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Page 6 of 8 Alexandre et al. Mini-invasive Surg 2020;4:35 I http://dx.doi.org/10.20517/2574-1225.2020.07

emotional function was the only subgroup where VATS was significantly better than open in the EORTC
QLQ C30.

Robotic surgery was evaluated with the SF-12 questionnaire at three weeks and four months in a
[21]
propensity-matched analysis considering rib and nerve sparing thoracotomies. Patients reported better
QOL scores in the RATS group. In particular, a higher mental QOL score three weeks postoperatively was
noticed. A similar trend was observed for physical QOL without statistical significance. At four months,
there was no difference between the two groups.

The major difficulty concerning QOL assessment is the important interaction between pain and respiratory
function. In conclusion, studies suggest that MIS is non-inferior to thoracotomy in terms of QOL,
and seem to give patients at least a better vision of their health, but larger-scale studies are needed to
demonstrate its superiority.

RESPIRATORY FUNCTION RECOVERY
Pulmonary function is objectively evaluated in the postoperative period by the Vital Capacity (VC) or
Forced Vital Capacity (FVC) and the Forced Expiratory Volume in one second (FEV1). A more practical
[22]
evaluation can also be performed with the 6 Minutes Walking Test (6MWT) . The preoperative
pulmonary function is mandatory to measure its evolution postoperatively. One must keep in mind that
patients who undergo VATS are often selected because they have worse preoperative conditions.

Studies evaluating VATS and non-sparing thoracotomies clearly show superiority for MIS. VATS and
[23]
PLT were compared in terms of arterial blood gas analyses (PaO and PaCO ) at 4, 7, and 14 days after
2
2
surgery and the pulmonary function (FVC, FEV1, and Peak Flow Rate) at 7 and 14 days, as well as at one
year. The VATS consisted in a 6-10-cm anterior access incision with two trocars while the PLT divided the
muscles and two ribs. Only patients from the PLT group benefitted from a continuous epidural anesthesia.
They observed no significant difference concerning the arterial blood gas analyses between the two groups.
Pulmonary testing was significantly better for VATS at Days 7 and 14. There was no difference at one year
[6]
between the two groups. Another study also demonstrated significant benefit for VATS when comparing
VC, FVC, and FEV1 at one and two weeks postoperative between VATS and posterolateral thoracotomy
with muscle division and one rib resection.

VATS and various thoracotomy approaches were compared with the VC parameter measured at 1, 2, 4, 12,
[24]
and 24 weeks after surgery, and the 6MWT at one week . They performed VATS with a 5-6-cm axillary
incision and three trocars, while the thoracotomies always divided the concerned muscles and one or
two costal cartilages (anterolateral, axillary, and posterolateral approach). The lengths of the incisions
were, respectively, 12, 20-25, and 30-35 cm. All patients benefited from a continuous epidural analgesia.
They also noted a clear significant disadvantage in the posterolateral group regarding VC and 6MWT.
VATS, anterolateral, and axillary approaches were not different in terms of VC during the follow-up
while the 6MWT was significantly better in the VATS and anterolateral groups compared to axillary and
posterolateral groups.

[7]
Equivalent results for VATS and anterolateral thoracotomy approaches have been confirmed with no
difference in term of VC, 6MWT, and respiratory muscle strength (measured with the maximal expiratory
[25]
and inspiratory pressure) at one and two weeks after VATS or anterolateral thoracotomy. However,
[9]
other studies have demonstrated the opposite with a significant advantage of VATS in comparison with
anterolateral, muscle sparing thoracotomy, concerning FEV1 and 6MWT at two days and one month after
surgery.