In conclusion, the authors consider VATS to be the technique of first choice for the treatment of pleural empyema when the disease is advanced or tube thoracostomy fails. It provides excellent results with a low level of invasiveness and considerably reduces the need for thoracotomy. These results can be achieved with good videothoracoscopic experience and the use of a very precise technique.

We believe that VATS, in performing pulmonary lobectomy, is a safe and effective approach and it seems to give the same long-term results as open surgery. Now the main problems concern the indications that should be strictly respected and the conversion to thoracotomy which should be undertaken without hesitation when the anatomic or pathologic conditions are not favourable.

The analysis of the literature and our experience show that VATS is a reliable approach to the diagnosis and treatment of pulmonary diseases with low complication rate. To further reduce intraoperative and postoperative morbidity, however, it is necessary to select the patients carefully, to adhere strictly to oncological surgical principles, and to adopt a meticulous technique. Although conversion to open surgery represents failure of VATS, it is mandatory when the procedure is not completely safe.

The use of video-assisted thoracic surgery (VATS) for carrying out major pulmonary resections in the treatment of lung cancer is still controversial. In order to contribute to knowledge about the long term results obtained with this technique in the treatment of stage I NSCLC, we present data relating to research in our institute over the past 10 years. From January 1993 to December 2002, 138 patients with peripheral clinical stage I NSCLC were selected to undergo VATS lobectomy. The procedure was based on a mini-thoracotomy without rib spreading, with hilar dissection and separate sectioning of the arteries, veins and bronchi; this was associated with hilar and mediastinal lymph-node sampling. Follow-up consisted of clinical and radiological examination every 6 months in the first 2 years after surgery, then once a year; a CT scan was carried out 1, 3 and 5 years after surgery. The probability of survival was estimated with the Kaplan-Meier method. Surgery by VATS was successfully completed in 122 cases, with a thoracotomy conversion rate of 11.6%. Of these, stage I was confirmed by pathological examination in only 104 cases: there were 56 T1N0 and 48 T2N0. With a mean follow-up of 65 months, the 5-year survival rate was found to be 67+/-10%; in the T1N0 it was 68+/-15%, whereas in the T2N0 it was 67+/-16%. The rate of local or regional recurrence was 4.8% while the systemic recurrence rate was 15.4%. From an appraisal of the study results we consider VATS to be a valid approach for carrying out lobectomy for the treatment of stage I pulmonary carcinoma. The long-term results are comparable to those obtained in open surgery both in terms of survival and the rate of local recurrence. Therefore in selected cases, where there is no increase in surgical risk, VATS may be the preferred approach.

VATS lobectomy in the treatment of selected typical carcinoids, both central and peripheral, seems to yield favorable results and is therefore preferable to thoracotomy since it is less invasive.