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The role of video-assisted thoracic surgery (VATS) in metastasis lung surgery is debatable. Randomized trials from early-stage lung cancer show that VATS access is superior to open lung surgery in respect to local pain, complication rate, length of hospital stay, recovery time and even long-term survival. There is no reasonable doubt that anatomical resection of single lung metastases by VATS can be offered with the same oncologic results as open surgery. But there is a considerable risk to miss previously undetected nodules when using VATS for the removal of multiple metastases, because through this approach manual palpation of the whole lung is impossible. To overcome this dilemma and increase identification of smaller nodules, maximum intensity projection (MIP) technique and computer-aided detection (CAD) may be used during preoperative computed tomography (CT) scan analysis. The sensitivity of preoperative CT scan is decreased in non-epithelial tumors, smaller main nodules (<5 mm) and with increasing numbers of metastases (>1). Removing deeper lesions by wedge resection is a risk factor for local recurrence at the staple margin. Therefore, VATS should be used for superficial lesions or for anatomical resections that guarantee adequate safety margins. Radical lymphadenectomy is essential for all anatomical resections as well as metastasis of renal cell carcinoma (RCC) and colorectal cancer (CRC). In case of non-anatomical resections, a lymph node sampling should suffice. The use of laser during VATS has not been adequately explored yet, but may provide an alternative for deeper lesions in the future.

Algorithm for the pulmonary metastasectomy based on number of metastases and histology