Background and Aims Thoracic surgery is traditionally performed under general anaesthesia. Increasing patient complexity with comorbidity and frailty requires consideration of detrimental impacts of general anaesthesia, and awareness of alternative approaches to enable surgery. Paravertebral block regional anaesthesia alone is an effective alternative to facilitate thoracic surgery. We present a case report from our series.

Methods We hypothesised thoracic surgery could be achieved for high risk frail, elderly, and comorbid patients with provision of paravertebral block regional anaesthesia alone. Our case description reflects the evolution of our approach to this high risk population in our dedicated thoracic surgical unit at Guy’s Hospital, London, UK.

High risk patients underwent surgical thoracoscopy, diagnostic pleural tissue sampling, and evacuation of pleural effusion with placement of indwelling drains.

We developed a process to facilitate surgery with ultrasound guided paravertebral regional anaesthesia alone. The procedures were successfully completed with no requirements for supplementary analgesia, intravenous sedation, or induction of general anaesthesia.

Results High risk patients were able to undergo successful thoracic surgery with diagnostic and therapeutic intent facilitated by ultrasound guided regional anaesthesia paravertebral block alone. All thoracoscopic procedures were completed with successful diagnostic and therapeutic outcomes.

Conclusions Non intubated awake thoracic surgery techniques have developed in parallel with adoption of videothorascopic surgical technology. Previous descriptions have utilised locoregional anaesthesia with either intercostal blocks or thoracic epidural anaesthesia, and intravenous sedation^1,2. We present a case description of our technique for successful thoracoscopic procedures in high risk patients performed under paravertebral regional anaesthesia alone without intravenous sedation or general anaesthesia.