Non-intercostal access for video-assisted thoracic surgery-analysis of technical advantages and disadvantages.

Background: Video-assisted thoracoscopic surgery (VATS) lobectomy has become an accepted method for the treatment of early-stage non-small-cell lung cancer (NSCLC). The standard VATS approach is an intercostal one which is often followed by postoperative pain due to injury of the intercostal nerve. The non-intercostal techniques of VATS include the subxiphoid, transcervical, transdiaphragmatic and transoral procedures.

Methods: The technical difficulty of operative management of the anatomical structures during VATS anatomical resection are compared for the intercostal, subxiphoid and transcervical approaches.

Results: Some operative steps have different range of difficulty, which are analyzed in detail.

Conclusions: The clearest advantages of the non-intercostal approaches include less postoperative pain and superradial bilateral mediastinal lymphadenectomy in case of the transcervical approach. However, the non-intercostal approaches are more technically demanding procedures, which therapeutic role has to be clarified in the future.