Thoracic surgery started the path to minimally invasive surgery over a hundred years ago, with the first thoracoscopic procedure performed by Jacobeus in 1910. Interestingly, these first procedures were performed using a single port approach and were used for diagnostic and minor procedures only. For a long period of time, the progress for minimally invasive thoracic surgery was considerably slow until the early 90s, when video assisted thoracic surgery started to be used for major pulmonary resections. Since then, video-assisted thoracic surgery (VATS) had a widespread use around the world and an ongoing search for a less invasive procedures evolved into uniportal VATS. Now, thoracic surgeons have a variety of choices for minimally invasive thoracic surgery and must be trained in these approaches to keep up with the evolution of the specialty and be up to date with the recommended treatments for diseases needing surgical intervention.The approach chosen by each surgeon is a matter of preference, while keeping in mind certain characteristics specific to the pathology and patient to be treated, the level of training of the surgeon, and the healthcare resources available. As more evidence is collected, the choice for video-assisted procedures, which have currently been proven safe, effective, less invasive and, in general, show good results, will prevail.Keywords: Video-assisted thoracic surgery (VATS); uniportal video-assisted thoracic surgery (uniportal Nowadays, it is not a matter about if a minimally invasive approach is better for patients but rather about which approach to choose to offer the optimal care for every patient. Each approach has its own benefits and which to select must be tailored to the surgeon, patient and disease.VATS is no longer a novelty or a trend, it is wellestablished and possibly the standard of care for many thoracic diseases requiring surgery. It has been proven that it enhances recovery, reduces pain (4), minimizes postoperative complications, and shortens the length of hospital stays (5).Currently, the thoracic surgeon should be able to train for and adopt a VATS approach and the question that is going to be faced is which VATS approach should be adopted. Should it be dealt in a step wise manner beginning with mini thoracotomy, hybrid VATS and then develop a pure VATS approach, starting with three port VATS and progressing through until finally arriving to a uniportal approach? Or should the surgeon select any of the approaches from the beginning and train to perfect it?The purpose of this article is to evaluate the different techniques available for minimally invasive thoracic surgery and the different factors that surgeons should consider in the process of developing any of them. Minimally invasive open chest surgeryMuscle sparring thoracotomy (MST) and hybrid VATS (combines muscle sparring thoracotomy and video assistance) can be included in this group. Both are performed with some degree of rib spreading, representing the major difference with pure VATS. Varying cr...

Video-assisted thoracoscopic surgery (VATS) has experience an exponential growth in lung anatomic resections. Since its beginnings in early 90s with the conventional multiport VATS to the more recent uniportal approach, a continuous search for a less invasive procedure has fueled the development of minimally invasive thoracic surgery. In this sense, subxiphoid uniportal VATS has surge as a uniportal option that avoids damage to the intercostal nerve created in a transthoracic approach. In order for this technique to become as an acceptable choice for lung cancer, oncologic principles must be respected, including a feasible and safe mediastinal lymphadenectomy. Although technically more difficult than other VATS approaches, a complete lymphadenectomy is possible in the hands of expert VATS surgeons through a subxiphoid approach.

The uniportal approach for major pulmonary resections began in 2010 with the first case being performed by González-Rivas and colleagues in La Coruña. Since then a number of teams around the world had being performing hundreds of cases, applying it to more advance and complex cases recently.The technique has been reported to be feasible and reliable with similar results to that obtained in early stage lung cancer lobectomies. The case presented in this article is an example of an extreme condition: very obese patient, strong adhesions, fused lower lobe to the diaphragm and enlarged inflammatory adenopathies that made the procedure very technically challenging. In addition, the surgery was performed during a live surgery event and it was broadcasted to an auditorium. However, the case was successfully completed through a uniportal VATS approach with no complications.