Non-intubated minimally-invasive lung surgery in Germany—current status and outlook

Lung surgery under spontaneous ventilation (non-intubated video-assisted thoracoscopic surgery, niVATS) picked up a lot of momentum during the past few years. Surgeons and anesthetists alike want to forgo known risks of orotracheal intubation and mechanical ventilation, ranging from local complications, like mucosal injury or even deleterious tracheal laceration and rupture, to increased release of pro-inflammatory cytokines and diaphragmatic dysfunction secondary to muscle relaxation. Despite initial adoption of VATS in Germany having been slow due to a general reticence towards it in smaller units, major thoracic centers nowadays have well-established minimally invasive programs and even perform minor non-intubated procedures on a regular basis. Experience with major niVATS cases still is sparse across Western Europe, and limited to specialized and highly trained centers, where exceptionally complex and often multimorbid patients can safely undergo lung surgery under spontaneous ventilation. Our group pioneered niVATS lobectomy in Germany back in 2018, and since then we tried to spread the technique by means of multidisciplinary Masterclass-courses held at our center, in which the participant's initial reticence to perform niVATS often changed to enthusiasm for the procedure. This in turn led several visiting units to start with their own programs, and some of them even reported their initial experience. This article offers a short historic overview of VATS in general, gives an insight into how niVATS got pioneered in Germany and presents the current state of affairs.