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Minimally invasive liver resection (MILR) has been steadily increasing worldwide. Since its introduction in the early 1990s, initially adopted in cases of wedge and minor anatomical resection for benign hepatic lesions, MILR has been extended to major liver resection and for malignant hepatic lesions (1). Laparoscopic lateral sectionectomy has progressively become a standard operation (2).

Background: The aim of the present study was to assess the impact of near-infrared angiography in guiding intraoperatively sublobar anatomical resection by video-assisted thoracic surgery (VATS). Methods: We retrospectively analyzed data from 67 patients who underwent segmentectomy by VATS from November 2014 to November 2017 at the University Hospitals of Geneva, Switzerland. The need to modify arterial or parenchymal resection based on intraoperative near-infrared imaging was considered the primary study outcome. Results: A total of 67 patients (28 men, 39 women, mean age 66±10 years) underwent anatomical pulmonary segmentectomy by VATS. Histological analysis revealed a primary lung tumor in 59 patients. The mean ± standard deviation (SD) operation time was 154±51 minutes. Identification of the intersegmental plane (ISP) with near-infrared angiography was achieved in 88% of patients and led to modification of the resection during segmentectomy in 7 patients (10%), avoiding inappropriate resection; 2 patients had distant tumor recurrences (3%). Conclusions: Near-infrared angiography during VATS segmentectomy is effective for identifying ISPs, with respect to the oncological margins, as well as for correcting the anatomical resection.

We propose a technique of uniportal VATS lobectomy using a posterior approach. The main differences of our technique versus standard anterior uniportal VATS are the following: (I) the surgical incision is performed in the auscultatory triangle instead of in the posterior axillary line and (II) the surgeon is placed posteriorly to the patient rather than anteriorly. For thoracic surgeons who are familiar with posterolateral thoracotomy, our technique allows to replicate the same maneuvers performed in the open approach. This strategy was applied with success in 19 consecutive patients for anatomical resection of neoplastic (n=17) and benign (n=2) diseases.

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide (1), with an upward trend in most countries over the last 20 years. While surgical resection remains as the first-line therapy for HCC, the relevant high postoperative recurrence rate is still the major concern, responding for poor survival in most cases (2). The comparison between anatomic resection (AR) and non-anatomic partial resection (NAR) has been discussed for several decades, making it more clear of their application based on tumor features and underlying liver disease, but yet much needs to be completed.

Pulmonary lobectomy is an operation in which the anatomical resection is obviously defined by the common anatomy of pulmonary lobulation and hilar structures in most cases. Lobectomy has been the standard operation for lung cancer since the publication of the prospective, randomized, clinical trial by the Lung Cancer Study Group comparing lobectomy and sublobar pulmonary resections (including wedge resection and segmentectomy) in 1995 (1). However, accumulating data show no significant differences between lobectomy and sublobar lung resection in selected patient populations, such as those with nodules of ground glass opacity (2,3). Furthermore, the number of older and compromised patients, and patients with multicentric lesions is increasing, and so the clinical need for sublobar lung resection is increasing.

Metastasectomy is steadily gaining place in the arsenal of treatments of patients suffering from lung metastasis of colorectal carcinoma (CRC). Meanwhile thoracotomy has been the gold standard approach during years for lung metastasectomy of CRC, the use of video-assisted thoracic surgery (VATS) in this field is currently thriving. Indeed, in addition of known advantages of minimally-invasive surgery, VATS has shown equivalent oncologic outcomes in comparison to open techniques. Otherwise, several questions in the management of these particular patients remained unsolved. In particular, only few studies have explored the role of anatomical resections (i.e., segmentectomy/lobectomy/pneumonectomy) compared to wedge resections. Despite their low level of evidence, these studies highlight interesting preliminary results, in particular a survival advantage of anatomical resections over non-anatomical. Most recent works have even suggested a potential role of molecular markers to select candidates who would benefit from an anatomical resection.

We have read the article with special interest on the impact of anatomical resection (AR) for hepatocellular carcinoma with microportal invasion (vp1) reported by Hidaka et al ., (electronically published in July 2018) (1). Even though the study is retrospective analysis, the key message in their article by propensity score matched analysis is that the AR did not influenced on the recurrence free survival and overall survival.

An established trend in obtaining a radical anatomical resection through a safe minimally invasive approach has been observed in the recent years. However, since the establishment of the three or more ports video-assisted thoracic surgery (VATS), the interest in the uniportal VATS to lung lobectomy has been gaining a phenomenal and global interest from the thoracic surgeons. A specific training in the uniportal VATS approach is crucial to ensure safety and radical treatment. It should aim at giving the surgeon independence and self-confidence throughout the procedure. The learning curve for a surgical intervention, especially in VATS, whereby surgeons acquire expertise, poses important ethical and medico-legal issues since practice, training and instituting a new surgical procedure is predominantly done on patients who, often, are not totally aware or properly informed. In this field, the role of training becomes mandatory, and simulation is decisive, providing a technological “close to reality experience” and a “hands off the patient” but “hands on the procedure”. A proper training aiming at safeguarding patients but at the same time promoting a standardised, close to reality experience to all thoracic residents during their training, and to those surgeons who wish to learn important advances in technical procedures (uniportal VATS), is presently important but will be a prerequisite in the near future. Industries in the thoracic field are encouraged to develop new technological advances [3D, virtual reality (VR)] which will allow a systematic, progressive, realistic and safe training in this global leap into uniportal VATS.

Safety and feasibility of lung resections by single incision thoracoscopy have been confirmed in large number of studies. As proponents claim its lesser invasive nature caused by lacking of additional intercostal port(s), opponents question the outcome measures of the approach especially in oncological manner. Since there is no major discussion regarding the superiority of video-assisted thoracoscopic surgery (VATS) on lung resections over the open technique in the surgical management of lung cancer today, advantage and disadvantage of single incision VATS lung resections was reviewed with the comparison of standard, multi-port VATS approach in this article. Overall, results of comparative studies confirm that single incision and multiportal thoracoscopy are similar, or single incision thoracoscopy has more advantages in the lung resection for lung cancer. Currently, the main disadvantage of single incision approach is the lacking of long-term oncological results.

Pulmonary blastomas (PB) are a rare type of primary lung tumour that significantly differ from other lung malignancies based on their histopathological features and prognosis. Three histological subtypes of PB are described: biphasic PB, pleuropulmonary PB and well-differentiated foetal adenocarcinoma. They are composed of a mixture of immature mesenchymal and epithelial cells resembling foetal lung tissue. Preoperative diagnosis is difficult and the prognosis poor. Surgery is the mainstay of treatment. More than one hundred cases have been described in the literature but none have reported the use of minimally invasive techniques such as video-assisted thoracic surgery (VATS) for surgical excision in the adult. We present two cases of PB in adults who were managed with thoracoscopic surgical resection. The first patient presented with cough and haemoptysis clinical stage was cT3N0M0 and the tumour excised by VATS bilobectomy. The second patient presented with cough, haemoptysis and weight loss and went on to have thoracoscopic resection of a right upper lobe tumour staged pT2bN0. These two cases demonstrate that PB can be resected safely through a minimally invasive approach with good outcomes in the short to medium term.