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Montagne et al. Mini-invasive Surg 2020;4:17 I http://dx.doi.org/10.20517/2574-1225.2019.74 Page 7 of 11

Postoperative complications affect mortality, and major one, as Grades ≥ 3 according to the Clavien-Dindo
classification, have a significant impact on mortality but are rare, with a rate of 4.3% in the multicenter and
[42]
retrospective review published by Cao et al. . This rate was comparable to outcomes of the CALGB 39802
[43]
study, which reported a rate of 7.4% for Grade ≥ 3 postoperative complications after a VATS lobectomy .
In robotic practice, better short-term outcomes were observed after lobectomy by RATS than by open
thoracotomy. However, most meta-analyses reported the same short-term outcomes, with as negative
points longer operative times and more costly procedures compared to VATS lobectomy [13,15,29-31,34-36,44] .
[14]
Only O’Sullivan et al. reported better short-term outcomes with fewer adverse events after lobectomy by
RATS compared to VATS in a systematic review with meta-analysis. Nevertheless, some authors reported
in retrospective studies a clear benefit of RATS compared to VATS. Reddy et al. recently reported a
[45]
propensity-matched comparison of lobectomies by surgeons who performed 20 or more VATS or RATS
procedures annually. With 838 patients in each group, they observed in the RATS group a lower rate of
conversion (4.8% vs. 8%, P = 0.007), a lower rate of 30-day complications (33.4% vs. 39.2%, P = 0.0128), and
no difference in mortality rate, but with longer operative times by 25 min (P < 0.0001). They concluded in
favor of RATS lobectomy for surgeons performing more than 20 procedures annually. One complication
that is less often reported after robotic lobectomy is postoperative anemia requiring blood transfusion.
Indeed, robotic surgery allows performing very precise gestures and in particular elective hemostasis
during hilar dissection and lymph node resection. For example, Adams et al. reported fewer blood
[29]
transfusion after a RATS lobectomy compared to a VATS or open lobectomy (P < 0.05).

[22]
Cost is presented as one of the major drawbacks of RATS . In the current context of resource
management, Gondé et al. conducted a precise assessment of the economic impact of RATS surgical
[46]
innovation compared to VATS. RATS lobectomy was found more expensive than VATS lobectomy, and
median total costs were €10,972 vs. €9637 (P = 0.007). Costs related to length of stay were not different (P
= 0.061), but excessive costs reported in the RATS group were explained by expensive medical devices and
supplies used for RATS lung resection (P = 0.004). Nevertheless, these authors reported a significantly lower
cost of their minimally invasive techniques compared to the mean cost in France (P = 0.001). Conversely,
VATS was found to be a cost-effective alternative compared to thoracotomy in the randomized controlled
[47]
[48]
trial of Bendixen et al. , with a savings of €4267 (P < 0.001). Subramanian et al. reported that, compared
to open lobectomy, RATS lobectomy was 13% more expensive (P < 0.001) and VATS lobectomy 2% less
expensive (P = 0.007). In their report, they analyzed operating room costs and in-hospital costs from
patients operated between 2008 and 2014 in Florida, with data from the Healthcare Cost and Utilization
Project Florida State Inpatient Database. Minimal approaches were also associated with improved clinical
outcomes compared to open lobectomy (P = 0.016), and increased operating room costs were compensated
[49]
by in-hospital savings. Recently, Kneuertz et al. reported a cost analysis performed at their center. They
analyzed data from 697 patients operated by RATS (n = 296), VATS (n = 161), and open (n = 240) for a
[46]
lobectomy between 2012 and 2017 and performed a propensity score adjustment. Unlike our report , and
that of Subramanian et al. , the overall cost - including operating room costs and in-hospital costs - of
[48]
the three approaches were similar: RATS $17,223, VATS $17,260, and open $18,075 (P = 0.48). Nevertheless,
RATS and VATS approaches were associated with higher operating room costs - RATS $9912 and VATS
$9491 - compared to open thoracotomy - $8698 (P = 0.001). Finally, according to their experience, despite
the higher operating room costs calculated for RATS and VATS, it was recovered by postoperative costs
reductions associated with improved postoperative outcomes and shorter hospital stay (P < 0.001). These
three articles [46,48,49] reported higher operating room costs for RATS lobectomy but compensated by
improved outcomes compared to thoracotomy. Nevertheless, RATS will always be more expensive, and
our goal is to reduce this economic gap. Because patients are well prepared and conditioned within the
framework of enhanced recovery protocols, they allow better short-term outcomes for patients operated by
thoracotomy and lead to fewer adverse events, shorter length of hospital stay, and logically cost reductions
for these patients in 2020 compared to patients operated 5 or 10 years ago.