepatic hydrothorax due to pleuroperitoneal fistula. Arch Bronconeumol. 2010 Dec;46(12):662-3. doi: 10.1016/j.arbres.2010.06.016. Epub 2010 Aug 7.  Letter with case report, photos and diagnostic imaging.

Sherman KE. (2011).  Advanced liver disease: what every hepatitis C virus treater should know.  Top Antivir Med. 2011 Aug-Sep;19(3):121-5. Review

Wojcikiewicz TG, Gupta S. (2009).  Primary biliary cirrhosis presenting with ascites and a hepatic hydrothorax: a case report.  A case report on patient with unilateral pleural effusion as part of initial presentation of hepatic malignancy.  J Med Case Rep. 2009 Jul 14;3:7371. doi: 10.4076/1752-1947-3-7371

Single port thoracoscopy for wedge resection – does size matter?

Dr. Chen discusses single port thoracoscopy – and specimen size.

Single port thoracoscopy for wedge resection – does size matter?
Dr. Chih-Hao Chen, Thoracic Surgeon, Mackay Memorial Hospital, Taiwan
Correspondence: musclenet2003@yahoo.com.tw

Case presentation and discussion

A 77 y/o woman was found to have a neoplasm in RML during routine health exam. (Full case presentation here.)
The incision was 2.5 cm. The specimen was removed successfully; patient experienced no complications and was discharged from the hospital without incident. However, when discussing this case with surgeon colleagues a specific question arose.

preparing to remove the specimen through the port

Does size matter? How big is too big to remove through a port incision?
An important issue is the theoretically smallest (and effective) incision size.  The issue is very challenging for most surgeons. In the past, other surgeons have questioned me :
“The specimen to be removed is more than 12-15 cm. How can you remove the specimen from a 3.5 cm incision?”

BUT, the fact is “the smallest size depends mostly on the solid part of the neoplasm “.

The lung is soft in nature. In my experience, a 3.5 cm port is usually enough for any lobe.  The only problem is that if the solid part is huge, pull-out of the specimen may be difficult.
Therefore, the solid part size is probably the smallest incision size we have to make, usually in the last step when dissection completed , if needed.

successful removal of lung specimen thru small port
Port with chest tube in place

Using endo-bags to avoid larger incisions
There is an exception. I have never do this but I think it may be possible.  We usually avoid opening the tumor (or cutting tumor tissue into half ) within the pleural space in order to prevent metastasis from spillage of cancerous tissue.

What if we can protect the tumor from metastasis while we cut it into smaller pieces? For example, into much smaller portions that will easily pass through the small port incisions?
My idea is to use double-layer or even triple layers of endo-bag to contain the specimen. If it is huge, with perfect protection, we cut it into smaller parts within the bag. Then the huge specimen  can be removed through a very tiny incision. This is possible.

We still have to avoid “fragmentations” since this might interfere or confuse the pathologist for accurate cancer staging. Therefore, in theory, we can cut it into smaller parts but not into fragments. However this idea is worthy of consideration, and I welcome debate from my fellow surgeons and medical colleagues.

Thank you to Dr. Chen.