Ideally, video-assisted surgery should be done with the endoscope and instruments triangulated and positioned opposite one another. This rule is, however, almost impossible to follow during endoscopic major pulmonary resections, for the following reasons:

A mechanical or motorized scope holder, according to the surgeon’s preference, holds the scope. Its position should be shrewdly chosen so that it does not conflict with the instruments. Endoscopic instruments and trocars are placed on a dedicated rack, and the conventional thoracic instruments are prepared on a separate table (◘ Fig. 1.2). Instruments used at our institution are listed in ◘ Table 1.1.

Three monitors are used for the surgeon, the assistant, and the scrub nurse, their positions being adapted throughout the procedure for perfect vision.

In past years, many technical articles have reported approaches using a single port, two ports, or three ports, as if the number of trocars was a major concern. This is most likely a false debate. The only concern is being well exposed, whatever the number of ports. However, although this has not been demonstrated, postoperative pain is most likely linked not only to the number of ports but also to their diameter. For this reason, we do not limit the number of instruments but, whenever possible, we use small-diameter ones in order to minimize the intercostal trauma. Many tasks can indeed be done with micro-instruments. In addition, it is preferable to have several small-diameter ports rather than 2–3 large ports, which may exert excessive torque with its inherent intercostal nerve compression.

Where the trocars should be positioned is a frequently asked question. Unfortunately, there is no fixed and definite position. It depends not only on the type of resection but also on the patient’s morphological type and on the surgeon’s habits and preferences. For instance, we prefer performing left resections with the instruments coming from the front (◘ Fig. 1.1), while right-sided resections are performed with a combination of dissection from the back and from the front. Other surgeons may feel more comfortable with another approach and different positioning. The only recommendations we would give are the following:

During open surgery or video-assisted thoracoscopic surgery (VATS), the surgeon usually stands at the patient’s back because the anatomical landmarks are more familiar to him/her that way. It is sometimes preferable to stand at the patient’s front. This means that 2–3 monitors should be used. The light in the operating room (OR) should be reduced as much as possible to enhance the monitor’s contrast. As working in the dark is tiresome for the staff, the best compromise is to have blue background lighting, which offers a nice contrast and does not oblige the staff to work in the dark.

Over the past 10 years, the picture quality displayed in the operating theater has dramatically improved. We have moved from standard definition (SDTV) with 640 × 480 resolution to a high-definition (HDTV) signal, which provides much better resolution (1920 × 1080) and better color rendering than in the past (◘ Fig. 1.3). In addition, modern camera chips are less sensitive to blooming or bleeding (that usually results in sudden darkness of the operative field). More recently, 4K technology, which has four times the resolution of full HD (4096 × 2160), has entered the OR and makes it possible to use large screens. Eventually, for those surgeons who feel more comfortable with a three-dimensional (3D) display, 3D technology is becoming mature and may be helpful for complex procedures or for some tasks, such as suturing.

Despite these outstanding technologies, it is striking how poor the general image quality remains in many ORs. Several minor problems deteriorate the native picture, such as an inappropriate choice of endoscope angle, an unstable image, and lens soiling and fogging. As a result, surgeons sometimes operate with a picture quality they would not accept when watching TV at home. The main consequence is a loss of safety for the patient.

A frequently asked question is what viewing angle of the endoscope is used for thoracoscopic major pulmonary resection (MPR). Some surgeons prefer a straight viewing scope (0°) because it gives a more natural vision. Others favor an oblique viewing scope, usually 30°, to avoid tangential vision when the target is remote from the endoscope insertion port. It is however rare that one of these two choices remains ideal throughout the procedure, especially when moving from close-up to overall views. This is the reason why having the possibility to switch from a straight viewing angle to an oblique one with a single endoscope is the best option. Two scopes are available on the market and have different technologies: the EndoCameleon® (Storz) and the LTF (Olympus). The EndoCameleon® is a rigid 10-mm scope housing a conventional rod–lens system. The distal lens can be tipped down so that its angle varies from 0° to 120°.

The LTF is based on a different technology. The endoscope is a 10-mm rigid one but has a flexible distal part housing the chip at its tip. The distal part can be deflected from 0° to 100° up–down and right–left or any combination of these movements, thanks to two levers located on the handle (◘ Fig. 1.4). Once the appropriate angle has been chosen, it can be locked. It is possible to switch from a direct view to a bird’s-eye view in just one action. We have been using this scope during all of our thoracoscopic MPRs for more than 10 years. It is especially helpful during lymph node dissection (◘ Fig. 1.5).

Although the LTF is very useful, it is not yet the ideal scope. It is indeed expensive, and the sheath of its distal part is fragile. In addition, when it is used in small chest cavities, the distal part is too long to be maneuvered. However, despite these minor drawbacks, this endoscope is perfectly adapted to most MPRs. A 5-mm version can be used for minor procedures.

From the early beginning of our experience in thoracoscopic surgery, we have worked with a scope holder for three reasons: (1) it allows the surgeon to avoid a shaking picture; (2) the operative field remains hands free, avoiding instrument conflicts and hands crowding over the patient’s chest; and (3) the assisting surgeon can concentrate on tasks other than holding the endoscope. However, few thoracic surgeons are familiar with this possibility.

The holder can be mechanical (◘ Video 1.1a) or robotized (◘ Fig. 1.6 and ◘ Video 1.1b). Unfortunately, few mechanical scope holders fit the thoracic surgeon’s needs. Their arm is usually too short and not suited to patients who are in the lateral decubitus position. After using a mechanical scope holder for more than 10 years, we have switched to a robotic manipulator, which can be controlled by a foot pedal or by voice, depending on the surgeon’s preference. In the 2000s, the most popular robotic scope holder was the AESOP® [Automated Endoscopic System for Optimal Positioning] system (Computer Motion, Inc.), which is no longer commercially available. It was efficient but was also cumbersome, heavy, and expensive. Lighter and more intuitive systems are now on the market (Freehand®, Freehand Ltd., Eastleigh, UK; or Viky®, EndoControl, Grenoble, France). We use the Viky® EP endoscope positioner (◘ Fig. 1.6b), which provides functions similar to those of old systems such as AESOP®, while being much lighter and easier to set up (◘ Video 1.1b). The Viky® EP can be fixed onto the operating table rail. Its long and thin arm saves space around the patient’s chest and avoids clashes with instruments. The system can move the endoscope forward and backward, up and down, and laterally. The combination of the movements of this scope holder and the viewing angles of the LTF thoracoscope makes it possible to reach most targets without manipulating the scope. As it is autoclavable, there is no need to protect it with a sterile sheath, thus allowing rapid setup.

One of the more frequently encountered problems during a thoracoscopic procedure is soiling of the endoscope tip by blood dripping along the trocar sheath. As shown in ◘ Video 1.1, blood sliding along the sheath goes back up by capillarity action inside the trocar tube and soils the lens (◘ Video 1.2). This forces the surgeon to remove the scope for cleaning, which can be tedious and irritating when done frequently.

Rather than cleaning the scope outside, one solution can be wiping it inside with a lens-cleaning system (EndoClear™, Virtual Ports) that can be released inside the chest cavity. The device is a single-use, butterfly-shaped cleaner made of two nonwoven materials mounted on two retractable triangles. The device is anchored to the parietal pleura (◘ Fig. 1.7 and ◘ Video 1.3). It has some drawbacks. The main one is that the cleaner is mounted on a rod that has a rigid loop as its basis for insertion and removal, thanks to a dedicated applier. This loop can be dangerous in the event of unexpected reventilation of the lung during the procedure.

We now favor a specific trocar, that is, a skirt mounted at the tip, which deflects blood drops (◘ Fig. 1.8 and ◘ Video 1.4). This simple tool is very efficient and is now used during all of our thoracoscopic procedures.

Lens fogging is a well-known concern and is a real impediment to clear vision. It is caused by condensation due to a temperature difference between the OR and the patient’s thoracic cavity. The more the surgeon has to retrieve the scope for cleaning or any other reason, the more he/she gets in trouble with fogging. Numerous tricks have been proposed to overcome this issue, such as heating the scope in a sterile thermos flask filled with hot water or using one of the commercially available antifogging solutions. As most surgeons know, none of these tricks are totally efficient, as they do not treat the cause, that is, the temperature difference.

To date, the most efficient system we have used is the built-in warming system in Olympus endoscopes. A fog-free element is located at the back of the leading-end objective lens. It is combined with a sensor that constantly monitors the temperature (◘ Fig. 1.9). The fog-free element warms the lens and maintains it at a predetermined temperature, that is, 39 °C. Since we have been using this system, we have not needed any antifogging solution or any other heating system.

Patients who are selected for a totally endoscopic MPR usually present with a clinical stage 1 tumor. This often means the tumor or nodule is small and not accessible for a preoperative biopsy, whatever the technique (computed tomography (CT)-guided or endobronchial navigation). Thus, many patients are operated on without a confirmed pathological diagnosis. When the nodule is small and subpleural, the easiest way is to perform a wedge resection with a frozen section. In other cases, we use a biopsy needle (Bard® Monopty®, Covington, GA, USA), which provides a pathological diagnosis in most cases (◘ Fig. 1.10 and ◘ Video 1.5). This maneuver is efficient but can be hazardous because the needle has a 2-cm path out of its shaft. This length must be taken into consideration before firing.