State of the art in thoracoscopic surgery

Background Herein we compare our personal experience with a series of > 2000 videothoracoscopic procedures with those reported in the literature to identify the procedures now accepted as the gold standard, those still regarded as investigational, and those considered unacceptable. Methods Between June 1991 and December 2000, we performed 2068 videothoracoscopic procedures, including lung cancer staging (n=910), wedge resections (n=261), lobectomies (n=221), pneumonectomies (n= 6) the diagnosis and treatment of pleural diseases (n=200), the treatment of pneumothorax (n=170), giant bullae (n=57), lung volume reduction surgery (LVRS) for emphysema (n=41), the diagnosis and treatment of mediastinal diseases (n=133), the treatment of esophageal diseases (n=39), and 30 other miscellaneous procedures. Results A review of the literature indicates that video-thoracoscopy is usually considered the preferred approach for the treatment of spontaneous pneumothorax, the diagnosis of indeterminate pleural effusions, the treatment of malignant pleural effusions, sympathectomy, and the diagnosis and treatment of benign esophageal or mediastinal diseases. The videoendoscopic approach to LVRS for emphysema is still under evaluation. Videothoracoscopic wedge resections for the diagnosis of indeterminate nodules and the treatment of primary lung cancer, metastases, and other malignancies are still controversial due to oncologic concerns. Videoendoscopic major pulmonary resections are usually considered investigational or even unacceptable due to oncologic concerns, technical difficulties, and the risk of complications. Conclusions Although we generally agree with the foregoing recommendations, we consider videoendoscopy the best approach for LVRS and particularly useful for the staging of lung cancer, where we always perform it as the first step of the operation. We widely perform videoendoscopic major pulmonary resections, but we believe that these procedures should only be used in strictly selected cases and at specialized centers.