This prospective cohort study evaluates lung injury, long-term clinical outcomes, and environmental impacts of tubeless video-assisted thoracic surgery (VATS) compared with conventional intubated VATS for lung cancer resection. The study aims to determine whether the tubeless approach reduces anesthetic exposure, minimizes lung injury, enhances patient recovery, and decreases carbon emissions, contributing toward sustainable surgical practices.

Minimally invasive thoracic surgery typically relies on general anesthesia with endotracheal intubation and mechanical ventilation, practices associated with increased anesthetic exposure, ventilator-induced lung injury, and environmental burden due to anesthetic gas emissions. To address these issues, our research group developed the tubeless VATS technique, employing spontaneous ventilation under monitored anesthesia care with supraglottic airway devices, nerve blocks, and minimal use of opioids and volatile anesthetics.

This multicenter study prospectively enrolls patients undergoing elective lung cancer resection via either tubeless or conventional intubated VATS, following a standardized protocol. The primary objectives include assessing the incidence and severity of lung injury using mechanical power metrics derived from a validated machine-learning model, quantifying anesthetic drug usage, evaluating postoperative recovery and complication rates, and analyzing long-term clinical outcomes including overall survival and quality of life measures.

Additionally, the study investigates the environmental impact of each anesthesia method by quantifying reductions in carbon emissions associated with decreased consumption of inhalational anesthetics. Findings from this research could significantly influence clinical practice guidelines by demonstrating the benefits of tubeless VATS in enhancing patient safety, improving long-term clinical outcomes, and advancing sustainable surgical practices.

Inclusion Criteria:

1. Patients aged ≥18 years scheduled for elective video-assisted thoracic surgery (VATS) for confirmed or suspected lung cancer.
2. Clinical stage suitable for surgical resection (lobectomy, segmentectomy, or wedge resection).
3. American Society of Anesthesiologists (ASA) physical status classification ≤III.
4. Ability to understand and willingness to provide written informed consent.
5. Agreement to adhere to scheduled postoperative clinical follow-up assessments, including pulmonary function tests and survival status evaluations.

Exclusion Criteria:

1. Patients requiring bilateral pulmonary procedures or planned open thoracotomy.
2. History of severe cardiopulmonary disease or unstable medical conditions that contraindicate minimally invasive thoracic surgery.
3. Emergency surgery due to acute respiratory or cardiovascular instability.
4. Inability to cooperate with the planned anesthetic and surgical protocols or postoperative follow-up procedures.
5. Pregnancy or lactation at the time of enrollment.
6. Known allergy or contraindication to anesthetic agents or materials used in the study.
7. Enrollment in another interventional clinical study within the past 30 days.