Conversion to thoracotomy in thoracoscopic surgery: damnation, salvation or timely choice?

Video-assisted thoracic surgery (VATS) is today universally adopted to perform a number of simple and more technically demanding surgical procedures including anatomical pulmonary resection for lung cancer, which are today increasingly performed following an intermediate contrasted period of proven feasibility and strong critics. In fact, the recent evolution of VATS benefitted of significant technological improvements in video-systems and instrumentation, enlarging institutional experiences, accumulation of research data documenting advantages in terms of postoperative pain, morbidity and hospital stay, and equivalent oncological outcomes with open thoracic surgery (1). On the other hand, the possibility to perform more complex surgical procedures in a closed chest as typical of modern VATS continues to stimulate the debate on indications and particularly to raise concerns as to when and how conversion to thoracotomy should be performed.