Can we sell something people don’t want?

© Video-Assisted Thoracic Surgery. All rights reserved. Video-assist Thorac Surg 2021 | http://dx.doi.org/10.21037/vats-21-8 Performing thoracic surgery in a patient who is not intubated under general anesthesia is an exciting idea. When I first heard and saw in earlier 2000 I was genuinely excited and sanguine for its promise. Finally, there was something new in our specialty and at our international meetings. An innovation. A game changer. On paper, it looked like a “can’t miss” disruptive technological advance. A true paradigm shift. Some thought it would quickly revolutionize how thoracic surgery was performed. Think of the all of the theoretical advantages it conveys, such as: the avoidance of muscle paralysis and the incumbent hemodynamic fluctuations and post-operative muscle pain that many patients experience, the elimination of intubation and the placement of a double-lumen tube which for the uninitiated takes significant time and has risk, the mitigation of atelectasis of one lung during the operation and thus the improved PaO2, the elimination of the need to reserve anesthetic agents and extubation that often causes large swings in intra-thoracic pressure and the propagation of air leaks, etc. Yet, despite these many theoretical advantages some of which have been shown to be true, it has not been widely accepted. Flash-forward 19 years later and how is its adoption? Non-intubated thoracic surgery or non-intubated minimally invasive pulmonary resection using video-assisted thoracoscopic techniques (VATS) or robotic techniques is rarely chosen, especially in the United States despite the fact that the concept has advantages and has been around for a long time. Why? The answer is simple. The consumers, the patients, the surgeons and the anesthesiologists do not want to do it. It is hard to sell something that the consumer does not want even if it “may be better for you.” Its marketing is poor to say the least. Before we explore the consumer part of this equation let’s see the actual data that may or may not support the purported advantages. The data