KARL STORZ LECTURE Thoracoscopy in infants and children: the state of the art Steven S. Rothenberg * Chief of Pediatric Surgery, The Mother and Child Hospital at Presbyterian/St Lukes, Denver, CO 80218, USA It is truly a great honor for me to be here addressing this congress today on the state of the art of thoracoscopy in infants and children. There are a number of reasons for this. BAPS was the first international meeting I ever attended as a resident. That encounter showed me the importance and the strength of the global pediatric surgery community and the impact it could and would have on the treatment for children. It also opened the door to many great friendships and collaborations. But the second is that my career as a thoracic surgeon really started in England during a year fellowship in Liverpool at Broadgreen Hospital, now known as the Cardiothoracic Center for Northern England. It was here that I honed my skills as a noncardiac thoracic surgeon and learned the beauty of chest surgery. It was also where I had my first exposure to thoracoscopy, although this was quite primitive by our standards (today). It consisted of the use of a single rigid trocar and modified cystoscopy equipment with the surgeon looking directly through the eyepiece of the scope. It allowed us to do limited explorations and pleural biopsies in patients with suspected malignancy. However, the combination of the vast open experience and introduc- tion to thoracoscopy allowed me to dream about possible applications for the future and build on the pioneering work of others. For me there has really been a dramatic evolution of pediatric thoracic surgery over the last 10 years which has coincided with my first decade as a pediatric surgeon. In the early 1990s I was focused on devising ways to minimize the trauma on infants and children having to undergo thoracic surgery because of the known morbidity of a major thoracotomy in these patients. This included not only the immediate pain and disability but the long-term sequelae including scoliosis and muscle girdle weakness. To this end I focused on a total muscle sparing technique with preservation of the latissimus dorsi and serratus anterior muscles, a technique I had learned in Liverpool and became convinced was associated with less pain and recovery. As laparoscopy progressed and the equipment improved we started performing more procedures using a video-assisted or VATS technique for evermore complex thoracic proce- dures. We used a combination of a minithoracotomy (4-5 cm) and 2 or 3 ports to perform more complicated lung and tumor resections. However, in truth, these initial procedures consisted of a limited amount of endoscopic surgery and a lot of time trying to look through the minithoracotomy and operate. But as we gained experience and equipment and as the technique improved we were to switch to a completely thoracoscopic approach performing even the most complex procedures through a series of 3- and 5-mm ports, resulting in a marked decrease in morbidity for our patients. One of the initial greatest hurdles we faced was the equipment we had available to us. The development of high- resolution cameras changed all of endoscopic surgery but much of the instrumentation available to us was larger than our patients and ill designed to try and perform many of the fine delicate tasks necessary in pediatric surgery. Initial pioneers such as Brad Rodgers were forced to modify equipment from other disciplines to try and do even the most basic procedures, often under significantly adverse conditions. However, his initial work along with a push in 0022-3468/05/4002- 0002$30.00/0 D 2005 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2004.10.021 Presented at the 51st Annual Congress of the British Association of Paediatric Surgeons, Oxford, England, July 27- 30, 2004. * Tel.: +1 303 839 6001; fax: +1 303 839 6033. E-mail address: steverberg@aol.com. Journal of Pediatric Surgery (2005) 40, 303–306 www.elsevier.com/locate/jpedsurg