[Thoracic Surgical Approaches - From Open Thoracotomy to Robot-Assisted Surgery].

Abstract

Background: The choice of surgical approach in thoracic surgery significantly influences postoperative outcomes. Over the past three decades, the spectrum has expanded from classical open thoracotomy to include various minimally invasive and robot-assisted techniques. This CME article provides a comprehensive, evidence-based overview of all relevant thoracic surgical approaches and their indication-specific application.

Methods: A narrative review was conducted based on current literature from PubMed, Springer, and Thieme. Open approaches (posterolateral, anterolateral, muscle-sparing, axillary, median sternotomy, mediastinal, thoracoabdominal), minimally invasive approaches (multiportal and uniportal VATS, subxiphoid, RATS, non-intubated VATS), and hybrid techniques were analyzed regarding indications, operative technique, and comparative outcomes.

Results: Meta-analyses demonstrate that uniportal VATS is associated with lower complication rates (OR 0.76) and shorter hospital stays compared to multiportal VATS. The VIOLET trial confirmed non-inferiority of VATS lobectomy versus open lobectomy regarding lymph node dissection. Robot-assisted surgery offers enhanced 3D visualization and seven degrees of instrument freedom but has not demonstrated survival advantages over VATS. ERAS protocols reduce perioperative morbidity (OR 0.72 per 10% compliance increase).

Conclusion: Modern thoracic surgery requires individualized approach selection considering tumor characteristics, patient factors, and institutional expertise. The integration of mediastinal staging techniques, thoracoabdominal approaches, and advanced minimally invasive methods has expanded the surgical armamentarium substantially.