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Page 2 of 8 Alexandre et al. Mini-invasive Surg 2020;4:35 I http://dx.doi.org/10.20517/2574-1225.2020.07

INTRODUCTION
Lobectomy for early stage non-small cell lung cancer has been described in the last decade with a large
[1]
variety of approaches . Open surgery can be performed by an anterior, axillary, or posterolateral incision.
Muscle-sparing techniques have recently been adopted to limit the thoracic trauma. The development of
video-assisted thoracoscopic surgery (VATS) first enabled reducing the size of the thoracotomy, usually
anterior, and is actually limited to the trocar incisions or a single portal approach. More recently, robotic
[2,3]
assisted surgery (RATS) offers better ergonomics as well as three-dimensional imaging . Despite many
papers encouraging clear benefits on pain for minimally invasive techniques, criticism must be made of the
compared surgical open methods, mostly involving non-sparing techniques.

In this paper, we focus on pain, quality of life, and functional pulmonary recovery after lobectomy for early
stage non-small cell lung cancer depending on the surgical technique. This represents an important aspect
[4]
in the rise of patients’ involvement in their own care .

Relevant studies were obtained by searching the PubMed and Uptodate databases until 31 October 2019.
The search terms included “lung cancer” AND “lobectomy” AND “pain” OR “quality of life” OR “pulmonary
function” in the title, abstract, and keywords. Tables 1 and 2 summarize characteristics and operative details
of the cited articles.

PAIN
Pain assessment is subjective and depends on the personal tolerance, culture, and psychological context.
The postoperative analgesia protocol will influence the results. Pain is an important factor because it can
result in hard coughing and mobilization, leading to potential secondary pneumonia. Pain management
after surgery is obviously a basic principle in current medical care. Having pain at the surgery site for more
than two months is considered as chronic pain.

Analgesia can be provided by epidural or para-spinal catheter placed before surgery; inter-costal nerve
block, para-vertebral catheter, or wound infiltration during surgery; and patient-controlled/not controlled
intravenous analgesics, intramuscular, oral, or suppository postoperatively. Catheter analgesics are usually
stopped after removal of the thoracic drain.

The most used questionnaires for pain are the Visual Pain Score, the Visual Analog Scale, and the
[5]
Numerical Rating Scale . In addition, chronic pain can be evaluated by the Pain Detected Questionnaire.
Several studies showed clear benefit on pain from minimal invasive techniques compared to non-sparing
[6]
thoracotomies: a prospective study showed a significant decrease of the postoperative pain at Days 0, 1,
7, and 14 in a VATS group (two trocars with a 7-cm-long anterior incision) compared to a non-sparing
posterolateral thoracotomy group (with one or two ribs resection and no muscle sparing). All patients had
[7]
an epidural catheter. A similar retrospective study showed a significant decrease in the postoperative
pain in a VATS procedure (6-cm anterior access incision and three trocars) compared to an anterolateral
thoracotomy (12 cm long with a section of a costal cartilage but muscle sparing) at the first week after
surgery. That difference disappeared in the second postoperative week. A continuous epidural analgesia was
present for every patient until the third postoperative day.

[8]
A prospective randomized study compared VATS (with three-trocar technique and a 4-cm anterior
utility incision) and anterolateral thoracotomy (16-cm incision) with muscle and rib sparing, every patient
receiving an epidural catheter. They assessed the postoperative pain by Numerical Rating Scale at 2, 4, 8, 12,
26, and 52 weeks and found a significantly lower level of pain in the VATS group during the entire follow-