Video-assisted thoracoscopic surgery (VATS) for locally advanced lung cancer.

First described over two decades ago, video-assisted thoracoscopic surgery (VATS) is now well established for the treatment of early stage non-small cell lung carcinoma (NSCLC) (1-6). Thoracoscopic approaches are preferred for many common thoracic procedures because of their predictable salutary effect on outcomes likely brought about by perioperative pain reductions. As widespread surgeon experience has grown with VATS, so has reliability. Low conversion rates are now commonplace despite the challenges associated with higher stage tumors and the tissue effects brought on by induction chemoradiotherapy. Tumors once thought unapproachable by thoracoscopic techniques are now frequently resected by VATS. Video assisted thoracoscopic surgery offers many potential benefits compared to conventional muscle-splitting thoracotomy. Some established examples are decreased postoperative pain, diminished inflammatory response, decreased hospital length of stay (LOS), and faster recovery (7,8). By potentially allowing more patients to receive adjuvant chemotherapy compared to patients who undergo thoracotomy (9), VATS could potentially improve survival of patients with advanced NSCLC. Most large series examining results for VATS in lung cancer have been limited to early stage disease, and thoracotomy remains a staple for the surgical approach to locally advanced NSCLC (10). A variety of concerns regarding the completeness of oncologic resection, technical challenges, and potential safety concerns has limited the incorporation of thoracoscopy for more advanced stages of lung cancer. For patients requiring more extensive resection such as pneumonectomy and/or en bloc chest wall resection, thoracoscopic resection is even less common. As previously demonstrated with many minimally invasive procedures, there is a learning curve with thoracoscopic anatomic resections (11). In general, this learning curve for advanced thoracoscopic cases has been aided by improved video, stapling, hemostatic, and retraction technologies. Excellent exposure is enabled by high-definition camera systems that allow viewing from various different angles (Figure 1). Endoscopic staplers have been modified to facilitate negotiation of delicate pulmonary vessels (Figure 2). Improved topical hemostatic technologies are useful when dealing with diffuse oozing from extrapleural or inflammatory dissections after induction therapy. Several companies now produce 5 mm low profile lung graspers (Figure 3). Up to 4 of these instruments can be placed through a single port incision to replicate the traction and counter-traction employed in open operations. These technological advances have made thoracoscopic surgery safer allowing for the expansion of indications for thoracoscopic resection. This potentially increases treatment options for patients who otherwise may have previously been considered inoperable with thoracotomy. Here we will discuss key technical points/considerations for thoracoscopic resection for lobectomy in locally advanced non-small cell carcinoma, thoracoscopic pneumonectomy, and thoracoscopic en bloc chest wall resection.