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similar to those who were operated by an open approach (P = 0.56). Moreover, 30-day mortality was similar
[39]
(P = 0.69). Veronesi et al. reported a multicenter retrospective cohort of patients with stage III NSCLC
and operated by a RATS procedure in seven high volume centers. They reported 223 NSCLC, 32% of which
were diagnosed cN2 preoperatively and 68% intraoperatively. The rate of conversion to thoracotomy was
9.9%, and the rate of Grade 3 and more complications was 10.3%. For patients who received neoadjuvant
chemotherapy, the rate of conversion to thoracotomy was 15%, the rate of Grade 3 and 4 complications
was 12%, and all were resected with R0 margins. Overall 90-day mortality was 4% but no patient who
received neoadjuvant chemotherapy died. Three-year overall survival was 61.2%, while 60.3% in the group
of patients treated by neoadjuvant chemotherapy (P = 0.6).

DISCUSSION
In this mini-review, we compare short-term outcomes between lobectomy performed by minimally
invasive VATS and RATS and lobectomy by open surgery. For several decades, VATS lobectomy has
allowed better short-term outcomes compared to open surgery with at least the same long-term oncologic
outcomes. These results were obtained by systematic review and meta-analysis of retrospective series and
of some randomized controlled trials.

Before discussing the reported results, the common points and differences among RATS, VATS, and open
approaches are clarified. Together, there are three surgical approaches but two surgical feelings and two
resection concepts for lung lobectomy.

Regarding surgical feelings, also called haptic - force and tactile - feedback, compared to open surgery,
VATS allows us to feel each tension exerted on the tissues, because we directly manipulate the tissue,
lung, lymph nodes, and other structures. Conversely, the robotic platform is a robotic device guided by
the surgeon using a digital interface. With the Da Vinci platform, we do not receive sensitive feedback in
our hands. This lack of feedback is one of the criticisms made of this surgical tool. However, “when one
feeling is lacking, we say that another develops”. Thus, surgeons who can no longer rely on touch see their
eyes sharpen, becoming an extension of their hands. With training, they learn and feel the tension exerted
on the tissue by seeing the latter exerted on the tissue, allowing them to exceed this limit. The surgeon
assistants who expose and retract the lung will also help the operator surgeons, because they can feel
the exerted tension on lung by the robot and thus the operator. Nevertheless, robotic surgery industries
are studying haptic feedback, but each robotic system is different, thus each research system is different.
Moreover, it is important to first understand how we perceive force and tactile information, because it will
[40]
affect the way we design haptic displays .

Regarding resection concepts, compared to VATS and the anterior approach - e.g., fissureless technique -
RATS allows us to mimic open surgery techniques. The robotic platform allows thoracic surgeons to perform
a lobectomy, as they would have done using an open approach. Conversely, the fissureless approach in
VATS lobectomy is a necessary adaptation of a surgical technique.

[18]
In 2016, Bendixen et al. published a randomized controlled trial comparing lobectomy by VATS and by
anterior muscle sparing thoracotomy. For VATS, the authors observed less pain on Postoperative Day 1
(P = 0.0012) and during the year after resection (P < 0.0001), as well as better quality of life according to
EuroQol 5 Dimensions (EQ5D) (P = 0.014). Nevertheless, they found no difference between VATS and
thoracotomy for postoperative Grade 3 and 4 adverse events, and quality of life according to the European
Organisation for Research and Treatment of Cancer 30-item quality of life questionnaire (QLC-C30) (P =
[41]
0.13). More recently, the first results of the randomized controlled VIOLET study confirmed better short-
term outcomes after lobectomy by VATS than by open surgery.