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Table 1. Main characteristics of publications related to pain and respiratory recovery after lobectomy
Comparison
First author Published Country Subject Period n Type groups
Kwon et al. [11] 2017 USA Pain (VPS and PDQ) 2010-2014 502 Retrospective RATS vs. VATS
vs. open
Van der Ploeg et al. [12] 2019 The Nederlands Pain (NRS) 2015-2016 57 Retrospective RATS vs. VATS
vs. open
Nakata et al. [23] 2000 Japan Respiratory function Nov 1996-Aug 21 Retrospective VATS vs. open
(arterial blood gaz, FVC, 1997
FEV1 and PFR)
Nomori et al. [24] 2003 Japan Respiratory function (VC 1991-2000 112 Retrospective VATS vs. open
and 6MWT)
Nagahiro et al. [6] 2001 Japan Pain (VAS) and respiratory Jun 1999-Apr 22 Prospective non VATS vs. open
function (VC, FVC and 2000 randomized
6MWT)
Handy et al. [10] 2009 USA Pain (VAS), QOL (SF36) 1998-2007 241 Retrospective VATS vs. open
and respiratory function
(FEV1 and 6MWT)
Bendixen et al. [8] 2016 Denmark Pain (NRS) and QOL Oct 2008-Aug 206 Prospective VATS vs. open
(EQ5D and EORTC 2014 randomized
QLQ-C30)
Nomori et al. [7] 2001 Japan Pain (VAS) and respiratory Aug 1999-Dec 66 Retrospective VATS vs. open
function (VC, 6MWT 2000
and respiratory muscle
strength)
Andreetti et al. [9] 2014 Italy Pain (VAS) Apr 2011-Jan 145 Prospective non VATS vs. open
2013 randomized
VPS: visual pain score; PDQ: pain detected questionnaire; NRS: numerical rating scale; FVC: forced vital capacity; FEV1: forced expiratory
volume in 1 sec; PFR: peak flow rate; 6MWT: 6 min walking test; VAS: visual analog scale; EQ5D: euroQol 5 dimensions; EORTC QLQ-C30:
european organisation for research and treatment of cancer 30 item quality of life questionnaire

up. A comparable prospective study evaluated pain by Visual Analog Scale at 1, 12, 24, and 48 h between
[9]
VATS (three-trocar technique and an anterior access incision of 4 cm) and anterolateral thoracotomy (a
9-10-cm incision) with muscle and rib sparing, showing a significantly lower level of pain for VATS. All
patients benefited from an intercostal nerve block and continuous intra-venous analgesia.

[10]
Mid-term evaluation has been reported with no significant difference in the pain level (using Visual
Analog Scale) at six months between open procedures (thoracotomy with muscle sparing or median
sternotomy) and VATS (a three-trocar technique with an anterior 5-6-cm incision). Although the pain level
was the same, there was a significantly lower consumption of painkillers in the VATS group.

An interesting retrospective study compared RATS, VATS, and posterolateral thoracotomy (PLT) in
[11]
terms of pain from the first to the ninth postoperative day (by Visual Pain Score) and at two months (by
Pain Detected Questionnaire). The RATS consisted in a 4 + 1-port technique while the VATS was a three-
or four-port technique, with an access incision less than 5 cm long. The PLT was mostly serratus sparing
with resection of the sixth rib. Thoracotomies benefited from epidural or para-spinous catheter while
minimal invasive surgery (MIS) had intercostal nerve block and PCA. The study showed no significant
difference for acute or chronic pain between VATS and RATS, but a significant difference between MIS and
thoracotomy starting at Postoperative Day 4. Concerning the chronic pain, no significant difference was
noticed between MIS and thoracotomy.

A similar study also evaluated minimally invasive approaches (VATS and RATS) and anterolateral
[12]
thoracotomy (ALT) at Postoperative Day 1, 3, and 5 via Numerical Rating Scale. All patients benefited from
thoracic epidural analgesia. The RATS used 4 + 1 ports, the VATS three trocars with a 4-cm anterior utility
incision, and the anterolateral thoracotomy was 20 cm long with muscle sparing but no rib resection. There