Through the minithoracotomy, the surgeon can directly observe the hilum of the diseased lobe, and can dissect the bronchi and vessels using standard surgical instrumentation. We prefer 30-cm-long scissors (model 101-8098-30; Mayo-Harrington; Stille, Sweden) with a backhand grip, holding them upside-down, for sharp dissection (Fig 1, bottom left, C, bottom right, D) and forceps covered with a nonconducting material. As well, lengthy needle holders and forceps are usually used for suturing with synthetic material (Vicryl and PDS-II; ETHICON; Tokyo, Japan), and, especially, long, curved dissecting forceps are our favorite instruments for individually ligating the vessels. Also, coaxial endosurgical instruments may be employed to assist the retraction of the parenchyma during the dissection. Television monitor guidance is variably utilized during the procedure when dissecting an area out of direct view such as the mediastinal lymph nodes, the lower lung ligament, and adhesions. The lower access port established primarily for a thoracoscope is usually used to subsequently introduce the stapler (Endocutter; Ethicon Endo-Surgery Inc; Cincinnati, OH) for pulmonary vascular or bronchial closure, while the stapler can be inserted directly through the thoracotomy if the angle is more appropriate. In general, we use a stapler to completely cut and close the lobar bronchi in the case of standard lobectomy, although we prefer to suture bronchi manually during the course of the segmentectomy. When the intersegmental plane is being cut during segmentectomy or the fissure is absent or incomplete even during lobectomy, direct vision in hybrid VATS is extremely significant. In these cases, the three-dimensional understanding of pulmonary anatomy is crucial to avoid ambiguous procedures. The segmental plane can be stapled, which makes the adjacent remaining portion severely distorted and restricted from full expansion, and therefore we commonly use electrocautery or a combination.10–11 Using a commercially available fibrin sealant (Bolheal; Chemo-Sero Therapeutic Institute; Kumamoto, Japan) that is composed of fibrinogen and thrombin and an absorbable polyglycolic acid felt (Neoveil; Japan Medical Planning Co; Kyoto, Japan), the raw surface of the remaining lung allows minimum or no air leakage following the procedure. The affected lung tissue is wrapped in a surgical bag whenever there is a fear of increased risk of cancer dissemination due to the difficulty of removing it through the small wound. Routinely, the chest is drained using a single chest tube under a water seal, which is put through the incision that was initially established for a thoracoscope.