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Dolan et al. Mini-invasive Surg 2020;4:40 I http://dx.doi.org/10.20517/2574-1225.2020.17 Page 5 of 10

contention remains whether VATS is equivalent in terms of safety, lymph node evaluation, and outcomes to
[32]
open thoracotomy .

Perioperative outcomes
Contemporary studies have demonstrated equivalent or better perioperative outcomes for VATS and
[33]
RATS [33-36] . Huang et al. performed one of the earlier studies that called attention to VATS treatment
in locally advanced NSCLC. They reviewed 43 patients with Stage IIA-IIIB per UICC 7th edition staging
who underwent neoadjuvant therapy from 2006 to 2012 and proceeded on to VATS. Overall, 97.7% of the
patients’ resections were completed VATS. Blood loss was 253.57 ± 117.08 mL for 28 lobectomies, 5 double
lobectomies, 5 wedge resections, 4 pneumonectomies, and 9 sleeve resections. No perioperative deaths were
reported. While this study lacked a comparison group, the overall conclusion was that VATS was safe and
[34]
[33]
feasible in this group of patients . Park et al. soon followed up on this report with a 428-patient study,
397 thoracotomy vs. 17 RATS and 14 VATS (referred to as MIS collectively), who had been diagnosed as
clinical Stage II and IIIA and underwent surgery after induction therapy. From 2002 to 2013, they noted a
conversion rate from MIS of 26% with R0 resection rate of 97% MIS vs. 94% open (P = 0.71). Complications
were similar between groups at 32% and 33% (P = 0.99), with more of the open complications related to
the cardiovascular system, 11%. Four perioperative deaths were noted in the open group with none in the
MIS group. Median length of stay was 4 days in MIS vs. 5 days in open (P < 0.001). This allowed them to
[35]
[34]
conclude that perioperative outcomes for MIS were equal or better than open surgery . Veronesi et al.
built on this and, similar to Huang et al. , focused on RATS for locally advanced NSCLC. In total, 223
[33]
patients were retrospectively collected from multiple international sites who were diagnosed as Stage III
preoperatively or intraoperatively. They divided the groups into neoadjuvant (15%), adjuvant (63%), and
no neoadjuvant/adjuvant treatment (22%). Overall, 10.3% of patients experienced Clavien-Dindo Grade
III-IV complications with no difference noted between groups (P = 0.14). Overall, 9.9% of cases were
converted large tumor size and > 2 positive lymph nodes significantly associated on univariate analysis,
which did not carry over to multivariable analysis. Mean hospital length of stay was 5.3 days (P = 0.641) .
[35]
[36]
Lastly, Gonfiotti et al. reported their retrospective review of the Italian VATS Group database, including
3720 early stage patients and 454 locally advanced stage patients who all underwent VATS. They defined
locally advanced as cT2b to cT4 in the 7th edition staging and/or received neoadjuvant treatment. They
noted a lower estimated blood loss for the advanced stage patients at 169.44 ± 63.69 mL than prior studies
but greater than early stage, 186.69 ± 69.65 mL (P = 0.038) [31,34] . Conversions were more common in the
advanced stage group (13.0% vs. 9.3%, P = 0.018); however, bleeding was more commonly the reason for
the early stage group, 33.4% (102), while tumor extension was the predominant cause for locally advanced
tumors, 25.4% (15). Complication rate was higher in the locally advanced group which was significant,
37.0% vs. 30.4% (P = 0.040). Thirty-day mortality was not significantly different between locally advanced
vs. early stage, 1.5% vs. 1.6% (P = 0.880), nor was length of stay, 7.96 ± 10.10 vs. 7.35 ± 29.39 (P = 0.660) .
[36]
Taken together, these data indicate that perioperatively the outcomes for MIS methods, including for locally
advanced NSCLC, is safe with equivalent or better perioperative outcomes.

Lymph node evaluation
[37]
Tian et al. focused on lymph node evaluation after neoadjuvant treatment with VATS compared to
thoracotomy. For 127 patients, 56 VATS and 71 open from 2000 to 2016, they did propensity matching
between the two surgical groups to get 28 pairs to evaluate the sufficiency of mediastinal lymph node
dissection between VATS and open. All cases were lobectomies or larger resections. They found no
difference in the completeness of resection (P = 0.611), but a nonsignificant difference in adequacy of
mediastinal lymph node dissection. The guidelines they quoted required evaluation of three hilar and
interlobar lymph nodes and three mediastinal lymph nodes from three stations. They noted that 60.7%
of the open cases did not meet this guideline while 75.2% of VATS cases did. Most importantly, however,
when the lymph node numbers and stations sampled were compared, there was no statistically significant