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With advances in diagnostic imaging techniques, small-sized lung cancers are now diagnosed much more often. Lobectomy has been the standard surgical procedure even for small lung for decades. Is it necessary to remove uniformly such a large amount of lung tissue for all tiny cancers? Extended segmentectomy as an intentional lesser resection for a peripheral clinical N0 lung cancer tumor 2 cm or less in diameter in patients able to tolerate a lobectomy, in which the resection line of the lung is placed beyond the burdened segment if required for sufficient margins, requires confirmation of surgical N0 disease by intraoperative examination of lymph node frozen sections. The procedure should be converted to standard lobectomy if the sections are positive. Recently, several reports have suggested that the prognosis after lesser resection in such highly selected patients is no worse than that following standard lobectomy. In addition to preservation of pulmonary function, this lung-saving surgery provides a second chance to patients who have a higher risk of metachronous disease after surviving the first disease. Extended segmentectomy might be an alternative standard surgery for patients with small peripheral lung cancers. However, patient selection with intraoperative pathologic examination and accurate technique with wide lesion margins must be strictly adhered to.

The technique of video-assisted thoracic surgery, a minimum invasive surgical procedure is discussed. The characteristics are as follows: through utility thoracotomy, which is smaller than a card of 54 x 85 mm in size, we carry out the procedures using both eyes-vision with right perspective and palpation with fingers. We use conventional tools besides endoscopic tools, such as ultra-long scissors of 30 cm in length, 26 cm long Péan's forceps, which have 2 groove at the tip that allow one to push the knot. We covered a body of a forceps, while tip and the other end are not covered to allow transmission of the electrostream. We have carried out more than 70% of standard lobectomies with modified lymph node dissection for lung cancer according to this technique under the same quality of operation as conventional open thoracotomy. The procedure did not differ from conventional approach in the operation time and amount of bleeding.