Abstract: Objective To explore the clinical value of total thoracoscopic lobectomy. Methods From November 2008 to November 2009, 38 cases of total thoracoscopic lobectomy were performed, 26 male and 12 female, aged 18-69 years (46.3±8.6 years). Among them, there were 6 cases of right upper lobectomy, 3 cases of right middle lobectomy, 15 cases of right lower lobectomy, 4 cases of left upper lobectomy and 10 cases of left lower lobectomy, and mediastinal lymph node dissection was also performed in the same period for 31 cases of primary lung cancer. Results: All the operations were successfully completed, 1 case was transferred to open chest, the operation time was 158.6±34.4min, the intraoperative bleeding was 183.5±76.5ml, the time of closed chest drainage was 5.3±2.6d, and the postoperative hospitalization time was 7.6±3.5d. The postoperative pathological diagnosis was: 31 cases of primary lung cancer, 3 cases of lung metastasis, 2 cases of inflammatory pseudotumor, 1 case of lung isolation, 1 case of pulmonary aspergillosis, and 1 case of pulmonary aspergillosis. case. Two patients with primary lung cancer developed distant metastases at 6 and 9 months after surgery, respectively, after 1 to 12 months of follow-up. Conclusion Total thoracoscopic lobectomy has reliable efficacy and feasible technique, with the advantages of safety, minimally invasive and rapid recovery, and is suitable for early peripheral lung cancer and benign lung diseases requiring lobectomy, but requires skillful endoscopic treatment of blood vessels and lymph node clearance and other key techniques. Lobectomy is one of the standard surgical procedures for the treatment of lung cancer, bronchiectasis and inflammatory pseudotumor, etc. The traditional surgical procedure requires a surgical incision of about 30 cm, which not only cuts off a lot of muscles of the chest wall, but also requires the use of thoracotomies to open the intercostal space in order to expose the surgical field, which leads to huge trauma, severe pain in the postoperative wounds, long recovery time, long surgical scars, and a lot of complications. In recent years, with the updating of videoassisted thoracoscopic surgery (VATS) equipment and the maturation of surgical techniques, most lobectomies can be accomplished through auxiliary small incisions, and some of them can be accomplished completely under thoracoscopy. 1, Data and Methods 1.1 Clinical data: The group consisted of 38 cases, 26 males and 12 females, aged 18-69 years (46.3±8.6 years), with a disease duration of 2 weeks to 3 years (5.7±2.6 months). The main complaints were cough in 14 cases, chest pain in 8 cases, bloody sputum in 5 cases, and asymptomatic physical examination revealed pulmonary nodules or masses in 11 cases. 1.2 Surgical equipment and instruments: 0° or 30° thoracoscope, monitor imaging system, endoscopic vascular clamp, endoscopic oval forceps, endoscopic linear cutter-suture (Johnson & Johnson Echelon), endoscopic vascular lock (Hemolok), ultrasonic knife, electrocoagulation hook, endoscopic suction and endoscopic scissors and so on. 1.3 Surgical methods: 1.3.1 Anesthesia, position, incision design and exploration: general anesthesia with double-lumen endotracheal intubation, one-lung ventilation on the healthy side, and the healthy side lying at 90°. A thoracoscopic observation port of about 1.5cm in length was made in the mid-axillary line between the 7th or 8th ribs, an auxiliary operation port of about 1.5cm in length was cut in the subscapularis angular line between the 8th or 9th ribs, and the main operation port of about 3-5.5cm in length was taken in the anterior axillary line between the 4th or 5th ribs, and the soft tissues of the skin, subcutaneous, and thoracic muscles were pushed aside with the papillary spreader to facilitate the operation of endoscopic instruments without the need for a thoracic spreader to open up the rib gap. The thoracic cavity was firstly explored, and the intrathoracic adhesions were separated and the lung lesions were explored under the cavity microscope. For lesions that could not be detected visually, the preoperative CT localization points could be referred to, and the forefinger was inserted to touch the lung tissues in order to clarify the location. If the pathological nature of the lesion or the lesion is located in the deep lung parenchyma is clear before surgery, lobectomy will be performed directly; if the pathological diagnosis is not clear before surgery and the lesion is located in the periphery of the lung parenchyma, wedge resection of the lung can be sent to the rapid frozen pathology examination, and if malignant tumors are reported, then lobectomy with lymph node dissection will be performed. 1.3.2 Anatomical lobectomy and lymph node dissection: use electrocoagulation hook, ultrasonic knife, Aixilon and Hemolok to deal with pulmonary artery, pulmonary vein, bronchus and interlobular fissure, and take out the specimen of completed anatomical resection of lung lobe after putting it into the specimen bag through the main operation hole. In patients with primary lung cancer, mediastinal lymph node dissection was performed at the same time. At the end of the operation, after checking that there was no obvious air leakage and active bleeding, a closed chest drain was left in the thoracoscopic observation port, and a closed upper thoracic drain was also needed to be left in the auxiliary operation hole in the case of upper lobectomy. 2, Results The whole group of surgery were successful, 1 case due to the lymph node and pulmonary artery adhesion dense, can not be separated under the microscope, and then transferred to open the chest. A total of 6 cases of right upper lobectomy, 3 cases of right middle lobectomy, 15 cases of right lower lobectomy, 4 cases of left upper lobectomy and 10 cases of left lower lobectomy were performed. The operation time was 158.6±34.4 min, intraoperative bleeding was 183.5±76.5 ml, closed chest drainage time was 5.3±2.6 d, and the postoperative hospitalization time was 7.6±3.5 d. There were no serious postoperative complications. Postoperative pathology reported 31 cases of primary lung cancer, 3 cases of lung metastasis, 2 cases of inflammatory pseudotumor, 1 case of pulmonary isolation, and 1 case of pulmonary aspergillosis. After 1 to 12 months of follow-up, 2 patients with primary lung cancer developed distant metastasis at 6 and 9 months after surgery, respectively, and the rest of the patients had no recurrence or metastasis. 3, Discussion As a minimally invasive procedure rising in recent years, total thoracoscopic lobectomy, with its advantages of large operative field, less trauma, less pain, quicker recovery, and fewer complications, has allowed more patients whose cardiopulmonary function is at a critical value and cannot tolerate conventional open thoracotomy to have access to surgery, and greatly improved patients’ postoperative quality of life. Since Lewis first reported VATS-assisted lobectomy in 1992, the development of thoracoscopic lobectomy has progressed from “decapitated” to “anatomical” and “assisted small incision” to “total lobectomy”. The development of thoracoscopic lobectomy has made two leaps from “beheading” to “dissection” and from “assisted small incision” to “total thoracoscopy”. The difference between “beheading” and “anatomical” lobectomy is that the pulmonary artery, pulmonary vein and bronchial tubes at the root of the pulmonary hilum are not dissected out one by one and ligated and cut off, but rather nailed and cut with a linear cutter, which is a high-risk procedure with many complications. The difference between full thoracoscopy and auxiliary small incision is: ① no need to open the chest to expose the field, all operations are done through endoscopic clamp, electrocoagulation hook, linear cutting and suturing equipment such as endoscopic surgery; ② the operator is no longer through the surgical incision to look directly at the surgical field during the entire operation, but rather look at the magnified surgical field on the monitor screen to complete a series of complex surgical operations, such as separation, cutting and suturing. Lung mediastinal lymph node dissection is an indispensable part of radical resection for lung cancer, and there are still controversies about the thoroughness of dissection and long-term efficacy in China.Naruke firstly reported that total thoracoscopic radical surgery for lung cancer could reach the standard of lymph node dissection of traditional open thoracotomy, and Li Jianfeng et al. believed that the efficacy of total thoracoscopic radical surgery for lung cancer was the same as that of traditional open thoracotomy. We believe that TV thoracoscopy can observe the magnified images of every corner of the chest cavity in close range, and at the same time, with the delicate endoscopic instruments to clear the lymph nodes, lymph node clearance is more thorough and safer than the traditional open thoracic surgery, but the operator must have skillful luminal technique. Combined with the cases in this group, the experience and lessons learned are as follows: (1) Indications for surgery: ① peripheral type lesions, the distance between the lesion and the bulge is >3cm, and the diameter of the lesion is ≤5.0cm; ② mediastinum and hilum are free of enlarged, metastatic and calcified lymph nodes, and there is no dense adhesion in the pleural cavity; (3) lung diseases such as primary lung carcinoma, isolated metastatic tumors, and benign foci, which meet the previous two requirements. (2) Contraindications to surgery: ① central lung cancer, cancer tissue invades important organs such as main bronchus, vena cava and main trunk of pulmonary artery; ② hilar or mediastinal lymph nodes are obviously enlarged and calcified; ③ extensive dense adhesion in the pleural cavity; ④ large foci, with a diameter of >5.5cm and a distance from the bulge of <2cm; ⑤ poor systemic condition, insufficiency in heart, liver, kidney and other important organs, abnormal coagulation function, or those who cannot tolerate one-lung ventilation. tolerate one-lung ventilation. (3) Incision design: according to the size and location of the lesion determined by preoperative CT and luminal microscopy, the size of the incision and the position of the approach can be flexibly adjusted (the main operation port is generally selected as the 4th intercostal space for upper and middle lobectomy, and the 5th intercostal space for lower lobectomy), and the anatomical resection of the lobes of the lungs and lymph node dissection can be conveniently and safely accomplished due to the absence of interference from the thoracotomy apparatus and the advantage of the magnification of the operative field of the endoscopy. (4) The order of operation: generally deal with the order of pulmonary vein, bronchus, pulmonary artery and interlobar fissure, but it is not restricted to the form, with the importance of surgical safety, convenience and thoroughness. If there are more lymph nodes in the hilar region of the lungs and the bronchus is closely adhered, the pulmonary veins can be dealt with first, then the interlobar fissures can be separated, the pulmonary artery can be revealed and dealt with, and then the bronchus can be tractioned in order to expose and clear the lymph nodes, and finally the bronchus can be dealt with. (5) The choice of pulmonary vessels and bronchial treatment: first of all, must be fully dissected and free, and set the line traction to make enough space to put in the Aixilon or Hemolok. pulmonary veins and bronchial tubes are thicker, and generally use the Aixilon (the pulmonary veins choose the white nailing compartment, and the bronchial tubes choose the green nailing compartment) to deal with the safer, more reliable, if the pulmonary veins and bronchial tubes are shorter or difficult to free, resulting in difficulties in the passage of the Aixilon, the use of silicone tubing into the Aixilon. Silicone tube set into the head of the Aixilon in order to guide its passage; pulmonary artery is smaller, more branches, ultrasonic knife is a good choice, but the thicker blood vessels is best to use Hemolok both ends of the clamping cut off, the method of the effect of accurate, inexpensive, can significantly reduce the total cost of the operation, the widespread development of this operation will play a role in promoting. (6) the treatment of accidental hemorrhage: mostly occurs in the use of electrocoagulation hook cauterization, free lymph node adhesion more serious blood vessels, first of all, the operator should be calm, quickly in the mirror with a small gauze pressure, suction to clean up the surgical field, endoscopic pliers, titanium clamps temporary clamping to stop the bleeding, and then use the Aisinosaurus (vein) and Hemolok (arterial) occlusion and separation. After the above treatment can generally be successful hemostasis, do not blindly clamping, cauterization, resulting in blurred field, forced to transit open heart surgery. (6) Indications for intermediate thoracotomy: (1) the thoracic cavity was found to be densely adherent, which could not be separated; (2) the lesion was found to be large, encroaching on the main bronchus, <2 cm from the rupture, or encroaching on the vena cava and the main trunk of the pulmonary artery, which could not be resected under the total thoracoscopic approach; (3) the mediastinal lymph nodes were found to be enlarged, adherent, or calcified, which could not be separated smoothly from the pulmonary artery, pulmonary vein, and bronchus, and so on. In conclusion, the efficacy of total thoracoscopic lobectomy for lung treatment is reliable and technically feasible, with the advantages of safety, minimally invasive and rapid recovery, which is especially suitable for early peripheral lung cancer and benign lesions that require lobectomy. However, it is necessary to strictly grasp the indications for surgery, screen suitable cases, and master the key techniques such as skillful endoscopic treatment of blood vessels and lymph node dissection, and if the operation encounters difficulties that are difficult to be solved, the safety and thoroughness of the operation should be emphasized, and the thoracotomy should be promptly intermediated.