Introduction
Thoracoscopy, the introduction of an illuminated tube through a small incision made between the ribs, was first used in 1910 by Hans Christian Jacobaeus for the treatment of tuberculosis. This allowed the surgeon to visualize structures inside the chest and to perform simple procedures. Visibility was generally limited to the surgeon until the development of video-endoscopic equipment which allowed the entire operating team to view and assist in the operation.

Advantages of Video-assisted Thoracic Surgery
When compared with a traditional open chest procedure, VATS has reduced the amount of chest wall trauma, deformity, and post-operative pain. While an open procedure generally requires a 30-40 cm incision, video-assisted biopsies can be performed through three 1 cm ports and a VATS lobectomy, a resection of one lobe of the lung, is performed using a 5-8 cm incision.

Diagnosis of Pulmonary Nodules
With the increasing use of helical computed tomography (CT) scans, patients are presenting more frequently with incidental pulmonary nodules. The potential for malignancy depends on the patient’s age, exposure to tobacco smoke, size of the nodule, and growth pattern. A CT-guided needle biopsy is the least invasive and can offer a specific diagnosis. However, there is a 20% admission rate after percutaneous biopsy, and a 5% incidence of pneumothorax, or air leak from the lung, requiring a chest tube. PET scanning is a modality that can identify metabolically active nodules more than 1 cm in diameter. Newer scanners have been reported to identify activity in nodules as small as 6 mm in diameter.

Malignant Pleural Effusion
VATS can be useful in the diagnosis of pleural effusions, fluid that has collected between the lung and chest wall, for which no cause has been found. In malignant pleural effusions, the microscopic results are inconclusive 40% of the time after thoracentesis, where the fluid is drained using a needle, while VATS is successful in making a diagnosis in 90% of cases due to the ability to visualize suspicious areas for biopsy. In addition, VATS allows other interventions to be performed at the time of exploration including pleurodesis, using talcum powder to encourage the formation of scar tissue sealing the surface of the lung to the chest wall and preventing the recurrence of effusions.

Video-assisted Lobectomy
A lobectomy, the resection of one lobe of a lung, is generally performed for the excision of lung tumors. While VATS lobectomy is technically demanding, it is performed safely in carefully selected patients with conversion to an open procedure when necessary. VATS should be considered in patients with a peripheral early stage tumor with no evidence of enlarged lymph nodes or fibrosis.

Lymph node staging and surgical resection margins are equal to those obtained during an open procedure. Post-operative complications and length of stay are also reduced.

Conclusions
Over the past decade, the use of VATS has become widespread and has allowed surgeons to perform complex procedures that previously required a thoracotomy, or open chest procedure. Although the use of VATS in the management of lung cancer continues to evolve, the procedure is now being used from diagnosis and staging to treatment and palliation with comparable results as well as decreased pain and complications when performed by experienced thoracic surgeons.