Costotomy and "hand inside": a useful adjunct to video-assisted thoracic surgery or just a silly idea?

We report on our first experiences with an access in video-assisted thoracoscopic surgery (VATS) which to the best of our knowledge has not yet been reported. One of the main problems in VATS is the absence of palpation which evidently plays an important role in tumor surgery. In three cases we therefore performed dorsolateral 8 cm incisions just beneath the scapula and resected a corresponding length on 6th or 7th rib to be able to insert one hand into the thorax. No rib-spreader was used in either case, the idea being that a small costotomy would be less painful and traumatic than a standard posterolateral thoracotomy. Visualization of the operative field was obtained by inserting a camera through the 9th intercostal space, one or two additional small incisions were made for the other instruments.