# Role of minimally invasive surgery in paediatric pulmonary metastatic disease

## TL;DR

Minimally invasive surgery is becoming a safer and effective option for treating lung metastases in children, but it has specific limitations and requires careful patient selection.

## Contribution

The paper evaluates the evolving role of minimally invasive surgery in pediatric pulmonary metastasectomy, emphasizing its benefits, limitations, and optimal use based on tumor characteristics.

## Key findings

- Thoracoscopy offers reduced postoperative pain and faster recovery compared to thoracotomy in pediatric patients.
- MIS is most suitable for peripheral nodules and limited disease, but may miss subpleural nodules in chemoresistant tumors.
- Advances in localization techniques have improved thoracoscopic precision, but open surgery may still be necessary in complex cases.

## Abstract

The role of minimally invasive surgery (MIS) in paediatric pulmonary metastasectomy is evolving, reflecting advances in imaging, localisation and instrumentation. Compared with thoracotomy, thoracoscopy offers benefits of reduced postoperative pain, shorter recovery and easier reoperation. However, limitations include anaesthetic challenges in smaller children and lack of manual palpation, which may miss subpleural nodules, which is particularly important in chemoresistant tumours such as osteosarcoma and nonrhabdomyosarcoma soft tissue sarcoma. MIS is most suitable for limited disease, peripheral nodules and histologies where complete manual exploration is unnecessary. Indications depend on tumour type, number and location of lesions, as well as patient stability and institutional expertise. Advances in nodule localization—such as wire or coil marking, fluorescence imaging and radiotracers—have improved thoracoscopic precision. Wedge resection remains preferred for peripheral nodules, with anatomic resection reserved for central or larger lesions. MIS contraindications include extensive disease, inability to tolerate single-lung ventilation or lack of required resources. Optimal outcomes depend on experienced multidisciplinary teams and readiness to convert to open surgery when needed. Overall, thoracoscopy is a safe, effective option in selected paediatric patients, providing therapeutic benefit while minimising morbidity when applied judiciously to tumour biology and disease extent.