Awake thoracic surgery: a historical perspective

During the early twentieth century, thoracic surgery procedures were frequently attempted through local anesthesia, although the pneumothorax created after opening of the chest wall was deemed invariably fatal. During the ensuing decades, some surgeons started performing awake thoracic surgery procedures taking into account the experience matured during the World War I, which suggested that soldiers with severe open thoracic traumas could eventually survive. In the 1940s, a multi-step analgesia protocol entailing multiple local blocks with Novocaine was developed in Russia. Using this technique, hundreds of major thoracic surgery procedures including major lung resections and esophagectomies, were carried out. Subsequently, Buckingham first reported on major surgery procedures using sole thoracic epidural anesthesia in awake patients. The introduction of double-lumen tube ventilation in the 1950s led to the birth of modern thoracic surgery and general anesthesia with one-lung ventilation is still considered m andatory to allow accomplishment of more complex surgical procedures including lung resections. Awake thoracic surgery fell into disuse until recent years when, thanks to the better knowledge of potential adverse effects of general anesthesia, some surgeons again started to investigate the possibility of performing thoracic surgery operation in awake patients Awake thoracic surgery could not have been developed without the previous experience of pioneering thoracic surgeons. Moreover, continuing technological advances and the increased knowledge in cardiopulmonary physiology, are leading to a potentially revolutionary strategy capable of minimizing both surgical and anesthesiological trauma to eventually offer patients comprehensive non-invasive surgical management.