Minimally invasive surgery is the trend of today’s surgical development, and minimally invasive thoracic surgery, represented by video-assisted thoracoscopic surgery VATS, is widely used in the diagnosis and treatment of thoracic tumors, becoming another major technological revolution in thoracic surgery since the introduction of extracorporeal circulation technology. Total thoracoscopic lobectomy has become a new type of surgery for lung cancer treatment. Thoracoscopic lobectomy for lung cancer has the advantages of minimally invasive, small fatigue and fast recovery. Worldwide studies have shown that for stage I non-small cell lung cancer NSCLC, thoracoscopic lobectomy with mediastinal lymph node removal/clearing can achieve a 5-year survival rate comparable to that of conventional open-heart surgery. Especially with the recent application of surgical robotic system in thoracic surgery, the limitations of thoracoscopic techniques have been fundamentally solved, making thoracoscopy reach new heights in the surgical diagnosis and treatment of lung tumors. According to the database of the American College of Thoracic Surgeons, the first thoracoscopic lobectomy for lung cancer in the United States was performed in 1992, and the proportion of thoracoscopic lobectomies in the United States has been increasing year by year since then, from 5% in 2003 to 18% in 2006 and 20% in 2007. In fact, the proportion of thoracoscopic lobectomies in some hospitals in the United States has long exceeded 80%. McKenna, for example, performed his first thoracoscopic lobectomy in 1992, and by 2003, 89% of his lobectomies were performed thoracoscopically, reaching 94% in 2005. Therefore, it is predicted that by 2011, more than 80% of early-stage lung cancers in the United States will be completed by thoracoscopic surgery. The role of total thoracoscopic lobectomy in the treatment of benign or palliative malignant lung lesions is worthy of recognition, but there is still some controversy regarding the selection of indications, the extent of lymph node dissection, and the incidence of complications and mortality. This means that the indications for total thoracoscopic lobectomy have basically covered the current internationally recognized indications for lung cancer surgical treatment, and therefore total thoracoscopic lobectomy is fully applicable to stage IA to IIB NSCLC and some of the lung cancers. The safety and superiority of total thoracoscopic lobectomy are worthy of recognition. Since Jacobaeus first introduced the clinical application of thoracoscopy, thoracoscopic surgery has a history of nearly 100 years. 1910-1986 was the stage of conventional thoracoscopy; 1910-1922 was mainly used in the treatment of tuberculosis; 1922-1945 entered the heyday of conventional thoracoscopy, the instruments were updated, endoscopic vision and clarity were improved, and electrocoagulation equipment was also significantly advanced. From 1945 to 1986, traditional thoracoscopy was at a standstill, as the application of streptomycin and artificial pneumothorax therapy were gradually eliminated and traditional thoracoscopy came to a halt; after 1986, the development of television endoscopy technology brought new life to endoscopic surgery, and for the first time, a miniature endoscopic camera was connected to the laparoscope to complete human cholecystectomy. In the second year, this technique became one of the routine surgical procedures in countries all over the world. Especially by the end of 1980s, the application of endoscopic sutured incisors provided the conditions for the 2nd comprehensive revitalization of thoracoscopy. The clinical application of modern thoracoscopy first started in 1992, mainly including thoracoscopic lobectomy, thymectomy and esophageal myotomy [}6-‘0} 0 In 1992, a VATS collaborative group was formed by 41 famous hospitals in the United States to carry out training of thoracoscopic surgeons, which provided good conditions for the accumulation of experience and efficacy assessment of thoracoscopic surgery. At present, thoracoscopy has become a relatively mature surgical technique. With the introduction of da Vinci Cda VinciTm and robotic surgery system, the advantages of its assisted total thoracoscopic lobectomy will surely be shown to a greater extent. 2.The indications and contraindications of total thoracoscopic lobectomy Total thoracoscopic lobectomy has little damage to the chest wall muscles, no need to open the ribs or only need to slightly pull the ribs, so it can keep the chest wall intact, reduce the pleural breast connection, reduce bleeding and lymphatic fluid loss, and at the same time has the advantages of large surgical field, light postoperative pain, small dose of analgesic drugs, fast recovery of the patient’s body and fast degeneration of the incision fatigue. The advantages. 1. stage I A and some IQ A NSCLC, tumor diameter <3 cm, no mediastinal lymph node metastasis; 2. stage II A NSCLC, tumor diameter <5 cm, fiberoptic bronchoscopy suggests no central bronchial invasion, CT suggests 1 or 2 enlarged lymph nodes in the hilum and diameter <1.5 cm; 3. metastatic lung cancer requiring lobectomy; 4. no pleural mammillary connection. The lung lobes are well developed, the lung fissures are fully developed, and the pleural cavity is free of mammary connection. However, the indications for surgery are relative, and the specific application needs to be combined with the actual clinical situation to select the surgical modality. The choice of surgical modality depends on the experience of the surgical operator. 2. 2. Contraindications to surgery 1. central lung cancer and mediastinal lymph node metastasis; 2. severe or dense mammillary connections in the pleural cavity, including severe inflammatory lesions and pleural fusion; 3. stage II B to III B NSCLC} cancerous tissue invading the main bronchus or invading the main pulmonary artery, with marked enlargement of hilar or mediastinal lymph nodes; 4. poor general condition, liver and kidney function and coagulation disorders, or intolerance of Single lung ventilation; 5. Progressive malignant tumors; 6. Larger tumors >9 cm in diameter, including benign tumors. 3. Type of surgical incision and conventional surgical approach Thoracoscopic lobectomy anesthesia was performed by double-lumen tracheal intubation with general anesthesia and unilateral healthy lung ventilation. The patient is placed in the 90-degree position on the healthy side, the lumbar bridge is elevated, and the upper limb on the operated side is suspended on the anesthesia head frame. Lobectomy is followed by positive pressure ventilation of the affected lung to allow adequate expansion of the residual lung to avoid the presence of thoracoscopically indistinguishable restrictive pulmonary atelectasis. The surgical incision usually consists of a 1.5 cm-long thoracoscopic light source incision, one to three 1.5 cm-long operating trocar incisions or a small 5-7 cm-long chest wall-assisted incision. 3. 1. The thoracoscopic light source incision is usually chosen between the anterior and mid-axillary lines of the 8th intercostal space. The choice of incision location varies slightly depending on the patient and the lobe of the lung being removed. 3.2 The operating trocar incision is generally chosen from 1 to 3, and its location can be determined after thoracoscopic exploration of the chest cavity, in order to facilitate surgical operation. The operating hole of the retractor is usually chosen near the posterior axillary line of the 7th and 8th intercostal space. The location of the small incision in the chest wall is generally chosen between the anterior and posterior axillary lines of the 5th or 4th intercostal space, and can be determined according to the surgical needs and the different lobes of the lung to be removed. Small incision selection should generally follow the principle of closer to the pulmonary hilum to reduce chest wall muscle injury and keep the incision fatigue scar from developing hyperplastic contracture. 3.4. The surgical approach of total thoracoscopic lobectomy is to complete lobectomy by ligating the vessels and bronchi separately under the thoracoscope in the presence of a single lung ventilation. A 5 mm trocar with a 30-degree thoracoscope was placed in the 8th intercostal space in the mid-axillary line, and a 2 cm long incision was made in the 6th intercostal space in the mid-axillary line. An oval forceps is placed through the incision and the lung is pulled back to expose the pulmonary veins. If an upper lobe resection is performed, a secondary incision is made directly over the upper pulmonary vein; if a middle or lower lobe resection is performed, the incision is moved down 1 intercostal space. The incision begins at the anterior border of the latissimus dorsi muscle and is approximately 4 to 6 cm long; in some patients, an additional incision of 1 cm in length is made at the auscultatory triangle. The operator stands in front of the patient and performs a middle or upper lobe resection, starting with the pulmonary veins and working anteriorly and posteriorly to the hilum. After mechanical closure of the vessels, the pulmonary fissures are separated with a mechanical closure device. For lower lobectomy, the inferior pulmonary ligament is treated first, followed by mechanical closure of the pulmonary veins. After locating the pulmonary artery, a plane is trimmed on the surface of the pulmonary artery with Metzenbaum scissors and the pulmonary fissure is mechanically separated to expose the pulmonary artery. The anatomic lobectomy method is generally chosen, i.e., the pulmonary arteries, veins, and bronchi are treated separately. The finer pulmonary arteries can be double treated with a standard type of vascular clamp, while the larger pulmonary arteries are treated by ligation or with Endo-GIA. The principles of pulmonary vein processing are basically the same as those of pulmonary artery processing, but because of the thick and short pulmonary veins and their thin walls, they should be carefully separated and processed. The specimen is then placed in a specimen bag and removed through a small incision, followed by lymph node dissection or biopsy. Upper and lower chest drains are placed in the upper lobe resection and lower chest drains are placed in the lower lobe resection, both through the thoracoscopic or operating hole. The upper chest drain can be placed along the lateral side of the lung up to the apex of the chest, and placement of the chest drain should be done under direct thoracoscopic view. With the assistance of direct thoracoscopy, the pleura and intercostal muscles are closed, then the chest wall tissues are sutured sequentially, and finally the trocar incision is sutured. Routine preoperative examinations should include: pulmonary function tests, chest CT and PET. all patients should undergo mediastinoscopy except for those with stage IA PET and CT findings. The most dangerous step in surgery is the management of the pulmonary vasculature, which can be accidentally injured during both intraoperative dissection and treatment of the pulmonary vasculature, causing intraoperative hemorrhage. The causes of hemorrhage include: 1) inappropriate selection of cases, such as patients with severe perivascular mammary connexions, or poor inflammation control resulting in brittle vessel walls, or incomplete lung fissures and difficult dissection of the pulmonary hilum; 2) inappropriate operation, such as the failure to detect the variant vessels in time and treat them accordingly, or improper dissection techniques that damage the vessels. Once the accidental injury bleeding, can not use the vascular clamp blindly to stop bleeding, so as not to aggravate the vascular injury. If the injury is light, the anatomical structure of the pulmonary hilum is clear, the bleeding site and vascular injury are clear, the surrounding blood can be aspirated in time, and then the bleeding can be controlled by non-invasive vascular forceps through a small incision in the chest wall and then further treated as appropriate. If the bleeding volume is large and the pulmonary vascular injury and hilar anatomy are unclear, the bleeding point should be compressed with gauze through a small incision immediately for effective temporary hemostasis, while promptly switching to open-heart surgery. A non-randomized controlled trial conducted by Sugiur. et al. compared 22 patients who underwent total thoracoscopic lobectomy with 22 patients who underwent open lobectomy and found no statistically significant difference in complication rates and mortality between the 2. Demmy et al. showed that blood loss was less in thoracoscopic lobectomy compared with open thoracotomy. Total thoracoscopic lobectomy is safer compared to open thoracotomy. Regarding the control of bleeding during total thoracoscopic lobectomy, no intraoperative bleeding occurred in a study of 1,578 patients undergoing total thoracoscopic lobectomy. This shows that the risk of major bleeding is very low. Advantages of total thoracoscopic lobectomy include a shorter hospital stay, shorter chest tube retention time, and shorter time to return to full preoperative activity compared with open surgery; the incidence of pain at 3 weeks after thoracoscopy is significantly lower than that of open surgery [Cn7]. Therefore, it has been suggested that total thoracoscopic lobectomy may reduce patient pain and allow for a faster recovery, especially in those who are frail and in those who have had a full thoracoscopic lobectomy. Especially those frail patients and high-risk patients may benefit from it. In a prospective randomized controlled trial comparing total thoracoscopic lobectomy with Muscle-Sparing open lobectomy, Giudicelli et al. showed a significant reduction in postoperative pain. In contrast, a randomized controlled trial conducted by Kirby et al. showed no statistically significant difference in postoperative pain. 5. Common postoperative complications and their management The complications after thoracoscopic lobectomy are basically similar to those after open lobectomy, but the incidence is significantly lower. The management of postoperative complications is basically the same as that of open thoracotomy. Patients are routinely admitted to the intensive care unit for supervised treatment after surgery, encouraged to cough up sputum, and aspirated to reduce the occurrence of complications, which are rare after thoracoscopic surgery. krasn. et al. reported a complication rate of only 4% after 348 thoracoscopic procedures, mainly including persistent pulmonary air leak, hypoxic syndrome, infection, and Horne: syndrome, with distant complications including malignant disease of medically disseminated and chronic pain. 5. 1. 1. Pulmonary complications 1. persistent pulmonary air leak, the most common complication after thoracoscopic surgery is persistent pulmonary leak, which can lead to subcutaneous emphysema and pneumothorax, etc. Risk factors associated with postoperative pulmonary air leak include emphysema, large apical pulmonary scar lesions, smoking and hormonal medication. The principle of treatment is partial removal of the pleura to reduce the strain on normal lung tissue and avoid the presence of surgical pleural remnants.2. Hypopneumonia syndrome refers to increased airway secretions after one-lung ventilation, occurrence of pulmonary atelectasis and pneumonia, etc. It can occur in one or both lungs and is more common in patients with intubation bleeding. The principles of management are early and effective removal of airway secretions, strengthening intraoperative airway suction, and timely postoperative removal of airway secretions and blood accumulation. Minimally invasive tracheotomy is feasible for patients who cannot sputum voluntarily after surgery. 5.2. Infection Infection is a possible complication after all surgical procedures. Infections after thoracoscopic surgery include local wound infections, pulmonary infections and septic chest. Most reports state that the incidence of infection after thoracoscopic surgery is <1%. The principle of management is the rational use of antibacterial drugs as well as symptomatic treatment. 5. 3. malignant lesion dissemination There is no clear report on the incidence of malignant lesion dissemination, but there are reports of tumor dissemination from incisions, cutting sutures, and mural and dirty pleura after thoracoscopic surgery. The principle of treatment is that specimens should be placed in sterile specimen bags rapidly after removal, thus reducing tumor dissemination and implantation in the wound. Postoperative flushing of the chest cavity with a large amount of sterile water can reduce tumor dissemination and implantation in the pleural cavity. 5.4. Chronic pain can be triggered by either open-heart surgery or thoracoscopic surgery. The literature reports that the incidence of postoperative chronic pain is 10%-40%, among which 2%-4% of patients have difficulty in tolerating chronic pain. landreneau et al. reported that compared with open thoracotomy, the former may reduce the wound pain and shoulder dysfunction for 1 year after surgery, but the difference between the two is not statistically significant. Thoracoscopic surgery can cause local chest wall tissue damage, which can lead to chronic postoperative pain. The principle of management is to use a smaller diameter thoracoscope and surgical instruments that can be bent and angled, and caution should be exercised when placing trocars and surgical instruments. 5.5, Pulmonary hernia of the chest wall Hause: et al. reported 2 patients who underwent thoracoscopic surgery and had a pulmonary sore in the chest incision 1 year after surgery. The lung tissue prolapsed from the thoracic incision when the patient coughed, probably due to poor postoperative wound healing and the patient's poor general condition. The principle of management is to strengthen aseptic management after surgery, to appropriately supplement protein and vitamins, and to improve the blood supply to the wound. Correct selection of surgical indications is the best way to prevent complications of thoracoscopic surgery. Intraoperative complications due to double-lumen tube intubation, single-lung ventilation, intrathoracic intercostal nerve block and cardiac arrhythmia should be taken seriously and treated with active symptomatic treatment. The upgrading of thoracoscopic techniques and the application of new surgical methods will help to reduce and prevent complications associated with thoracoscopic surgery. 6.Long-term survival quality Long-term survival quality is the most important criterion to evaluate whether the surgical method is reasonable. At present, the reports on the survival quality of thoracoscopic surgery for lung cancer are mainly summaries of single-center experiences. Kaseda et al. reported that the 4-year survival rate of stage I lung cancer treated with total thoracoscopic surgery was 94%, which was better than the survival rate of conventional open-heart surgery reported in the literature. The 3-year survival rate for patients with clinical stage I NSCLC was 93%, while the 3-year survival rate for patients with postoperative pathological stage I was 97%, and the 3-year tumor-free survival rate was 79% and 89% for patients with clinical stage I and pathological stage I, respectively. Lewis et al. reported that the survival rate of patients after thoracoscopic lung cancer was 86%, with a mean survival time of 18. 6 months. sugiur. et al. noted that the 5-year survival rate of patients after total thoracoscopic lobectomy was 90%, compared with 85% after open lobectomy P=0. 74, . McKenn. et al. reported that the 5-year survival rate after total thoracoscopic lobectomy was 72% o. Walke: et al. reported that the 5-year survival rate after total thoracoscopic lobectomy was 77.9%. This shows that the survival rate of lung cancer patients after thoracoscopic lobectomy is the same as that of open thoracotomy. Patients undergoing thoracoscopic lobectomy have less impaired lung function. A non-randomized controlled study showed that oxygen partial pressure, oxygen saturation, 1st second expiratory volume on exertion, and spirometry on exertion were better in patients undergoing thoracoscopic lobectomy than in patients undergoing open thoracotomy at 7 d and 14 d postoperatively. Demmy et al. reported that patients undergoing thoracoscopic lobectomy returned to preoperative activity earlier, and Sugiur et al. reported that patients undergoing thoracoscopic lobectomy had a significantly shorter time to return to preoperative activity than those undergoing open thoracotomy, had less postoperative pain in the thoracoscopic group, and had a higher rate of satisfaction with postoperative fatigue size in the thoracoscopic group. Functional obstruction of the shoulder joint was significantly less after thoracoscopic lobectomy compared with open thoracotomy. The length of hospital stay for total thoracoscopic lobectomy was shorter than that for conventional open-heart surgery. 7.Deficiencies and development direction of total thoracoscopic surgery At present, total thoracoscopic surgery is still under continuous development and improvement, so there are still some deficiencies, which limit the indications of total thoracoscopic surgery, mainly in the following seven aspects: 1, pleural mammillary connection is not easy to remove; 2, inflammatory tissue or lymphatic tissue wrapping the pulmonary hilum and pulmonary vessels, which is not easy to remove; 3, small and deep lesions are not easy to resection; 4, the pulmonary lobes are difficult to pull; 5, intra-thoracic hemorrhage is not easy to control; 6, lack of effective tools, unstable surgical field images, difficulty in implementing fine operations, and difficulty in controlling the pulmonary artery; 7, complexity of the technique and longer learning time. In addition, a small number of scholars are also skeptical of all-thoracoscopic surgery, mainly in the following five aspects:1, the lack of multicenter, large sample and long time studies and effective evaluation of the operation;2, the inability to reduce intra-thoracic pain;3, the excessive time of lung atrophy;4, the inability to shorten the hospital stay;C5} the difficulty of minimally invasive specimen removal. The introduction of robotic surgical system into thoracoscopic surgery can fundamentally solve the current limitations of total thoracoscopic surgery. Robot-assisted total thoracoscopic surgery is the main development direction of future total thoracoscopic surgery [Cze, zs 7. Robot-assisted total thoracoscopic surgery with clearer and more stable images of the surgical field reduces the visual fatigue of the operator, shortens the operation time, ensures the safety of the surgery, improves the ability of fine endoscopic operation, makes total thoracoscopic surgery possible in deep and complex surgical spaces, further reduces intraoperative bleeding and loss of lymphatic fluid. The reduction in the number of personnel and walking around the operating room controls the flow of contaminated air. A comparison of robot-assisted total thoracoscopic surgery with conventional total thoracoscopic surgery is shown in Table. Future prospective controlled studies are needed to further accumulate experience in order to validate the therapeutic effects, and in particular, multi-center, large sample, long-term studies of total thoracoscopic lobectomy need to be strengthened. The surgical technique of total thoracoscopic lobectomy should be continuously improved to reduce unnecessary trauma and expand its surgical indications. By concentrating the advantages of multidisciplinary specialties to carry out comprehensive treatment for lung cancer in order to improve its therapeutic effect. 8.Summary In conclusion, compared with traditional open lobectomy for the same stage of lung cancer, the differences between total thoracoscopic lobectomy and traditional open lobectomy are not statistically significant in terms of cure rate, postoperative complications, tumor recurrence rate and survival rate, and total thoracoscopic lobectomy has unique advantages that traditional open surgery does not have. The long-term postoperative survival rate of total thoracoscopic lobectomy was the same as that of traditional open-heart surgery, and the quality of patient survival was higher than that of traditional open-heart surgery. The non-infectious inflammatory response to the organism brought by the minimally invasive total thoracoscopic lobectomy is lighter than that of traditional open-heart surgery, and the postoperative complications and lung function recovery are better than those of traditional open-heart surgery, which is beneficial to the recovery of lung cancer patients. Especially in the field of total thoracoscopic surgery, the introduction of the robotic surgery system can simulate a greater degree of activity and finer operation than that of a human hand. It is in line with the habit of direct vision in thoracic surgery. The system can magnify the image more than 10 times to achieve complete removal of tumor tissue and lymph nodes, while preserving normal structures. The new generation da Vinci system has four robotic hands, which further increases the operability of total thoracoscopic lobectomy. Total thoracoscopic lobectomy can accomplish complete resection of tumor and lymph node dissection in the anatomical sense, with low complication and mortality rates and low risk of intraoperative bleeding and incisional recurrence. With the continuous improvement of the surgical method of total thoracoscopic lobectomy and more precise surgical instruments being put into clinical application, the complication rate of total thoracoscopic lobectomy will be further reduced, the survival rate of lung cancer after surgery will be further improved, the scope of surgical indications will continue to be expanded, and total thoracoscopic lobectomy will definitely become the main surgical modality for the surgical treatment of lung tumors.