VATS for advanced T status (large tumors, mediastinal invasion and vascular control)
At centers of excellence, surgeons have mastered thoracoscopic lobectomy for early stage patients and seen benefits, often from reductions in complications. Once minimally invasive surgery becomes the preferred daily routine, surgeons naturally tend to expand video-assisted thoracoscopic surgery (VATS) indications to include patients with more advanced stages in order to standardize work flows and possibly improve outcomes. While managing lymphatic metastases can be challenging particularly when they invade pulmonary vessels, dealing with advanced T-stage can be the biggest obstacle to obtaining high rates of thoracoscopic reliability. In this article, we review the outcomes of surgeons who have attempted to address patients with advanced (select T3 and T4 tumors). Some T3 categories, like chest wall invasion, are covered by other articles in this issue. In addition to outcomes, we describe the fundamentals of dissection and exposure that we feel are very useful in taking on such cases as well as the tools that we find are particularly useful. It seems likely that there will be ongoing interest in this area requiring additional innovation and research support to maximize thoracoscopic indications while maintaining safety and oncologic validity.