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Page 2 of 11 Montagne et al. Mini-invasive Surg 2020;4:17 I http://dx.doi.org/10.20517/2574-1225.2019.74

INTRODUCTION
Surgery is the cornerstone of early stage non-small cell lung cancer (NSCLC) treatment, and lobectomy is
[1]
currently the preferred type of lung resection for clinical stages I and II of NSCLC . Minimally invasive
approaches, namely video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic
surgery (RATS), are preferred for early stage NSCLC, and are even recommended for those early stage
[2]
[3]
NSCLC . Robotic thoracic surgery has developed rapidly since the first publication by Melfi et al. in
2002, which reported the first cases of robotic thoracic procedures including five lobectomies.
Thoracic surgery approaches have evolved during the last two decades, as has the way of performing
lung lobectomy, but not its goal. Lobectomy for NSCLC involves two steps, namely lung resection and
complete lymph node resection, according to international recommendations [1,4-12] . Minimally invasive
surgery provides better short-term outcomes compared to open surgery, with fewer adverse events and
shorter length of hospital stay [13-15] . Until recently, many systematic reviews with meta-analyses and large
retrospective databases comparing VATS and RATS lobectomy have provided conflicting results regarding
short-term outcomes.

Our goal in this mini-review is to report the main results of recent systematic reviews and meta-analyses
comparing the short-term outcomes of patients treated by RATS, VATS, or open surgery for lobectomy.

METHODS
PubMed and Web of Science were searched to identify potentially eligible literature up to 1 October
2019 reporting lobectomy performed by open surgery, VATS, or RATS and to collect data on the short-
term outcomes of patients according to each surgical approach. The search items were: “video-assisted
thoracoscopic surgery” OR “VATS”, “robotic-assisted thoracoscopic surgery” OR “RATS”, “thoracotomy”,
“lobectomy”, “lung cancer”, “techniques”, “systematic review” AND “meta-analysis”, AND “national
database”. Only articles in English language were included.

RESULTS
Performing lobectomy: common points and differences between RATS, VATS, and open
thoracotomy
With the advent and the spread of minimally invasive surgery, such as VATS and RATS, the use of open
thoracotomy as the “gold standard approach” has decreased. Thoracotomy includes two approaches:
anterolateral thoracotomy and posterolateral thoracotomy. With both approaches, whenever possible,
a muscle sparing incision is made. To perform lobectomy for NSCLC, a hilar dissection or a fissureless
technique is used. Mediastinal lymph node dissection is done before or after lobectomy. Thoracotomy
is still the main approach to perform lobectomy for early stage NSCLC: between 2010 and 2012, 67% of
lobectomies were performed by open thoracotomy, 26% by VATS, and 7% by RATS, as registered in the
[16]
USA nationwide cancer database .
VATS for early stage NSCLC is now well accepted, with better short-term outcomes [17,18] [Table 1]. With
VATS, a fissureless technique is preferred and mediastinal lymph node dissection is done at the end of the
procedure. Despite the benefits associated with VATS lobectomy, this approach is not universally used for
many reasons. The main reason is the technical difficulty in performing complete hilar, lobar, interlobar,
[19]
and mediastinal lymph node resection according to international recommendations.
RATS offers some advantages compared to VATS. First, structures are magnified with a stable, high-
quality 3D optical instrument directed by the surgeon and not by the surgeon’s assistant. Instruments have
up to seven degrees of freedom due to the Endowrist system. With RATS, lobectomy adheres to oncologic