Slow rise Surgery would not be possible without detailed knowledge of human anatomy. In the 16th century Andreas Vesalius published his “De humani corporis fabrica”, providing very detailed anatomy of the human body. He also understood the importance of teaching, already internationally, and performed the first endotracheal intubation in pigs. William Harvey described the anatomy of the cardiovascular circulation. Ambroise Paré rediscovered blood vessel ligation, applied specific wound dressings and already designed rudimentary limb prostheses. General surgical interventions quickly developed (1). Thoracic surgery only developed very late due to the fact that opening of the chest resulted in collapse of the lung and pneumothorax (2). Opposing views ensued whether the thoracic interventions should be performed by “Unterdruck” or “Überdruck” (negative versus positive pressure). Gotthard Bülau introduced closed water seal drainage to re-expand the lung. After experimental studies, Ferdinand Sauerbruch designed a negative pressure chamber to perform thoracic interventions, principle of which was also used in the “iron lungs” during the polio epidemic. However, its use was not quite practical and finally, positive pressure became the preferred option after development of a positive pressure apparatus by Ludolph Bauer. Tuberculosis: start of thoracic surgery After introduction of endotracheal intubation and intratracheal anesthesia, thoracic surgery developed as a separate specialty from general surgery. Pulmonary tuberculosis became a wide-spread problem and specific tuberculosis centers (sanatoria) were created with multidisciplinary medico-surgical cooperation “avant la lettre”. This provided a clear impetus towards further development of thoracic surgery. Devastating infections were encountered necessitating a variety of special procedures as extrapleural dissection, rib resection, cavernostomy with open drainage, and sometimes an extensive thoracoplasty. Théodore Tuffier is credited for performing the first successful lung resection for tuberculosis in 1891, putting a clamp on the apex after extrapleural dissection followed by resection of diseased lung parenchyma and closure of the lung surface by a continuous suture. Lung resection: pneumonectomy Alexis Carrel who won the Nobel prize In 1912, contributed enormously to further development of surgical techniques by providing detailed description of vascular sutures, organ transplantation and even extracorporeal circulation. Thoracic surgical oncology started to develop with Evarts A. Graham performing the first one-stage pneumonectomy for lung cancer in 1933. Patient was a 48-year-old gynecologist who resumed practice afterwards and died at the age of 78 years. In the era before computed tomography, pneumonectomy became a standard procedure for lung cancer to obtain a complete resection. Lung resection: less than pneumonectomy Surgical principles of lobectomy developed somewhat later, although Arthur Tudor Eduards performed the first lobectomy for tumor in 1928 but this case was only published ten years later. Initially a mass-suture ligation technique was used for which a lobectomy tourniquet was developed. Later on, individual dissection with ligature or suture of hilar structures was introduced. William Rienhof described the modern technique of bronchial suture with interrupted silk sutures. He already advocated an atraumatic dissection, preservation of blood supply and covering of the bronchial stump. Lung resection: less than lobectomy Elective resection of pulmonary segments was described by Edward D. Churchill who performed the first anatomical lingulectomy in 1939. Especially for tuberculosis and bronchiectasis, segmentectomies were performed. With the introduction of the new WHO and 8th TNM classifications of lung tumors, there is currently an ongoing discussion whether sublobar resection comprising an anatomical segmentectomy and wide wedge excision for small (< 2 cm) early-stage lung cancer, provides similar results as lobectomy (3). The results of randomized trials are eagerly awaited for. Bronchoplastic and tracheoplastic surgery Not only resection of lung parenchyma became common practice but also reconstruction of the bronchus and trachea in selected patients with central lung tumors. Although initially considered “impossible surgery,” Paul Gebauer in 1948 described bronchial excision and reconstruction by a wire-supported dermal graft. The first sleeve lobectomy was performed in 1947 by Sir Clement Price Thomas in a Royal Air Force cadet as an alternative to pneumonectomy which would have made an end to his career as military pilot. Tracheal surgery was further developed by Griffith Pearson and Hermes Grillo who both obtained an extensive experience with tracheal resection and reconstruction for non-malignant and malignant diseases. Minimally invasive surgery: Although generally, the principles of surgical resection of lung, mediastinal and pleural tumors have been well-established, the approach still remains controversial. Initially, for extensive disease posterolateral thoracotomy and sternotomy were routinely used. With better imaging techniques, especially computed tomography and later on, positron emission tomography, and new technical developments, minimally invasive procedures were introduced from 1990 on. There was a slow transition from muscle-sparing thoracotomies to minimally invasive approaches by video-assisted thoracic surgery (VATS) or more recently, to robotic-assisted thoracic surgery (RATS). VATS can be performed by multiple ports, a single port without rib spreading, and more recently, by a subxiphoid approach. The relative contribution of each technique has not been clearly established but medium-term results seem to be similar to open techniques on the condition that oncological principles are not compromised. Complete resection including systematic lymph node dissection for lung cancer still remains the most important prognostic factor. Undoubtedly, minimally invasive techniques will be refined in the near future making thoracic surgery a fascinating specialty. 1. Naef A. P. The story of thoracic surgery. Hogrefe and Huber Publishers, Toronto, 1990 2. Naef A.P., von Segesser L.K. (eds). Thoracic and Cardio-vascular Surgery. From the magic mountain to rocket science. European Association for Cardio-thoracic Surgery, Windsor, 2010 3. Sihoe A., Van Schil P. Non-Small cell lung cancer: when to offer sublobar resection? Lung Cancer 2014; 86: 115-120 History, Thoracic Surgery, evolution