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Advances in Surgery: Lung surgery via keyhole while awake

Dr. Diego Gonzalez Rivas, the young, trailblazing Spanish thoracic surgeon we profiled last year, is not content to rest on his laurels. Despite racking up an impressive array of awards, accolades and publications, Dr. Gonzalez Rivas remains humble, accessible and committed to advancing the field of thoracic surgery. Since we spoke to him last year, he has continued to push forward; his latest technique is a mouthful; “Non-intubated, awake single port video- assisted thoracoscopic surgery.

Dr. Gonzalez Rivas in the operating room
Dr. Gonzalez Rivas in the operating room
courtesy Dr. Gonzalez Rivas
with Dr. Gonzalez Rivas
with Dr. Gonzalez Rivas
photo courtesy of Dr. Gonzalez Rivas

Making surgery safer

The importance of his latest advancement to patients is multi-fold. As Dr. Gonzalez Rivas explains, his latest technique reduces the risks of surgery by “minimizing the adverse effects of tracheal intubation and general anesthesia like intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade , impaired cardiac performance, and postoperative nausea and vomiting. By avoiding general anesthesia, we also reduce the length of the hospital stay and procedure-related costs. It also results in a faster recovery with immediate return to daily life activities”.

Who is Dr. Diego Gonzalez Rivas?

Frequently published and internationally known, Dr. Gonzalez Rivas is widely credited with inventing and popularizing the single port VATS (video-assisted thoracoscopic surgery) technique, which allows thoracic surgeons to perform major lung and mediastinal surgeries for cancer and other conditions including lobectomies, pnuemonectomies, sleeve resections, thymectomies and other tumor resections, through a single 2.5cm incision. In the world of surgery, he is a master, among young thoracic surgeons, he's a rockstar.

In addition to performing single port surgery, Dr. Gonzalez Rivas travels the world to teach his techniques to others.

Traveling professor of surgery

In the month of May alone, Dr. Gonzalez Rivas traveled to Turkey, Italy, several parts of China, Madrid and the United States to demonstrate his techniques. But despite his hectic schedule, when he returns to his home town, he continues to operate and innovate at the Minimally Invasive Thoracic Surgery Unit (UCTMI) at Coruna University Hospital in Coruna, Spain.

What is “Non-intubated, Awake Single Port Video-Assisted Thoracoscopic Surgery?”

His latest technique, which will be published in Interactive Cardiovascular and Thoracic Surgery is a combination of two advanced surgical techniques. The first is Dr. Gonzalez Rivas' own; the single port VATS approach. The second part; the avoidance of general anesthesia and patient intubation is a technique adopted from two other thoracic surgeons, Dr. Chen from Taiwan and Dr Jianxing He from Guanzhou, China.

Newest advance in thoracic surgery: Non-intubated and awake

While the idea of being awake during lung surgery may sound like the plot of a B -rated thriller, nothing could be further from the truth. In reality, ‘awake’ is a bit of a misnomer. Think conscious, or “not comatose” instead. It means that patients undergo surgery without general anesthesia, which induces a coma-like state that requires intubation or placement of a breathing tube to prevent airway obstruction. Instead, patients are given medications in a technique often called, “conscious sedation” or “Twilight” to produce a state of relaxation without loss of consciousness. Depending on the level of conscious sedation, patients can follow instructions, talk and otherwise interact with staff during the procedures. Many of the medications have another effect called “retrograde amnesia” which means patients may be fuzzy or forgetful about the details of the procedure afterwards.

Now, don’t worry readers; you won’t feel a thing; Dr. Gonzalez Rivas and his team are using a combination of agents, including midazolam infusion and agents such as remifentanyl or propofol for sedation and relaxation, an intercostal nerve block and topical anesthesia for analgesia during surgery. As people often say, “you will be awake, but you won’t care.”

Lung surgery patients often have ‘bad’ lungs

By the nature of lung surgery, the very patients who need the surgery the most are often at the highest risk of these complications, so having a procedure that avoids these risks entirely is a huge bonus. In fact, when combined with the single port technique, “non-intubated, awake” surgery represents a huge advancement in the field of surgery.

If you are too sick to “go to sleep”

The benefits of awake surgery are numerous. One of the biggest benefits is that it allows surgeons to operate on patients who might be otherwise considered too sick to have surgery. That’s because one of the biggest risks of conventional surgery is general anesthesia. General anesthesia can be risky for anyone with a history of cardiac or respiratory problems. One of the main complications of general anesthesia is an intra-operative or early post-operative heart attack. Another is related for the need to secure the airway and ventilate the patient during surgery. For patients with significant lung disease, extubation or removing the breathing tube at the end of the surgery isn’t always that easy. Once some patients are intubated, doctors may find out that the patient is not strong enough to breath for themselves after surgery. These patients may require mechanical ventilation or life support to keep them alive for hours or even days after surgery. Some patients end up developing additional complications like post-operative or ventilator-caused pneumonias. Some patients even up requiring long-term ventilator support and tracheostomies.

But barring these major complications, avoiding general anesthesia means avoiding other potential complications such as rare but life-threatening allergic reactions, dangerous hypotension (low blood pressure) as well as the more frequent, but not life-threatening side effects of the medications including over-sedation and respiratory depression as well as the most common after effect; nausea and vomiting.

One little incision + avoidance of general anesthesia = less time in the hospital

One of the biggest benefits of the single port approach is that it utilizes one small incision versus traditional thoracotomies or even the more modern but multiple port techniques. For patients, a smaller incision means less pain, and less recovery time. It also means a shorter length of stay or less time in the hospital. Since hospitals are brimming with resistant bacteria and other nasties, a quick “in-and-out” is about more than just convenience; it’s in the best interest of the patient.

By avoiding general anesthesia, Dr. Diego Gonzalez Rivas takes this a step farther, and a step closer to ‘out-patient surgery’ status. He’s not there yet – and neither is anyone else, but while you can’t have a lobectomy on Monday morning and stop by McDonald’s for lunch afterwards, this technique does avoid pit stops in the intensive care unit (ICU) and shorter overall time in the hospital. Dr. Gonzalez Rivas and his team have performed six cases so far, and the results have been impressive.

Home in 36 hours?

The first person was able to go home 36 hours after surgery and there have been no complications in any of the people having this technique. One of the more notable cases involved an 86 year old woman, (as featured in the accompanying video), who was able to go home within 72 hours of having a major lung operation. All six patients went home within 2 to 3 days.

As Dr. Diego Gonzalez Rivas explains, “using single port VATS lobectomy, no intubation, no epidural, no central line, no urinary catether, no vagus block, it is the least invasive lobectomy ever!”

While these ground-breaking surgical techniques are changing the lives of patients for the better, don’t expect your local surgeon to be well-versed in these techniques. At least, not until they have been trained by Dr. Gonzalez Rivas.