The future of thoracoscopes

Designs of thoracoscopes have undergone radical transformation on the growing predominance of minimally invasive surgical techniques over the open thoracotomy method for a multitude of thoracic indications. The actualized benefits and remaining challenges identified amongst commercial and experimental thoracoscopes must to be consolidated to formulate a clear direction for further advancement of the field. As such, a review of published literature on thoracoscopes, or more broadly, visualization systems employed in minimally invasive thoracic surgery has been performed. Via PubMed, 46 articles met the inclusion/exclusion criteria for this review. The thoracoscope designs were summarized into seven categories: (I) rigid thoracoscopes; (II) flexible thoracoscopes; (III) miniaturized thoracoscopes; (IV) flexible thoracoscopes for Natural Orifice Transluminal Endoscopic Surgery (NOTES); (V) thoracoscopes embedded in robotic systems; (VI) 3-dimensional thoracoscopes; and (VII) thoracoscopes with intra-parenchymal visualization. The appraisals were made according to the clinical data, experience and feedback from the experimenters within the respective category. The results were then compared across the different categories. Insights gleaned through this review reveal that commercial and experimental thoracoscopes have been making strides to overcome the two major challenges in thoracoscopic visualization: limitations in view maneuverability and misaligned intuition in control. Additional objectivity is required for comparison across the various categories of thoracoscopes to further ascertain clinical evidence regarding surgical performance and post-operative outcomes. Nevertheless, considerable room for innovation exists in tackling these two challenges, which, together, form the fundamental premise for future progression. A paradigm shift, therefore, from the current emphasis on hardware development is paramount to breakthroughs against the aforementioned challenges. The future of thoracoscopes points towards a complementary advancement of both hardware and software designs within visualization systems, with the ultimate ambition of replacing and surpassing the visual experience perceived through the open thoracotomy method.