From Awake to Minimalist Spontaneous Ventilation Thoracoscopic Mediastinum Surgery: How Far Are We?

Spontaneous ventilation (SV) video-assisted thoracic surgery (VATS) is aimed at offering less invasive alternatives to equivalent procedures under tracheal intubation with mechanical ventilation (MV) and its benefits have shown encouraging results in lung surgery. In addition, there is also growing interest in SV-VATS in mediastinum surgery. The rationale of SV in simpler mediastinum procedures is that MV anesthesia could be considered avoidable if SV anesthesia protocols could provide similar or even better results. On the other hand, for other indications involving more delicate patient subgroups, SV-VATS is aimed at offering a more rapid recovery with less anesthesia-related risks of cardio-respiratory complications. Based on encouraging initial results, SV is also being proposed for more demanding surgical procedures, including tracheal resection and esophagectomy. However, SV mediastinum surgery also implies contraindications, potential disadvantages and peculiar physiopathologic issues which must be clearly acknowledged. This perspective is aimed at providing a critical overview of the current knowledge about SV for mediastinum surgery, with a particular emphasis on the last 10 years of data about thymectomy, biopsy of mediastinal masses, thoracic sympathectomy, tracheal resection, pericardial window and esophagectomy.