Laser pulmonary metastasectomy by video-assisted thoracic surgery

Indications and surgical approach for pulmonary metastasectomy remain controversial as randomized clinical trials are lacking to validate its effectiveness. To this end, non-anatomical lung wedge resection, widely performed by staplers, persists as preferred surgical procedure. With the advent of new technologies, laser assisted surgery evolved and has been advocated mainly for multiple pulmonary metastases in open surgery fashion. However, video-assisted thoracic surgery (VATS) laser pulmonary metastasectomy has been rarely reported. This review is based on a selective search of the PubMed database for articles that were published from 1990 to 2018 and contained the keywords ‘laser assisted surgery’, ‘pulmonary metastasectomy’, ‘thoracoscopic laser metastasectomy’, and ‘VATS’. No prospective clinical trial has been performed to provide evidence whether to treat pulmonary metastasis with laser or conventional techniques. According to retrospective cohort studies and descriptive series, open approach laser assisted surgery facilitates the resection of a higher number of metastases, sparing healthy lung parenchyma, while obtaining similar recurrence rates compared to conventional staplers. In central lesions, optimal surgical margins can be achieved around the lesion avoiding injury to deep located structures such as major vessels or bronchus. However, evidence about thoracoscopic laser pulmonary metastasectomy is remarkably poor consisting in only a few small series of patients with one or two resected metastases. Laser assisted pulmonary metastasectomy is safe and effective. Video-assisted laser resection of lung metastases is a marginal technique to date. Postulated benefits of open laser assisted pulmonary metastasectomy could not be assumed by thoracoscopic approach with available data. Further studies are needed to demonstrate whether multiple and centrally lesions could be effectively resected by thoracoscopic laser metastasectomy.