1, pleural disease (1) pus thorax for acute pus thorax, should be early placement of closed chest drainage tube adequate drainage, for chronic pus thorax must be performed thoracotomy. At present, VATS is mainly used for the treatment of subacute pyothorax (disease duration less than 3 weeks), which can separate the adhesions under direct vision, break the fibrous segregation, completely remove the effusion of pus and moss and necrotic tissues, and promote the lung reopening, and optimal placement of tubes for drainage. Its surgical success rate is 72%-90%, comparable to that of conventional open heart surgery, and it is less traumatic, quicker recovery, and the hospitalization time is significantly shorter than that of the latter. If serious adhesions and difficulty in stripping the fiber plate are found during the operation, it should be promptly transferred to open thoracic surgery. (2) Malignant pleural effusion The traditional treatment for malignant pleural effusion is repeated thoracentesis or closed drainage, which has a short-term recurrence rate of more than 80% and may cause complications such as effusion segregation, pneumothorax, and pus chest. At present, pleural fixation under VATS is used for the treatment of malignant pleural fluid: it can separate pleural adhesions and fibrous septum under direct visualization, and drain the pleural fluid thoroughly; pleural biopsy can be carried out at the same time to clarify the histological diagnosis; and under the premise of guaranteeing a good lung reexpansion, talcum powder can be uniformly sprayed and withdrawn or the pleura can be widely electrocoagulated in the pleural cavity. (3) The incidence of celiac disease is 0.5-2%, the common causes are tumor and trauma, which is secondary to surgical injuries accounted for about 0.5%, and the latter is most common in esophageal surgery (2.9%). The mortality rate of celiac disease is as high as 50% if left untreated. It is usually treated conservatively first, and some patients can recover spontaneously, while the rest need surgery. There is no clear standard on the timing and mode of surgery. Some people advocate that after two weeks of conservative treatment, the drainage flow is still greater than 500ml/d must be operated. Ligation of the chest tube above the diaphragm through the original incision or right-sided open chest used to be one of the main surgical procedures. In recent years, VATS has been used in the treatment of celiac disease. It has a wide field of view and its magnifying function helps to identify the thoracic duct; after identifying the location of the injury, both ends are clamped shut with titanium clips; if the tissue around the thoracic duct is severely adherent or multiple branches are injured, a large piece of the tissue containing the main trunk of the thoracic duct should be ligated above the diaphragm between the singular vein and the aorta; (4) Spontaneous pneumothorax The preferred treatment for spontaneous pneumothorax for a long time has been closed thoracic drainage, but the recurrence rate was 20% and The recurrence rate is 20%, and is proportional to the number of episodes: the recurrence rate of the second and third episodes can be as high as 60% and more than 80%. Although the long-term follow-up results of traditional open thoracotomy show that the recurrence rate is less than 5%, due to the high complications caused by open thoracotomy, doctors usually do not consider surgical treatment unless they have no other choice. Currently, it is widely recognized that VATS can replace open thoracotomy as the gold standard for the treatment of spontaneous pneumothorax. The indications are: recurrent spontaneous pneumothorax, persistent lung leakage >5 days lungs can not be reexpanded, bilateral pneumothorax or accompanied by hemothorax, combined with pulmonary herpes, special occupations (pilots, divers, etc.) or in the lack of medical facilities environment. Commonly used methods include: endoscopic suture cutter (Endo-path) wedge resection, laser or argon (Nd:YAY) electrocautery, electrocautery, endoloop ligation, etc. Most people advocate concomitant pleural immobilization, which consists of (top of the chest) mural pleurectomy, friction, electrocautery, and talcum powder spraying. The results of VATS for spontaneous pneumothorax are less traumatic, less painful, and quicker to recover than open thoracotomy, and the long-term follow-up results are similar to those of open thoracotomy. Secondary spontaneous pneumothorax is mostly seen in middle-aged and old people, most of them are accompanied by diffuse emphysema and different degrees of lung function damage, and it is difficult to reflect the above advantages of VATS. Its treatment should be based on the severity of the primary disease and the patient’s general condition, and surgery should be cautious. 2, lung diseases (1) interstitial lung disease clinical diagnostic methods most of the lack of specificity, only open lung biopsy diagnosis rate is higher, has long been considered the gold standard of diagnosis. Traditionally, a small incision is used to enter the chest, combined with preoperative CT localization to biopsy the suspected diseased lung. The main disadvantage of this procedure is that due to the limitation of surgical incision, it is not possible to perform multi-point biopsy on different lung parenchyma, which affects the positive rate of biopsy and the accuracy of diagnosis. Compared with open lung biopsy, the main advantage of VATS lung biopsy is that it has a wide field of view, which not only can directly explore the lung, mediastinum and wall pleura, but also can take multiple lung tissue biopsies in different parts according to the diagnostic requirements, thus improving the diagnostic positivity rate. In addition, it is less traumatic, with fewer complications and faster recovery. This is especially important for patients with diffuse interstitial lung disease combined with lung function impairment. Most patients with chronic interstitial lung disease can tolerate one-lung ventilation and general anesthesia, and the diagnostic accuracy of VATS biopsy is 94%-100%. (2) Isolated pulmonary nodules are defined as round or oval nodules in a single lung of ≤4 cm, surrounded by normal lung tissue, and not accompanied by enlarged hilar lymph nodes or pulmonary atelectasis. The traditional method for its diagnosis is fiberscopy, which has a diagnostic accuracy of 10% for nodules <2cm in diameter and 40%-50% for those >2cm. Another method is transthoracic needle aspiration biopsy (TTN), which has an overall diagnostic rate of 43%-97% for peripheral nodules, but it still cannot completely avoid complications such as pneumothorax and hematoma of lung tissues, and has a high false-negative rate because of the small amount of tissue obtained. Finally, some patients still need open thoracotomy to make a definitive diagnosis.The indications for VATS in the diagnosis and treatment of isolated pulmonary nodules are: non-calcified pulmonary nodules located in the peripheral part of the lungs or in the subpleura of the visceral layer of the lung fissures, with diameters of ≤3 cm, which cannot be diagnosed clearly with the use of other tests, and lesions with diameters of more than 3 cm should be subjected to open thoracotomy. One of the keys to surgery is the precise localization of the nodule in the lung. After accurate localization of the nodule, a pulmonary wedge resection is usually performed using an endoscopic stapler, and the next treatment plan is decided based on the results of a rapid pathology examination: if the nodule is benign, then VATS ends as a therapeutic surgical procedure; if it is a malignant lesion, the mediastinal lymph nodes need to be further probed, and then a decision is made on whether to perform a standard open thoracotomy or VATS lobectomy, taking into account the patient’s general condition. (3) Chronic bronchitis with emphysema Cooper et al. achieved encouraging results in strictly selected COPD patients who underwent bilateral lung reduction via median sternal incision. In recent years, VATS has been used to perform lung decompression surgery, and some results have been achieved, but there are still controversies about the selection of cases (indications, contraindications), surgical procedures (open thoracotomy, median sternotomy, VATS), methods of cutting the lungs (suture cutters, lasers), unilateral or bilateral, and the evaluation criteria of the surgical results. Selection of surgical indications: With the improvement of surgical techniques, surgical indications are inevitably a process of constant change, and some relative contraindications are gradually changing to indications. At present, the generally recognized indications are stage I, early peripheral lung cancer with diameter less than 5cm, without obvious mediastinal hilar lymph node enlargement and obvious pleural thickening and calcification. Controversial indications: Stage II: central lung cancer not related to lobar bronchus, no obvious calcification of lymph nodes in the aggregate area, lymph nodes in hilar and mediastinal area less than 1.5cm and not fused into a mass and some IIIa patients. There are reports of complex thoracic surgery such as total thoracoscopic sleeve lobectomy, combined chest wall resection, total lung resection, tracheoplasty and partial lobectomy being performed. Wang Jun et al. concluded that 80% of all thoracic surgical procedures can now be performed thoracoscopically. Meanwhile, thoracoscopy can enable patients who are over 80 years old and have contraindications to traditional open-heart surgery such as FEV1<0.8 or FEV1<50% to be operated. So we say that the indications for total laparoscopic surgery are dynamic, and the surgeon rationally chooses the appropriate surgical procedure based on standardized treatment. It can be a total laparoscopic or laparoscopic-assisted completion of surgery, but the current direction should be total laparoscopic lobectomy. (1) Biopsy of mediastinal mass Most mediastinal tumors should be surgically resected, but in some cases, such as clinical diagnosis of suspected lymphoma or preoperative staging of lung cancer patients in order to formulate a treatment plan, it is necessary to take a biopsy of mediastinal tumors or enlarged lymph nodes to determine the nature. For enlarged lymph nodes in the paratracheal and subglottic areas shown on preoperative CT (groups 2, 3, 4, and 7), the diagnosis can be confirmed in most cases by cervical mediastinoscopy. It is simple, safe, effective, and remains the gold standard for evaluating upper mediastinal lymph nodes. Transsphenoidal anterior mediastinotomy allows exploration of the main pulmonary artery window and para-aortic lymph nodes (groups 5 and 6). However, neither of the first two can evaluate the paraesophageal, inferior pulmonary ligament, and hilar lymph nodes (groups 8, 9, and 10).VATS can explore groups 5-10 lymph nodes via the left side, and the entire group via the right side, and can be used as a complementary tool to transcervical mediastinoscopy. VATS is advantageous for the simultaneous exploration of pleural dissemination, intrapulmonary metastases, T4 tumors, and the management of malignant pleural effusions, and in cases of suspected highly malignant tumors, such as lymphoma, where sufficient tissue can be obtained from multiple sites to make a definitive diagnosis. If the biopsy result is negative, VATS lobectomy or open thoracotomy can be performed immediately; if the diagnosis is unresectable malignant tumor or non-surgical disease, local or systemic treatment can be performed at an early stage to avoid unnecessary complications caused by non-radical open thoracotomy (2) Anterior mediastinum Ectopic parathyroid gland Medrano et al. successfully performed VATS ectopic parathyroidectomy in 7 patients. He pointed out that ectopic parathyroid glands must be precisely localized preoperatively on the basis of CT, MRI, and thallium-technetium isotope scans, etc. VATS should be based on this localization and direct resection should be performed rather than extensive exploration. VATS thymectomy for thymic disease is less invasive than open or transthoracotomy and has a wider field of view than a transcervical incision. There have been more reports confirming the feasibility of complete thymectomy by VATS, but they are limited to patients with thymic cysts, some myasthenia gravis, and stage I thymoma. Thoracotomy or sternotomy is mandatory for those with known malignancy or evidence of localized extravasation of the thymoma. When localized extravasation or signs of malignancy are detected during VATS, to minimize the risk of incomplete resection of the thymoma, intermediate open thoracotomy or sternotomy is performed. (3) Middle mediastinum. Bronchial cysts Due to the introduction of the VATS technique, most now recommend surgical resection of all asymptomatic bronchial cysts in adults, and minimally invasive surgery is preferred. Intraoperatively, the cyst should be removed as completely as possible, and fine-needle aspiration and decompression helps to clamp and separate the cyst. When the cyst wall is tightly adherent to important mediastinal structures, part of the cyst may be left behind, but the mucosal layer must be disrupted by means of electrocautery to reduce the recurrence rate. For bronchial cysts with preoperative complications (rupture infection) or CT demonstrating tight adhesions to surrounding tissues, VATS is difficult to perform and standard open thoracotomy is preferred. VATS is safe and effective for bronchial cysts without obvious symptoms, complications and adhesions. (4) Posterior mediastinum Neurogenic tumors Most of the posterior mediastinal tumors are neurogenic, and malignant tumors in adults are rare, so surgery is the treatment of choice. It is now generally accepted that VATS is safe and effective for resection of small, non-invasive posterior mediastinal neurogenic tumors. Contraindications include: tumor diameter >6 cm, intraspinal invasion, consideration of malignancy, and high or low tumor location (beyond the 1st-12th intercostal nerves). Preoperative CT and MRI are routinely performed to rule out intravertebral canal invasion. This dumbbell-shaped tumor accounts for approximately 10% of cases and was once considered an absolute contraindication to VATS, requiring cooperation between a thoracic and a surgical surgeon for one-stage resection of the intravertebral canal and intrathoracic tumor. Hyperhidrosis Palmar or axillary hyperhidrosis is due to overproduction of sweat glands in the upper extremities. Conservative treatment of idiopathic hyperhidrosis is ineffective, and surgical excision or severance of the upper sympathetic chain is the best treatment. Thoracotomy, whether via supraclavicular, subaxillary, dorsal, or posterior lateral incision, is only used in a small number of patients due to the high level of trauma and complications.In 1954, Kux was the first to use conventional thoracoscopic sympathetic chain dissection for the treatment of idiopathic hyperhidrosis, but some surgeons still insist on the use of non-thoracoscopic surgical methods. Compared with conventional thoracoscopy, VATS has a wider field of view, and its magnification and contrast enhancement helps to accurately cut the T2 to T5 ganglion fibers during surgery, avoiding damage to the T1 ganglion (stellate ganglion), as well as separating some of the pleural adhesions, and identifying and severing the varicose nerves (Kuntz’s nerves), thus reducing the rate of complication and recurrence. Regardless of the procedure, compensatory hyperhidrosis is the most common postoperative complication, amounting to 50%-80%. The mechanism is unclear, but most patients have mild, self-limiting symptoms. Advanced pancreatic cancer pain due to advanced intra-abdominal tumors of the pancreas, hepatobiliary and other organs and chronic pancreatitis caused by severe intractable abdominal pain is transmitted through the abdominal plexus, abdominal ganglia and visceral size nerves. Blockade of the abdominal plexus with alcohol injection has a short-lived effect. visceral neurotomy can be performed via intrathoracic VATS. To reduce pancreatic secretion, an additional vagotomy has been suggested. Heller’s esophageal myotomy for cardia was once the classic procedure for the treatment of cardia, but later balloon dilatation has gradually replaced it with the advantages of less trauma and faster recovery. However, long-term follow-up results showed that the long-term symptomatic relief rate of the former was significantly higher than that of the latter, which was 95% and 65%, respectively. In recent years, VATS has been introduced into the treatment of achalasia, but more and more clinical practices have proved that laparoscopy has gradually replaced VATS as an ideal method for the treatment of achalasia due to its good exposure of the esophageal hiatus and the lower esophagus, and no need for one-lung ventilation and entry into the thoracic cavity, which are required by VATS. However, VATS should still be used in a few patients, such as those with esophageal smooth muscle tumors, esophageal diverticula, or those who need to incise the longer esophageal muscularis propria. Benign Esophageal Tumors For benign esophageal tumors, such as smooth muscle tumors and esophageal cysts, the standard surgical treatment is open thoracotomy, which is usually only used in patients with a less clear diagnosis or with progressively enlarging lesions. With the introduction of VATS, early lesions can be removed with fewer complications and satisfactory surgical results.VATS is most effective for smooth muscle tumors with a diameter of 2-5 cm. Contraindications include those who have had a recent mucosal biopsy (especially within 2 weeks) or with other severe esophageal disease. Esophageal mucosal tear is a relatively common complication, mostly due to large tumors, heavy adhesions, or intraoperative malpractice. Intraoperative cooperation of esophagoscopy is useful for localization of tumors less than 2 cm in diameter and for examination of mucosal integrity. VATS was initially used to free the intrathoracic esophagus in conjunction with a standard dissection and neck incision to complete the esophageal resection anastomosis.Depaula et al. were the first to report on esophageal cancer resection exclusively by laparoscopic techniques in 1996. Recently, Luketich et al. reported 77 cases of esophageal resection using combined TV thoracic and laparoscopic techniques. These included 52 cases of esophageal cancer, 19 cases of Barrett’s esophagus with highly abnormal hyperplasia (carcinoma in situ), and 6 cases of esophageal esophageal lesions. Most of the patients underwent preoperative combined TV thoracic and laparoscopic staging and EUS examination to exclude distant metastasis and estimate that the lesions could be resected. The average number of lymph nodes cleared during surgery was 16, the average operation time was 7.5 h, the 30-day perioperative mortality rate was 0%, and the complications were 27%. At a mean follow-up of 20 months, all of the benign lesion group (6 cases) survived. Tumor group (71 cases) survival rate of 81%.Luketich believes that TV thoracolaparoscopic combined resection is technically safe and feasible, compared with conventional surgery, it is faster recovery, shorter hospitalization time, but it is very demanding on the technology and instruments, and still need further research results to confirm whether it is better than conventional surgery. 4, thoracic trauma (1) diaphragmatic injury diaphragmatic injury in thoracic and abdominal trauma, the total incidence of about 3%, it often lacks the typical clinical signs, and combined injuries often mask the presence of diaphragmatic rupture, the misdiagnosis rate of up to 30% or more. This will cause chronic diaphragmatic hernia, and the hernia contents will become incarcerated or strangulated, and even cause death. VATS is not only accurate and safe for diagnosing diaphragmatic injury, but also has a wider field of view than laparoscopy, which can clearly detect diaphragmatic lesions on one side, especially on the right side, and can also diagnose and treat concomitant injuries in the ipsilateral thoracic cavity at the same time, thus avoiding the risk of tension pneumothorax caused by pneumoperitoneum and the risk of diaphragm rupture caused by laparoscopy. Avoid the risk of tension pneumothorax or peritoneal adhesion due to pneumoperitoneum, and MRI is feasible for those who are contraindicated to VATS. Traumatic diaphragmatic rupture should be operated once the diagnosis is clear. Small diaphragmatic rupture can be repaired by VATS, and large diaphragmatic tear or accompanied by abdominal organ injury should be operated by cesarean section at the same time. (2) Coagulative hemothorax Traumatic hemothorax or hemopneumothorax may develop into residual hemothorax in about 4-10% of patients even after closed drainage. It is defined as a pleural effusion that persists after 72h of chest tube drainage, regardless of whether it is infected or not. A small amount of fluid can be automatically absorbed by the body, while a moderate amount of fluid (>500 ml) may become infected and form a pyothorax or further transform into a fibrothorax. Traditional management includes additional chest tube placement or early thoracotomy. The former is less effective and increases the chance of infection, and the latter is associated with high complications associated with thoracotomy.VATS allows for rapid and complete drainage of blood and fibrous clots, identification and management of persistent hemorrhagic points, exploration and treatment of other intrathoracic injuries, and selection of the optimal location for tube drainage under direct vision.(3) Hemothorax, pneumothoraxProgressive hemorrhage, persistent air leakage, and intrathoracic foreign body due to thoracic injuries are the indications for surgical exploration. In cases that meet these criteria and are stable, VATS proves to be a safe and effective method. Bleeding or air leaks can usually be controlled by electrocautery, suturing, titanium clips, or suture cutters. If large vessel injury or main bronchial dissection is diagnosed intraoperatively, immediate conversion to open thoracotomy is often required. 5, Prospect VATS from the initial line of simple intrathoracic diagnostic and treatment operations to the lung, esophageal tumor resection and other difficult surgery only experienced more than ten years of time, which in the clinical application reflects a great superiority and great potential for development, has become an integral part of modern general thoracic surgery. However, at the same time, we should also clearly recognize that this is the result of strict patient selection, clear surgical indications, and proficiency in conventional surgery and VATS techniques. Only by continuing to follow this principle strictly, we have reason to believe that VATS will have a brighter future with the progress of science and the continuous improvement of surgical techniques.