Perspectives on thoracoscopy in general thoracic surgery

Abstract

ew advances have had such a rapid and widespread F influence on surgical practice as has the introduction of video-assisted thoracoscopic surgery in recent years. The challenge to adapt to this patient-driven demand has been overwhelming, exciting, and, at times, unsettling. As surgeons, we are accustomed to initiate a change in our technique, or in our surgical approach to a problem, based on our own experience and on information derived from publications and presentations at scientific meetings. Once we are satisfied that a new procedure or approach is well founded and produces documented benefits, we then consider incorporating it into our practice. However, with regard to thoracoscopy, I believe many of us have felt stampeded by the demands of patients, the aggressive marketing by hospitals and individual surgeons, and the hype sometimes generated by equipment manufacturers. The result has been the rapid dissemination and widespread use of thoracoscopic techniques without the perspective, the critical analysis, and the long-term follow-up that are ordinarily essential factors in a surgeon’s decision-making process. It is with these thoughts in mind that I have attempted to analyze the impact of thoracoscopy on the practice of general thoracic surgery. There can be no doubt that the introduction of thoracoscopic procedures into thoracic surgery is on balance a very positive development. The very fact that it is new, different, and fun adds excitement to a specialty that has, with few exceptions, changed little over the past 25 years. This in itself is a benefit. Furthermore, the reduced morbidity often associated with thoracoscopic procedures has focused our attention, as never before, on cost, morbidity, and patient acceptance. Thus, matters of postoperative pain relief, length of hospital stay, time off work, and overall cost-effectiveness have become issues for all surgical procedures, not just those performed thoracoscopically. It is my impression that we are more attentive to these issues than we once were. It is in fact specifically these issues that surgeons favoring thoracoscopic procedures have focused on. Unfortunately, however, other equally or more important issues have been ignored or received scant attention. Furthermore, even in the area of morbidity and cost-effectiveness, few data have been accurately documented. There is a general