Tube or tubeless? Non-intubated VATS as a contemporary strategy in thoracic surgery

Abstract Background Video-assisted thoracic surgery (VATS) is traditionally performed under general anesthesia with endotracheal intubation and one-lung ventilation. Renewed interest in non-intubated VATS (NIVATS) has refocused attention on thoracic surgery performed under spontaneous ventilation with regional anesthesia and carefully titrated sedation. This review examines the evolution, rationale, current evidence, and practical limits of NIVATS in modern thoracic surgery. Main body We summarize the terminology and development of NIVATS and discuss its physiological basis, indications, contraindications, patient selection, regional anesthesia, cough-control strategies, oxygenation adjuncts, and conversion pathways. Recent randomized syntheses and propensity-matched meta-analyses suggest that, in carefully selected patients managed in experienced centers, NIVATS can reduce airway-related morbidity, postoperative nausea and vomiting, chest-tube duration, and length of stay, with signals toward fewer postoperative pulmonary complications and faster recovery. These potential advantages are counterbalanced by specific intraoperative challenges, including respiratory motion, cough, permissive hypercapnia, and the need for immediate conversion to intubated anesthesia in cases of hypoxemia, bleeding, or inadequate surgical conditions. Successful implementation therefore depends on strict patient selection, high-quality regional analgesia, close surgeon-anesthesiologist coordination, and a predefined conversion strategy. Conclusion NIVATS should not be viewed as a universal replacement for intubated anesthesia, but as a complementary, precision-based approach for selected thoracic procedures. In experienced centers, current evidence supports its feasibility, safety, and clinical value, while broader adoption will depend on standardization, training, and robust long-term outcome data.