Notably, thoracoscope is the chief representative. How far the development history of thoracoscope technique steps is closely associated with the status of social scientific development at that time. Table 1 lists the important events in development history of thoracoscope technique. From these historical series, we can find that the development of thoracoscope technique is characterized by: a) developing from direct peep to artificial lighting, then combination with image and video technique in equipments; b) technically developing from diagnostic to therapeutic approaches; c) developing from simpleness to complexity in application scope; d) usually developing together with other techniques.

Mini-invasive thoracic surgery refers to the mini-open thoracic surgery performed mainly by using some instruments to control target tissues and organs based on the vision associated with multilimb coordination, which may be hand-assisted if necessary. This surgery is technically performed by using the reusable deep slender tools or disposable tools for excision or reconstruction of the target tissues, with combination of stereoscopic images from direct vision and two-dimensional video images from thoracoscope. Mini-invasive thoracic surgery consists of three approaches including video assisted thoracic surgery (VATS), video-assisted Hybrid and hand-assisted VATS. The pure video-based operation is one part of mini-invasive thoracic surgery but not the whole (2).

Mini-invasive thoracic surgery is a concept that minimizes the chest wall access-related trauma by modern techniques under circumstances where intrathoracic nidus treatment of mini-invasive thoracic surgery is as thorough as that of the conventional thoracotomy hence the mild trauma and injury to body systems of patients. Mini-invasive thoracic surgery refers to its surgical incision is relatively smaller than that of conventional thoracic surgery but not absolutely small in size. In addition, the injuries to functions of heart, lung, liver and kidney, nervous system and locomotor system caused by mini-invasive thoracic surgery are very few statistically.

The definition of mini-invasive thoracic surgery has a very wide-ranging scope, which contains two concept quintessences in terms of the current status of mini-invasive development in cardiothoracic surgery and abdomen surgery at home and abroad: a) Mini-invasive thoracic surgery refers to the surgery involving a minimal injury to patients’ organ function; b) The incisions of mini-invasive thoracic surgery is significantly contracted as compared with those of the conventional surgery. At present, any thoracic surgery that satisfy the two requirements above can be considered as mini-invasive thoracic surgery.

Lung biopsy and pneumoresection are surgeries that only need to remove a fraction of lung tissue from patients mainly for a definite diagnosis and sometimes for direct treatments. In the surgical diagnosis and treatments of lung diseases, these surgeries need the least excisional tissue, the lowest difficulty level of mini-invasive thoracic technique hence the most common use and most obvious advantages of mini-invasive thoracic technique, among which the most commonly seen are pulmonary nodule biopsy, diffuse lung disease biopsy and treatment of pneumothorax pulmonary bullae. Traditionally, the procedures above are performed using 2 or 3 incisions (1 observation incision + 1 or 2 operational incisions). Along with advance of delicate instruments and surgical skills, surgeries can be performed with only one incision by using one-channel cannula, or much smaller needle-type thoracoscope which further improves the mini-invasiveness of surgery.

For those surgeries requiring removal of a relatively larger part of lung tissue, they are usually performed after confirming diagnosis. These surgeries are usually performed when pulmonary lobectomy can’t be tolerated by tumor patients, including wedge resection, segmentectomy, and lung volume reduction surgery for severe emphysema and bullectomy. In addition, these surgeries are uncomplex and convenient mainly involving successive excision of lung tissue and suture by using the endoscopic suture cutting instrument, without individual treatment of pulmonary vessels and bronchia involved. Such mini-invasive surgeries also have significant advantages, and are commonly used.

Based on diseases requiring anatomic lobectomy of lung such as lung cancer, bronchiectasis and destroyed lung, anatomic treatments of blood vessel and bronchia are involved in these surgeries. Reliableness and safety are highlighted in order to avoid massive hemorrhage during surgery and bronchopleural fistula after surgery. Notably, lung cancer needs to be guaranteed a reliable efficacy of lymph node dissection. Microtrauma of thoracoscopic surgery enables some patients whose pulmonary function can’t tolerate conventional surgeries originally to undergo surgical treatments. In 1992, VATS pulmonary lobectomy was first reported by Lewis (3). So far the most commonly employed surgical approaches have two aspects: a) unopen incision. VATS is performed entirely under thoracoscope; b) open incision. Hybrid VATS is performed by combination of thoracoscope-assisted observation and macroscopic vision. There is technically no problem in pulmonary lobectomy performed using the first approach, with 1 observational incision + 1 longer surgical incision + 1or 2 incisions for assistance of stretch. For the second approach, surgeries need to be performed entirely on two-dimensional plane under thoracoscope by using relatively longer endoscopic surgical instruments, which greatly requires an intense surgical perception from a surgeon. The surgical time needed of this approach is much longer than that of the first approach, whereas the pain may be favorably alleviated after surgery. 1 observational incision + 1 longer open incision are usually needed in the second approach. Such surgeries can be performed on the operational field in combination of two-dimension and three-dimension under partial direct vision. Moreover, conventional instruments can be employed. The advantages of this approach are improved precision and speed, decreased time of manual suture and enlarged surgery space. This approach is more practical in surgeries involving reconstruction such as bronchoplasty. Nevertheless, there may be a more significant pain after surgery because of the opened incision and the accessorial incision over 2cm. Therefore, each approach has its own advantages and disadvantages, which should be selected depending on the performing level of surgeons, balance across safety, efficiency and economic expenditure, with no absolute rules.

Along with the increase of surgical practice, people have found various advantages of VATS pneumonectomy and dismissed many worries. The multicenter study (Cancer and Leukemia Group B 39802) supported by Swanson showed a lower incidence rate of postoperative complications and shorter retention time of thoracic ducts of VATS pneumonectomy as compared with those of the conventional thoracic surgery (4). Furthermore, a summary report of 1100 cases by McKenna demonstrated a very low mortality rate (5). In addition, more studies have shed light on other advantages of VATS pneumonectomy such as alleviated pain after surgery, minimal blood loss during surgery, more favorable pulmonary function after surgery (6).

There were still some conflicts over VATS technique for treatment of lung cancer before 2006. These problems mainly center on as to whether the longer surgical time and frequent stretch of pulmonary lobe will lead to iatrogenic metastasis, whether VATS technique contributes to a safe pulmonary lobectomy and an effective lymph node dissection under circumstance of nondirect vision. If it’s possible, whether the surgical time and learning time of VATS technique will be increased, and whether this will decrease the charm of microtrauma in this surgery. Actually, thoracoscope is an instrument used for diagnosis by surgeons, but not a diagnostic purpose. However by the year 2006, along with the application of VATS technique for 14 years, statistics of large numbers of cases and reports of event free survival had been done. Thus VATS radical resection of pulmonary carcinoma was identified and believed to be included in the standard treatment approach of resection of pulmonary carcinoma by National Comprehensive Cancer Network (NCCN) guideline, which is also greatly suggested for old people and people with poorer constitution. VATS system can provide better lighting and clear magnified images of the deep part and the details, which is impossible for the conventional surgeries. As long as surgeons have a good foundation of general thoracic technique and proficient skills in mastering thoracoscope, and the VATS technique and the conventional thoracotomy is organically combined, sufficient scope of excision and standard lymph node dissection can be accomplished during tumor surgery. If conventional surgeries can be performed with assistance of thoracoscope, this can also improve the surgeons’ grasp of the overall surgical situation. In the contrary, adhering too strictly to the incision 1cm longer or shorter than the standard will lead to the ossification of surgeries because the patient’s condition + equipment condition + the surgeon’s skill = personalized mini-invasive thoracic technique. For an individual person in realistic society, a patient needs the most suitable surgical approach but not really the highest technical approach. However, the thoracoscope just resolves the surgical access without changing the essence of thoracic surgery. The efficacy is the premise, and the safety is the first. If VATS or VAMT is found not to satisfy the safe radical excision and not to achieve the efficacy of conventional surgeries, such surgery should be immediately transferred into micro-incision surgery, which also should be a major principle of mini-invasive thoracic surgery. In recent years, along with the development of miniinvasive thoracic technique and an update of conception, miniinvasive thoracic surgery can be performed not only on patients with stage I or stage II lung cancer, but patients with stage III lung cancer by quite a few scholars.