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Alexandre et al. Mini-invasive Surg 2020;4:35 I http://dx.doi.org/10.20517/2574-1225.2020.07 Page 5 of 8

were no significant differences on pain among the surgical techniques; a non-significant benefit for RATS
was noticed.

The technical details for the RATS and VATS procedures are quite similar considering the number of ports
(2-4 for VATS and 4 + 1 for RATS) and the length of the access incision (4-7 cm). The number of ports
[13]
does not seem to impact the postoperative pain . However, thoracotomy techniques greatly vary, with
anterior or posterior incisions, and muscle/rib sparing or non-sparing techniques. Non-randomized studies
usually indicated small and peripheral tumors for MIS, while open procedures were performed for larger
and central tumors.

We can conclude that, in the early postoperative period, minimal invasive techniques or limited sparing
open techniques offer better results with respect to pain compared to large and non-sparing open
techniques. The MIS techniques allow a lighter analgesia protocol. However, the clear benefits on pain from
the MIS seem to disappear in the mid-term postoperative period.

QUALITY OF LIFE
Quality of life is defined by the World Health Organization as “individual’s perceptions of their position
in life in the context of their culture and value systems in which they live and in relation to their goals,
[14]
expectations, standards and concerns” . We focus here on how daily life is impacted by the surgery.

Two questionnaires are mainly used for this assessment: the Short Form 36 Health Survey (SF36) and the
European Organization for Research and Treatment of Cancer 30-Items Quality Of Life Questionnaire
(EORTC QLQ C30) [15-18] . The first one evaluates patients on both physical and emotional component scales
that can be compared to the healthy population. The second one is more focused on the cancer population
and evaluates the impact of the disease and its treatment on the daily life.

[19]
A prospective study described a one-month temporary decrease in quality of life (QOL) functioning scores
(EORTC QLQ C30) after lobectomy, with concomitant increase in pain and dyspnea. The scores return to
baseline at three months postoperatively. Comparing thoracotomy to VATS, significant differences are seen
in favor of VATS in this study. Antero- and posterolateral thoracotomy are comparable for QOL evolution.

However, while improvements in QOL have been demonstrated in a few studies in favor of MIS, there is
[9]
no current evidence supporting its superiority. A retrospective study compared the quality of life between
VATS and open procedures (median sternotomy and muscle sparing thoracotomies) preoperatively and at
six months after the surgery using the SF36 questionnaire. It showed no significant difference at 6 months.
However, in the VATS group, a significant improvement at 6 months is described for bodily pain and
general health compared to the preoperative status. Regarding the open group, a significant worsening is
highlighted after the surgery on the physical functioning, role, and social functioning.

[20]
A prospective study using SF36 every four months after surgery for 12 months showed similar physical
component summary between VATS and thoracotomy during the first 12 months after surgery, with a
mental component summary score worse in the VATS group at four and eight months. Such results might
be explained by the higher expectations by the patients for MIS.

[8]
A quite exhaustive protocol study evaluated two questionnaires [EuroQol 5 Dimensions (EQ5D) and
EORTC QLQ C30] at 2, 4, 8, 12, 26, and 52 weeks after surgery (VATS and anterolateral thoracotomy).
EQ5D questionnaire evaluated mobility, self-care, usual activities, pain and discomfort, anxiety, and
depression. The scores for EQ5D were significantly better during the entire follow up for the VATS group
while there was no significant difference for the EORTC QLQ C30 between VATS and open surgery. The