Key Points

• Advantages of VATS pulmonary resections over the open approach include decreased postoperative pain and narcotic use, improved postoperative pulmonary function, improved postoperative quality of life, improved postoperative shoulder function, decreased cost and decreased effects on the immune system.
• Intermediate and long-term survival rates for lung cancer patients undergoing VATS pulmonary resection are as good, if not better than the rates for patients undergoing thoracotomy.
• The principles of safe surgery and adequate resection must never be compromised to maintain minimal access.
• Avoidance of rib spreading is the distinguishing feature of VATS and must be observed.

Minimally invasive approaches in thoracic surgery were initially met with reserve: unlike the abdomen, the chest is a non-expandable entity, making operative visualization more challenging. It also contains multiple dynamic structures, adding another level of complexity to minimally invasive approaches. Bleeding from major thoracic vessels can furthermore cause rapid hemodynamic collapse precluding timely conversion and control. However, today minimally invasive approaches to pulmonary resections are considered the gold-standard and should be an expectation for thoracic surgeons to be able to offer to their patients.