Awake on the operating table

Jack* had been turned away by doctors reluctant to remove a mass on his only lung, so when Dr. Ara Klijian was approached by Jack, he took pause. Dr. Klijian, a cardiothoracic surgeon affiliated with Sharp Grossmont Hospital, originally thought to side with his counterparts, but then reconsidered.

Along with only having a single lung, Jack had COPD (chronic obstructive pulmonary disease) and emphysema-like lung changes due to years of smoking.

“The mass in his lung was cancer that was not responding to traditional chemotherapy nor radiation, so really, there weren’t too many options left for him,” recalls Dr. Klijian.

Jack’s condition did not qualify him for traditional lung surgery known as video-assisted thoracic surgery (VATS), which involves inserting a camera, breathing tube and other surgical tools through small incisions made in the body. VATS also requires the patient to undergo general anesthesia. For vulnerable patients such as Jack, general anesthesia posed high risks.

But what if the cancer could be removed without having to put the patient under? Dr. Klijian realized that the chest wall and space between the lungs — not the lungs themselves — contained nerve or pain fibers. So to block pain, anesthesia may only be needed locally in the chest wall and lung space, where pain would be felt.

From this idea, Dr. Klijian helped pioneer AVATS, or awake video-assisted thoracic surgery.

The main difference from traditional surgery and AVATS? Rather than general anesthesia, local anesthesia and sedation are used.

“The patient is not completely out, but rather groggy. They are usually sleeping during the surgery,” says Dr. Klijian.

Benefits of AVATS
Dr. Klijian has performed more than 1,800 AVATS cases to date. He initially reserved the procedure for only the most severe cases — patients unable to tolerate the possible side effects of general anesthesia. However, after performing several cases early on, he saw the remarkable benefits. Now he performs AVATS on most of his patients.

Patients who undergo AVATs typically have a shorter length of stay in the hospital, as well as faster recovery time, among other benefits.

“Aside from a little soreness at the surgical site, and feeling tired, I feel healthier than when I came to the hospital,” says Bob Gookin, a patient interviewed just hours after AVATS.

A terrible fall last year left Bob with broken ribs and injuries to his brain and lungs. He underwent thoracic surgery to repair damage and drain fluid buildup in his right lung. The surgery was under general anesthesia. Bob then needed another surgery the following year, when fluid began to build up in his left lung, making it difficult to breathe.

The second surgery was done using the AVATS approach.

“It was easier for Bob to come out of local anesthesia compared to general anesthesia,” says Laura Gookin, Bob’s wife. “This second time around he’s as bright as a light bulb.”

Gaining traction
AVATS is performed to assess or treat various chest-related diseases and conditions, such as:

• Benign and malignant lung cancers

• Lung tissue infection

• Scarred or fibrous tissue

• Fluid buildup in the lungs and chest

• Damage to the esophagus (the tube connecting the throat to the stomach)

Dr. Klijian has presented the technique at major scientific meetings and in several medicine journals.

“The use of AVATS has steadily grown,” says Dr. Klijian. “Studies have shown that it is a safe and effective option, even for those patients with exceedingly poor heart and lung function and other co-morbidities. Results are comparable and often better than traditional VATS. AVATS is an extension of the traditional approach, which in turn opens surgical options to patients who may not otherwise have them.”

*Not his real name.

This story was updated in July, 2020.