Distant metastases regularly occur in cases of paediatric solid tumours. Overall the most common localisation of metastases is the lung. The correct treatment of lung metastases represents a prognostic factor in most paediatric solid tumours. Guidelines for the therapy of lung metastases are commonly included in the protocols of the different multicentric treatment trials. However, specific surgical aspects are usually not addressed in these protocols. The aim of this article is to present the principles of surgery for lung metastases in paediatric solid tumours. The principles of surgery for metastases of the most common extracranial paediatric solid tumours are presented including aspects of the diagnostic work-up, surgical preparations, and surgical procedures. Special points of interest are discussed focusing on the different entities. Surgery for lung metastases in paediatric solid tumours can be performed with a good surgical outcome regardless of the patients' age. Large numbers of sequelae can be surgically excised. Depending on the localisation sternotomy is an option concerning the surgical approach. Surgery for lung metastases in paediatric solid tumours is a safe method when respecting the principles for the procedure. It has a positive influence on the patients' prognosis. An aggressive surgical procedure may be justified depending on the tumour entity. An interdisciplinary approach including paediatric oncology and radiology is mandatory in any case.

There are only few pediatric surgical centers across the world with expertise for minimally invasive anatomical lung resections in children. Between September 2003 and September 2005, 67 children underwent thoracoscopic surgery at the Department of Pediatric Surgery, University Hospital of Tuebingen, Germany. In 19 of these cases a lung resection was carried out, 8 of them had an anatomical lung resection. All patients underwent general anesthesia without selective intubation for the procedure. Intrathoracic pressure with insufflation of carbon dioxide of 1.5 l / min was held at 3-5 mmHg. Two 5 mm ports for video and instruments and one 12 mm port for a stapling device were used. Resected lung specimens were removed from the thorax through an additional 2-3 cm long incision. A bronchoscopy was carried out during surgery in all patients. Median age at operation was 5.6 years (range 3 months-20 years). Median operation time was 150 minutes (range 94-250 min). Conversion to open surgery was performed in 3 cases. This was due to bleeding in one child, due to a stiff lung in another patient with cystic fibrosis and due to a vascular and bronchial malformation in a third child suffering from middle lobe syndrome. There were no postoperative complications. Our preliminary results show, that thoracoscopic lung resections in children can be performed without major complications and excellent cosmetic results. For the necessity of a conversion to open surgery possible reasons may be insufficient intrathoracic overview as well as congenital anomalies of the vascular and / or the bronchial tract. Co-morbidities such as rib-fusion, deformities of the thorax or scoliosis can be avoided using thoracoscopic procedures.