The Evolution of Video Assisted Thoracic Surgery

  • Alan D. L. Sihoe


Surgery is not a static entity, but a constantly evolving discipline. It adapts itself in response to changing patient needs, emergence of new technologies, and developments in medical knowledge.



The author wishes to thank Dr. Stephen Wang and the AME Publishing Company for technical support and permission to reproduce Figs. 1, 2, 3, 4, 5 and 7 from the Journal of Thoracic Disease.

Supplementary material

Video 1

Needlescopic VATS right upper lobectomy. Notice that the axis of the operation and camera view is essential the same as for a conventional three-port VATS approach. The view achieved with a 3 mm video-thoracoscope coupled with modern high-definition camera systems provides very good images. (WMV 97849 kb)

Video 2

Two-port VATS right upper lobectomy. Notice that the axis of the operation and camera view is essential the same as for a conventional three-port VATS approach. Compared with the Needlescopic approach in Video 1, the two-port approach is almost identical and the loss of the posterior port (admitting a 3 mm grasper only) is barely noticed. (WMV 146256 kb)

Video 3

Uniportal VATS right middle lobectomy. (WMV 31613 kb)


  1. 1.
    Sihoe ADL. The evolution of VATS lobectomy. In: Cardoso P, editor. Topics in thoracic surgery. Rijeka: Intech; 2011. p. 181–210.Google Scholar
  2. 2.
    Sihoe ADL. The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery. J Thorac Dis. 2014;6(Suppl 6):S604–17. Scholar
  3. 3.
    Sihoe ADL, Yim APC. Video-assisted pulmonary resections. In: Patterson GA, Cooper JD, Deslauriers J, Lerut AEMR, Luketich JD, Rice TW, Pearson FG, editors. Thoracic surgery. 3rd ed. Philadelphia: Elsevier; 2008. p. 970–88.Google Scholar
  4. 4.
    Sihoe ADL, Yim APC. VATS as a diagnostic tool. In: Shields TW, Locicero J, Ponn RB, Rusch VW, editors. General thoracic surgery. 7th ed. Philadelphia: Lippincott Williams & Wilkins; 2009. p. 313–32.Google Scholar
  5. 5.
    Braimbridge MV. Thoracoscopy: a historical perspective. In: Yim APC, Hazelrigg SR, Izzat MB, et al., editors. Minimal access cardiothoracic surgery. Philadelphia: WB Saunders; 2000. p. 1–10.Google Scholar
  6. 6.
    Karmakar MK, Ho AMH. Postthoracotomy pain syndrome. Thorac Surg Clin. 2004;14:345–52.CrossRefGoogle Scholar
  7. 7.
    Rogers ML, Duffy JP. Surgical aspects of chronic post-thoracotomy pain. Eur J Cardiothorac Surg. 2000;18:711–6.CrossRefGoogle Scholar
  8. 8.
    Lewis RJ. Simultaneously stapled lobectomy: a safe technique for video-assisted thoracic surgery. J Thorac Cardiovasc Surg. 1995;109:619–25.CrossRefGoogle Scholar
  9. 9.
    Lewis RJ, Caccavale RJ, Sisler GE, et al. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg. 1992;54:421–6.CrossRefGoogle Scholar
  10. 10.
    Lewis RJ, Caccavale RJ. Video-assisted thoracic surgical non-rib-spreading simultaneously stapled lobectomy. In: Yim APC, Hazelrigg SR, Izzat MB, et al., editors. Minimal access cardiothoracic surgery. Philadelphia: WB Saunders; 2000. p. 135–49.Google Scholar
  11. 11.
    Pearson FG. Commentary. In: Yim APC, Hazelrigg SR, Izzat MB, et al., editors. Minimal access cardiothoracic surgery. Philadelphia: WB Saunders; 2000. p. 151.Google Scholar
  12. 12.
    Kirby TJ, Mack MJ, Landreneau RJ, et al. Initial experience with video-assisted thoracoscopic lobectomy. Ann Thorac Surg. 1993;56:1248–53.CrossRefGoogle Scholar
  13. 13.
    McKenna RJ. Lobectomy by video-assisted thoracic surgery with mediastinal node sampling for lung cancer. J Thorac Cardiovasc Surg. 1994;107:879–82.PubMedGoogle Scholar
  14. 14.
    Roviaro CG, Varoli F, Rebuffat C, et al. Videothoracoscopic major pulmonary resections. Ann Thorac Surg. 1993;56:779–83.CrossRefGoogle Scholar
  15. 15.
    Yim APC, Ko KM, Chau WS, et al. Video-assisted thoracoscopic anatomic lung resections: the initial Hong Kong experience. Chest. 1996;109:13–7.CrossRefGoogle Scholar
  16. 16.
    Sugiura H, Morikawa T, Kaji M, et al. Long-term benefits for the quality of life after video-assisted thoracoscopic lobectomy in patients with lung cancer. Surg Laparosc Endosc. 1999;9:403–8.Google Scholar
  17. 17.
    Walker WS, Pugh GC, Craig SR, Carnochan FM. Continued experience with thoracoscopic major pulmonary resection. Int Surg. 1996;81:255–8.PubMedGoogle Scholar
  18. 18.
    Demmy TL, Curtis JJ. Minimally invasion lobectomy directed toward frail and high-risk patients: a case control study. Ann Thorac Surg. 1999;68:194–200.CrossRefGoogle Scholar
  19. 19.
    Giudicelli R, Thomas P, Lonjon T, et al. Video-assisted mini-thoracotomy versus muscle sparing thoracotomy for performing lobectomy. Ann Thorac Surg. 1994;58:712–8.CrossRefGoogle Scholar
  20. 20.
    Kirby TJ, Mack MJ, Landreneau RJ, Rice TW. Lobectomy video-assisted thoracic surgery versus muscle-sparing thoracotomy: a randomized trial. J Thorac Cardiovasc Surg. 1995;109:997–1002.CrossRefGoogle Scholar
  21. 21.
    Landreneau RJ, Mack MJ, Hazelrigg SR, et al. Prevalence of chronic pain after pulmonary resection by thoracotomy or video-assisted thoracic surgery. J Thorac Cardiovasc Surg. 1994;107:1079–86.PubMedGoogle Scholar
  22. 22.
    Nomori H, Horio H, Naruke T, Suemasu K. What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery? Ann Thorac Surg. 2001;72:879–84.CrossRefGoogle Scholar
  23. 23.
    Mack MJ, Scruggs GR, Kelly KM, et al. Video-assisted thoracic surgery: has technology found its place? Ann Thorac Surg. 1997;64:211–5.CrossRefGoogle Scholar
  24. 24.
    Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest. 2013;143:e278S–313S.CrossRefGoogle Scholar
  25. 25.
    Sihoe DLA. Reasons not to perform uniportal VATS lobectomy. J Thorac Dis. 2016a;8:S333–43.PubMedPubMedCentralGoogle Scholar
  26. 26.
    Yim APC, Landreneau RJ, Izzat MB, Fung ALK. Is video assisted thoracoscopic lobectomy a unified approach? Ann Thorac Surg. 1998;66:1155–8.CrossRefGoogle Scholar
  27. 27.
    Shigemura N, Akashi A, Nakagiri T, Ohta M, Matsuda H. Complete vs assisted thoracoscopic approach. A prospective randomized trial comparing a variety of video-assisted thoracoscopic lobectomy techniques. Surg Endosc. 2004;18:1492–7.CrossRefGoogle Scholar
  28. 28.
    Shigemura N, Akashi A, Funaki S, Nakagiri T, Inoue M, Sawabata N, Shiono H, Minami M, Takeuchi Y, Okumura M, Sawa Y. Long-term outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multi-institutional study. J Thorac Cardiovasc Surg. 2006;132:507–12.CrossRefGoogle Scholar
  29. 29.
    Swanson SJ, Herndon JE 2nd, D’Amico TA, et al. Videoassisted thoracic surgery lobectomy: report of CALGB 39802-a prospective, multi-institution feasibility study. J Clin Oncol. 2007;25:4993–7.CrossRefGoogle Scholar
  30. 30.
    Laird MA, Gidal BE. Use of gabapentin in the treatment of neuropathic pain. Ann Pharmacother. 2000;34:802–7.CrossRefGoogle Scholar
  31. 31.
    Nicholson B. Gabapentin use in neuropathic pain syndromes. Acta Neurol Scand. 2000;101:359–71.CrossRefGoogle Scholar
  32. 32.
    Benedetti F, Vighetti S, Ricco C, Amanzio M, Bergamasco L, Casadio C, Cianci R, Giobbe R, Oliaro A, Bergamasco B, Maggi G. Neuorphysiologic assessment of nerve impairment in posterolateral and muscle-sparing thoracotomy. J Thorac Cardiovasc Surg. 1998;115:841–7.CrossRefGoogle Scholar
  33. 33.
    Bolotin G, Buckner GD, Jardine NJ, Kiefer AJ, Campbell NB, Kocherginsky M, Raman J, Jeevanandam V. A novel instrumented retractor to monitor tissue-disruptive forces during lateral thoracotomy. J Thorac Cardiovasc Surg. 2007;133:949–54.CrossRefGoogle Scholar
  34. 34.
    Maguire MF, Latter JA, Mahajan R, David Beggs F, Duffy JP. A study exploring the role of intercostal nerve damage in chronic pain after thoracic surgery. Eur J Cardiothorac Surg. 2006;29:873–9.CrossRefGoogle Scholar
  35. 35.
    Rogers ML, Henderson L, Duffy JP. Preliminary findings of a neurophysiological assessment of intercostal nerve injury during thoracotomy. Eur J Cardiothorac Surg. 2002;21:298–301.CrossRefGoogle Scholar
  36. 36.
    D’Amico TA. Thoracoscopic lobectomy: evolving and improving. J Thorac Cardiovasc Surg. 2006a;132:464–5.CrossRefGoogle Scholar
  37. 37.
    Bachiocco V, Morselli-Labate AM, Rusticali AG, Bragaglia R, Mastrorilli M, Carli G. Intensity, latency and duration of post-thoracotomy pain: relationship to personality trials. Funct Neurol. 1990;5:321–32.PubMedGoogle Scholar
  38. 38.
    Li WWL, Lee TW, Lam SSY, Ng CSH, Sihoe ADL, Wan IYP, Yim APC. Quality of life following lung cancer resection: video-assisted thoracic surgery versus thoracotomy. Chest. 2002;122:584–9.CrossRefGoogle Scholar
  39. 39.
    Li WW, Lee RL, Lee TW, Ng CS, Sihoe AD, Wan IY, Arifi AA, Yim AP. The impact of thoracic surgical access on early shoulder function: video-assisted thoracic surgery versus posterolateral thoracotomy. Eur J Cardiothorac Surg. 2003;23:390–6.CrossRefGoogle Scholar
  40. 40.
    Craig SR, Leaver HA, Yap PL, et al. Acute phase responses following minimal access and conventional thoracic surgery. Eur J Cardiothorac Surg. 2001;20:455–63.CrossRefGoogle Scholar
  41. 41.
    Ng CS, Lee TW, Wan S, Wan IY, Sihoe ADL, Arifi AA, Yim AP. Thoracotomy is associated with significantly more profound suppression in lymphocytes and natural killer cells than video-assisted thoracic surgery following major lung resections for cancer. J Investig Surg. 2005;18:81–8.CrossRefGoogle Scholar
  42. 42.
    Yim APC, Wan S, Lee TW, Arifi AA. VATS lobectomy reduces cytokine responses compared with conventional surgery. Ann Thorac Surg. 2000;70:243–7.CrossRefGoogle Scholar
  43. 43.
    Denlinger CE, Fernandez F, Meyers BF, et al. Lymph node evaluation in video-assisted thoracoscopic lobectomy versus lobectomy by thoracotomy. Ann Thorac Surg. 2010;89:1730–6.CrossRefGoogle Scholar
  44. 44.
    Sagawa M, Sato M, Sakurada A, et al. A prospective trial of systematic nodal dissection for lung cancer by video-assisted thoracic surgery: can it be perfect? Ann Thorac Surg. 2002;73:900–4.CrossRefGoogle Scholar
  45. 45.
    Watanabe A, Koyanagi T, Ohsawa H, et al. Systematic node dissection by VATS is not inferior to that through an open thoracotomy: a comparative clinicopathologic retrospective study. Surgery. 2005;138:510–7.CrossRefGoogle Scholar
  46. 46.
    Rueth NM, Andrade RS. Is VATS lobectomy better: perioperatively, biologically and oncologically? Ann Thorac Surg. 2010;89:S2107–11.CrossRefGoogle Scholar
  47. 47.
    Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg. 2008;86:2008–18.CrossRefGoogle Scholar
  48. 48.
    Yan TD, Black D, Bannon PG, McCaughan BC. Systematic review and meta-analysis of randomized and nonrandomized trials on safety and efficacy of video-assisted thoracic surgery lobectomy for early-stage non-small-cell lung cancer. J Clin Oncol. 2009;27:2553–62.CrossRefGoogle Scholar
  49. 49.
    Passlick B, Born C, Sienel W, Thetter O. Incidence of chronic pain after minimal invasive surgery for spontaneous pneumothorax. Eur J Cardiothorac Surg. 2001;19:355–9.CrossRefGoogle Scholar
  50. 50.
    Sihoe ADL, Au SS, Cheung ML, Chow IK, Chu KM, Law CY, Wan M, Yim APC. Incidence of chest wall paresthesia after video-assisted thoracic surgery for primary spontaneous pneumothorax. Eur J Cardiothorac Surg. 2004;25:1054–8.CrossRefGoogle Scholar
  51. 51.
    Sihoe ADL, Cheung CS, Lai HK, Lee TW, Thung KH, Yim APC. Incidence of chest wall paresthesia after needlescopic video-assisted thoracic surgery for palmar hyperhidrosis. Eur J Cardiothorac Surg. 2005;27:313–9.CrossRefGoogle Scholar
  52. 52.
    Sihoe AD, Lee TW, Wan IY, Thung KH, Yim AP. The use of gabapentin for post-operative and post-traumatic pain in thoracic surgery patients. Eur J Cardiothorac Surg. 2006;29:795–9.CrossRefGoogle Scholar
  53. 53.
    Sihoe AD, Manlulu AV, Lee TW, Thung KH, Yim AP. Pre-emptive local anesthesia for needlescopic video-assisted thoracic surgery: a randomised controlled trial. Eur J Cardiothorac Surg. 2007;31:103–8.CrossRefGoogle Scholar
  54. 54.
    Melfi FM, Menconi GF, Mariani AM, et al. Early experience with robotic technology for thoracoscopic surgery. Eur J Cardiothorac Surg. 2002;21:864–8.CrossRefGoogle Scholar
  55. 55.
    Veronesi G, Galetta D, Maisonneuve P, Melfi F, Schmid RA, Borri A, et al. Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg. 2010;140:19–25.CrossRefGoogle Scholar
  56. 56.
    D’Amico TA. Robotics in thoracic surgery: applications and outcomes. J Thorac Cardiovasc Surg. 2006b;131:19–20.CrossRefGoogle Scholar
  57. 57.
    Yim APC, Sihoe ADL, Lee TW, Arifi AA. A simple maneuver to detect airleak on-table following ‘needlescopic’ VATS. J Thorac Cardiovasc Surg. 2002;124:1029–30.CrossRefGoogle Scholar
  58. 58.
    Sihoe ADL, Yu PA, Wong JCC, Lee KM, Heung TCY, Ho TSY. Needlescopic video-assisted thoracic surgery for primary spontaneous pneumothorax. Respirology. 2012;17(Suppl 2):17–24.Google Scholar
  59. 59.
    Sihoe DLA. Uniportal videoassisted thoracic surgery (VATS) lobectomy. Ann Cardiothorac Surg. 2016b;5:133–44.CrossRefGoogle Scholar
  60. 60.
    Jutley RS, Khalil MW, Rocco G. Uniportal vs standard three-port VATS technique for spontaneous pneumothorax: comparison of post-operative pain and residual paraesthesia. Eur J Cardiothorac Surg. 2005;28:43–6.CrossRefGoogle Scholar
  61. 61.
    Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg. 2005;129:947–8.CrossRefGoogle Scholar
  62. 62.
    Gonzalez D, Paradela M, Garcia J, de la Torre M. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg. 2011;12:514–5.CrossRefGoogle Scholar
  63. 63.
    Gonzalez-Rivas D, Delgado M, Fieira E, Mendez L. Single-port video-assisted thoracoscopic lobectomy with pulmonary artery reconstruction. Interact Cardiovasc Thorac Surg. 2013a;17:889–91.CrossRefGoogle Scholar
  64. 64.
    Sihoe AD, Chawla S, Paul S, Nair A, Lee J, Yin K. Technique for delivering large tumors in video-assisted thoracoscopic lobectomy. Asian Cardiovasc Thorac Ann. 2014;22:319–28.CrossRefGoogle Scholar
  65. 65.
    Sihoe DLA. Clinical pathway for videoassisted thoracic surgery: the Hong Kong story. J Thorac Dis. 2016c;8:S1222.Google Scholar
  66. 66.
    Sihoe DLA, Yu SYP, Kam TH, Lee SY, Liu X. Adherence to a clinical pathway for videoassisted thoracic surgery: predictors and clinical importance. Innovations. 2016;11:179–86.PubMedGoogle Scholar
  67. 67.
    Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez L, et al. Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg. 2013b;95:426–32.CrossRefGoogle Scholar
  68. 68.
    Gonzalez-Rivas D, Fieira E, Delgado M, Mendez L, Fernandez R, de la Torre M. Is uniportal thoracoscopic surgery a feasible approach for advanced stages of non-small cell lung cancer? J Thorac Dis. 2014;6:641–8.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Hirai K, Takeuchi S, Usuda J. Single-incision thoracoscopic surgery and conventional video-assisted thoracoscopic surgery: a retrospective comparative study of perioperative clinical outcomes. Eur J Cardiothorac Surg. 2016;49:i37–41.PubMedGoogle Scholar
  70. 70.
    Zhu Y, Liang M, Wu W, Zheng J, Zheng W, Guo Z, Zheng B, Xu G, Chen C. Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer. Ann Translat Med. 2015;3(7):92. Scholar
  71. 71.
    Liu CC, Shih CS, Pennarun N, Cheng CT. Transition from a multiport technique to a single-port technique for lung cancer surgery: is lymph node dissection inferior using the single-port technique? Eur J Cardiothorac Surg. 2016;49:i64–72.CrossRefGoogle Scholar
  72. 72.
    Mu JW, Gao SG, Xue Q, Zhao J, Li N, Yang K, Su K, Yuan ZY, He J. A matched comparison study of uniportal versus triportal thoracoscopic lobectomy and sublobectomy for early-stage nonsmall cell lung cancer. Chin Med J. 2015;128:2731–5.CrossRefGoogle Scholar
  73. 73.
    Wang BY, Liu CY, Hsu PK, Shih CS, Liu CC. Single-incision versus multiple-incision thoracoscopic lobectomy and segmentectomy: a propensity-matched analysis. Ann Surg. 2015;261:793–9.CrossRefGoogle Scholar
  74. 74.
    Guido Guerrero W, Gonzalez-Rivas D, Hernandez Arenas LA, et al. Techniques and difficulties dealing with hilar and interlobar benign lymphadenopathy in uniportal VATS. J Visc Surg. 2016;2:23.Google Scholar
  75. 75.
    Sihoe DLA. Opportunities and challenges for thoracic surgery collaborations in China: a commentary. J Thorac Dis. 2016d;8:S414–26.CrossRefGoogle Scholar
  76. 76.
    Li Z, Ng CS. Future of uniportal video-assisted thoracoscopic surgery—emerging technology. Ann Cardiothorac Surg. 2016;5(2):127–32. Scholar

Copyright information

© Springer Nature Singapore Pte Ltd. 2019

Authors and Affiliations

  • Alan D. L. Sihoe
    • 1
  1. 1.International Medical CentreHong KongHong Kong SARChina

Personalised recommendations