From trapdoor to 3mm-Operative access routes in thoracic surgery

Modern thoracic surgery encompasses a multitude of different and specific surgical approaches. This article aims to give an overview of contemporary surgical techniques for access to the thoracic cavity and mediastinum, their indications and implementation. Thoracotomy is the classical approach in emergency situations and for the resection of large tumors or in cases of pleural adhesions due to previous surgery. Despite the successful implementation of minimally invasive techniques, thoracotomy remains an essential part of thoracic surgery especially as it serves as a safe technique in cases of major bleeding and probably necessary conversion from minimally invasive surgery to open procedures. Nowadays, video-assisted thoracoscopy is the procedure of first choice especially in oncology because of its small access-related trauma and low perioperative and postoperative morbidity and rapid recovery. Robotic-assisted thoracoscopy is the superior procedure, particularly for mediastinal tumors and gains increasingly more importance for thoracic operations as well. Resection of tumors infiltrating the anterior mediastinum or upper thoracic aperture requires sophisticated techniques. Today, these techniques are often combined with minimally invasive procedures.