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Page 8 of 11 Montagne et al. Mini-invasive Surg 2020;4:17 I http://dx.doi.org/10.20517/2574-1225.2019.74
[1]
Minimally invasive lobectomy performed by VATS or RATS is recommended for early stage NSCLC and
the majority of series in this mini-review included stage I NSCLC. Some authors advocate the effectiveness
of VATS and RATS for loco-regionally advanced NSCLC. More and more studies have described the
[50]
effectiveness of a VATS approach for N positive status and combined resection of a lobe, e.g., with the
[52]
[51]
[53]
chest wall , the superior vena cava or a sleeve resection . For stage IIIA NSCLC, a VATS approach
allowed at least the same long-term outcomes compared to thoracotomy, but with better short-term
[38]
outcomes . Extended indications for loco-regionally advanced NSCLC are being explored in robotic
thoracic surgery. With the benefits of improved visualization, stability, dexterity, and accuracy, some
technical aspects of lobectomy, with complete lymph node dissection, are described as easier to perform by
RATS than by VATS [23,54-56] , with no difference in long-term outcomes.
Performing minimally invasive surgery using a digital interface has enabled the use of innovative
techniques and concepts. The first concept is the use of the simulation tool in the technical learning
process. Thus, before performing their first minimally invasive lung resection on a patient, trainee
surgeons are able to train on high definition digital simulators close to the reality of the operating room
and thus improve their technical skills [57,58] . Moreover, with a high-definition CT scanner and 3D modeling,
[59]
it is possible to precisely plan a complex lung resection such as a segmentectomy on 3D representation .
In addition, 3D modeling can be visualized on screen. This augmented reality can be used for liver surgery,
for example, but still requires development for lung resection. 3D augmented reality could be used for
VATS and RATS surgery and even for open surgery, by using specific glasses. The second concept is the use
of safety controls via the robotic platform. Thus, before starting a procedure, security elements are specified
to unlock the robot or even the optics of the VATS column to prevent intraoperative accidents.

The majority of the included studies did not use propensity matching, but included heterogeneous groups
of patients in terms of disease stage, comorbidity, and surgical approaches. This heterogeneity could
potentially mask some results, but reflects “real-life practices in our unit”. As such, this mini-review does
not provide conclusive evidence regarding the superiority of RATS compared to VATS for short-term
outcomes. A randomized controlled trial is required to provide conclusive answers.

CONCLUSION
Robotic lobectomy could be a valid alternative to open surgery, and provides at least the same short-term
outcomes compared to VATS. Based on the findings of recent meta-analyses, lobectomy performed by
RATS compared to VATS could allow lower 30-day morbidity and mortality, but with longer operative
times and higher surgical costs. According to recent reports, robotic technology seems to be a reasonable
alternative to VATS and open surgery. This result must be interpreted with caution, as we cannot exclude
an inherent bias related to meta-analyses. A randomized controlled trial with cost analysis and long-term
follow-up may be useful to understand the role of robotic technology in thoracic surgery for the benefit of
patients with NSCLC.

DECLARATIONS
Acknowledgements
The authors are grateful to Nikki Sabourin-Gibbs (Rouen University Hospital) for her help in editing the
manuscript.

Authors’ contribution
Collected and selected articles: Montagne F, Baste JM
Participated in manuscript, writing and review: Montagne F, Baste JM
Participated in reviewing: Bottet B, Sarsam M, Mbadinga F, Chaari Z, Rinieri P, Melki J, Peillon C