A thoracotomy incision is traumatic and painful and frequently leaves the patient with a cosmetically unappealing scar. Two percent of thoracotomy patients have incapacitating pain that lasts for more than a year, 4% have upper extremity disability, and 40% have persistent mild to moderate discomfort. Reducing the incision size appears to reduce the trauma, pain, and disability. Endoscopic thoracic surgery appears to accomplish these goals.

Three types of thoracic endoscopic procedures can be performed.

It is essential to obtain a chest computed tomography (CT) scan before performing any form of endoscopic thoracic surgery. This allows three-dimensional operative planning and appropriate positioning of the surgical ports. The most appropriate patients for the thoracoscopic or video-assisted procedure are those whom have had no prior thoracotomy, have a large thoracic cavity, are not ventilator dependent, and are not obese. Lesions most suitable for access through this approach are smaller than 3 cm and are peripherally located. Preoperative pulmonary function testing is very helpful in assisting intraoperative and postoperative management.

Anesthetic intubation management is dependent on the procedure planned. All three procedures may be performed using (a) single-lumen intubation with apnea or CO₂ insufflation, (b) double-lumen intubation, or (c) bronchial blocker. For brief, pleurally-based procedures, apnea may be appropriate. Ventilator-dependent patients may require CO₂ insufflation. Single-lung ventilation by either double-lumen tube technique or bronchial blocker is desirable because it improves intrathoracic visibility, minimizes respiratory motion, reduces pulmonary parenchymal bleeding, and decreases the damage to the lung and the pulmonary vasculature. The greater the complexity of the intended endoscopic procedure, the greater these factors must be realized.