Video-assisted and minimally-invasive open chest surgery—finding the balance

“Everything should be made as simple as possible. But not simpler.”

—Albert Einstein

“Improve is to change. Being perfect is to change often.”

—Winston Churchill

The present Special Issue on “Video-assisted and minimally-invasive open chest surgery—finding the balance” is not published on the idea of open and video-assisted thoracic surgery as competing techniques. On the contrary, it is based on the assumption that whatever the proportion of procedures performed with one technique or the other, indications for both will remain.

In the same line of thinking, the thoughts of Albert Einstein and Winston Churchill shown above should be equally applied to any decided approach.

We start with a historic consideration. I believe that after more than two decades of a surgical innovation which, as expected, went through several additions and changes, it is worthwhile to have a resumed “bird’s-eye view” of its evolution and learning obtained, considered by somebody who has been both, witness and protagonist of it.

Ethical aspects, always of paramount importance in medical practice, have some peculiarities in surgery and deserve special considerations in case of surgical innovations. A specific chapter is devoted to them.

Institutional and societal regulatory bodies, responsible of the authorization to perform surgical procedures, usually place the baseline to habilitation when competence is acquired. Competence is understood as the ability to perform a procedure in a safe, effective and independent way. In fact, patients or anybody of us would like to have something else added to the competence. For example, proficiency.

Proficiency implies two characteristics: one is “efficiency” usually measured in operating time and length of stay as short as possible. The other is “consistency” understood as habit and regularity in performance of a procedure and the absence of outliers’ events. All of this aimed to obtain a sort of gold standard on competence we all know as “mastery”. It also implies two characteristics: Intuitive decision-making and resiliency, which mean to have acquired the capacity to instantaneously resolve either minor or catastrophic adverse events.

An important aspect of this chapter refers on how the patient should be informed about innovative procedures and very importantly, how the training process of young surgeons should be adapted to be certain that trainees effectively understand the process of acquiring competence and efficiency becoming capable to correctly inform their patients about the proposed procedure.

As in any mayor surgical procedure, the possibility of an intraoperative crisis, always exist. We also know that the best way to avoid that situation is by choosing correctly the type of procedure to be used.

In my view, there is some inconsistency not easily understood by some patients in recommending an innovative procedure like video-assisted thoracic surgery followed by the advice that, in case of need, may be necessary to turn to what immediately before had been presented as a superseded technique, that is, opening the chest. A special chapter is devoted to this controversial topic and hence the need for preoperative election criteria.

Assuming that indications will remain for open chest surgery and following Winston Churchill’s thought regarding improvement and changes, it appears useful to include a chapter on open chest surgery evolution along the last several decades, what should be understood nowadays by “standard open chest surgery” and how it fits in a fast-track management process.

Finally, chapters on specific areas of thoracic surgery are included, were experienced thoracic surgeons provide criteria on when, why and how to apply either video-assisted or minimally-invasive open surgery, mainly directed to young surgeons with the objective of avoiding they acquire those criteria through their own experience on patients.

Ricardo A. Navarro, MD