Video-assisted thoracic surgery (VATS) of the lung

Background Video-assisted thoracic surgery (VATS) in the diagnosis and treatment of pulmonary diseases has been used since the early 1990s, yet its impact on intraoperative and postoperative morbidity has not yet been fully evaluated. This report aims to provide a retrospective analysis of the literature and the authors' clinical experience with VATS in pulmonary surgery, with the goal of ascertaining rational criteria that explain operative complications and thus improve outcomes. Methods Over a period of 15 years 1,615 VATS procedures were performed in our department, 743 of which involved only the lung. The accesses employed were based on the use of three ports through which a thoracoscope, endoscopic instruments, and an endostapler were inserted; for major pulmonary resections, a utility thoracotomy without rib spreader was added. Resections less than segmentectomy were performed using the endostapler directly on the parenchyma, whereas in the anatomic resections all the hilar structures were isolated and separately sectioned. Results The procedures performed were as follows: surgical biopsy, 98; wedge resection, 412; segmentectomy, 15; lobectomy, 217; pneumonectomy, 1. Besides the cases in which there were intraoperative complications that could be resolved thoracoscopically, it was necessary to convert to open surgery in 80 patients (10.8%): in 24 (3.3%), for general reasons linked to the technique of VATS itself; in 56 (7.5%), for specific causes correlated to the type of exeresis. The overall postoperative morbidity rate was 8.3% with no deaths. Conclusions The analysis of the literature and our experience show that VATS is a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. To further reduce intraoperative and postoperative morbidity, however, it is necessary to select the patients carefully, to adhere strictly to oncological surgical principles, and to adopt a meticulous technique. Although conversion to open surgery represents failure of VATS, it is mandatory when the procedure is not completely safe.