Minimally Invasive Thoracic Surgery 3.0: Lessons Learned From the History of Lung Cancer Surgery

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Over the past 2 decades, general thoracic surgery has been revolutionized by rapid development and assimilation of minimally invasive techniques for lung cancer surgery. Whereas these gains have been impressive with great benefit to thousands of patients, focus upon mere minimization of number and size of incisions may distract surgeons from other vital considerations. In fact, surgical trauma includes not only incisional injury, but also functional loss due to organ removal, and also systemic and psychological trauma induced by surgical stress. Therefore, minimally invasive surgery (MIS) by its definition should be an idea to “minimize surgical trauma, but still achieve comparable or better therapeutic results.”1
In fact, the history of general thoracic surgery can be viewed as a gradual and inexorable development of MIS by the broad definition above. The first radical resection of lung cancer was completed via a left pneumonectomy by Dr Evarts Graham in 1933.2 Although lobectomy was described earlier and used for benign conditions, it was initially thought to be inadequate for patients with lung cancer. However, pneumonectomy was quickly replaced by lobectomy for patients with peripheral lung cancer in the next decade because the latter was shown to remarkably reduce operational mortality and morbidity without making impact on long-term survival. This landmark evolution directly led to the development of bronchoplasty and arterioplasty for the treatment of selected patients with central lung cancer, whose lung cancer and quality of life were greatly improved.3 Both examples highlight the importance of lung parenchyma preservation in reducing surgical trauma and thus should undoubtedly be considered MIS. However, the more modern concept of MIS was only realized and became popular in the early 1980s after the application of the “keyhole” video-assisted procedures which were quickly adopted by thoracic surgeons in the 1990s.4 Over the next years, advances in minimally invasive lung cancer surgery can be expected to occur in size/number of incisions, extent of resection, and systemic response to surgery.

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