In the latest two decades, the video-assisted thoracoscopic surgery (VATS) technique has gained recognition as an effective alternative to conventional open surgery, and the field of its application has gradually extended to more complex diseases, such as locally invasive non-small cell lung cancer (NSCLC) requiring combined lung and chest wall resection. The en bloc chest wall resection can be accomplished by using a typical VATS port placement, each time adjusted to allow a better thoracoscopic guidance and a correct resection of the tumour to achieve negative margins. Different approaches have been described by experienced surgeons, with a remarkable variability in the number and disposition of the ports, in the surgical tools used and in the strategy of sparing the covering tissues. The common denominator of these experiences is the aim of extending the criteria of functional and oncological operability to high-risk patients who are not suitable for a conventional thoracotomy. Indeed, the VATS approach has shown effectiveness in reaching unchanged oncological outcomes in comparison with the thoracotomic technique but involving significantly less postoperative pain, faster recovery, shorter hospitalisation and lower overall complications. lobectomy with en bloc chest wall resection and compared their outcomes with those of 14 additional patients who underwent thoracotomic approach for primary or secondary chest wall neoplasia (6). KeywordsIn the wake of these experiences, some attempts were made for the resection of primary chest wall tumours, including chondrosarcoma and liposarcoma, barely considered so far due to their rare occurrence and the unknown effects on long-term results. Abicht et al. used a 3-incision approach to remove a mass involving the 6 th rib and a piece of polytetrafluoroethylene (PTFE) to cover the defect (7). Hennon and Demmy performed an en bloc dissection of a chondrosarcoma involving the second and third ribs using a 3-portal approach and an additional incision to dissect the cartilaginous portion adjacent to the sternum. On postoperative day (POD) 43, the patient underwent a second operation using the same incisions to obtain negative margins, with no evidence of recurrence or lung herniation at 24 months from the initial surgery (8).Finally, Gonzalez-Rivas updated the chest wall resection to the gaining recognition uniportal VATS technique; in the case report of a right upper lobe (RUL) adenocarcinoma was described the use of a single anterior incision to perform the lobectomy and to allow the thoracoscopic vision while resecting the fourth and fifth posterior ribs, which was achieved through a single posterior incision (for a total of two incisions) (9). Techniques in comparisonThe patient is positioned in lateral decubitus. It is widely agreed that limited en bloc chest wall resections can be accomplished by using port placement similar to that used for typical VATS anatomic resections, especially when the utility incision is placed close to the site of ribs excision...

Abstract:The magnetic anchoring guidance system (MAGS) is one of the most promising technological innovations in minimally invasive surgery and consists in two magnetic elements matched through the abdominal or thoracic wall. The internal magnet can be inserted into the abdominal or chest cavity through a small single incision and then moved into position by manipulating the external component. In addition to a video camera system, the inner magnetic platform can house remotely controlled surgical tools thus reducing instruments fencing, a serious inconvenience of the uniportal access. The latest prototypes are equipped with self-light-emitting diode (LED) illumination and a wireless antenna for signal transmission and device controlling, which allows bypassing the obstacle of wires crossing the field of view (FOV). Despite being originally designed for laparoscopic surgery, the MAGS seems to suit optimally the characteristics of the chest wall and might meet the specific demands of video-assisted thoracic surgery (VATS) surgery in terms of ergonomics, visualization and surgical performance; moreover, it involves less risks for the patients and an improved aesthetic outcome.