Video-assisted thoracoscopic surgery as redo approach after prior open lobectomy: is it safely feasible?-challenges and pitfalls of a complex surgical technique.

Minimally invasive segmentectomy/lobectomy is an alternative to traditional thoracotomy for the treating lung cancer, offering benefits such as reduced postoperative pain, shorter recovery times and improved cosmetic outcomes. However, its feasibility in patients with a history of prior thoracotomy remains debated due to potential pleuro-parenchymal adhesions, scarring and hilar fibrosis with altered anatomy, which may increase the complication rate. This paper addresses some technical considerations about redo video-assisted thoracoscopic surgery (VATS) major lung resection in patients with a history of thoracotomy. We describe the preoperative planning, anesthetic preparation for these cases, and a step-by-step description of the surgical strategy used in our center. Moreover, we discuss principles for postoperative care and follow-up, with specific attention to managing complications. The main concerns in redo cases are about the higher rates of postoperative bleeding and prolonged air-leaks, often associated with mobilizing dense adhesions and scar tissue during surgery. Redo VATS major lung resections following a prior thoracotomy offer substantial advantages in terms of reduced morbidity and faster recovery, but also present challenges related to adhesions, compromised anatomy and patient-specific factors. The decision to pursue this approach is made on a case-by-case basis, weighing the patient's overall performance status, challenges posed by the prior surgery and the surgeon's expertise.