Contemporary Video-Assisted Thoracoscopic Lobectomy for Early-Stage Lung Cancer

Abstract

The treatment of non-small cell lung cancer (NSCLC) has evolved tremendously in recent decades as innovations in medical therapies advanced concomitantly with minimally invasive surgical techniques. Despite early skepticism regarding its benefits, video-assisted thoracoscopic surgery (VATS) techniques for the surgical resection of early-stage NSCLC have now become the standard of care. After being the subject of many studies since its inception, VATS has been shown to cause less postoperative pain, have shorter recovery time, and have fewer overall complications when compared to conventional open approaches. Furthermore, some studies have shown it to have comparable oncological outcomes, though more higher evidence studies are needed. Newer technologies and improved surgical instruments, advancements in nodule localization techniques, and improved preoperative staging procedures have allowed for the development of newer, less invasive techniques such as uniportal VATS and parenchymal-sparing sublobar resections, which might further improve postoperative rates of complications in specific cases. These minimally invasive approaches have allowed surgeons to offer surgery to high-risk patients and those who would otherwise not tolerate conventional thoracotomy, though some relative contraindications still exist. This review aims to describe the evolution of VATS lobectomy, current techniques, its indications, contraindications, preoperative testing, benefits, and outcomes in patients with stage I and II NSCLC.

Introduction

Lung cancer is the leading cause of cancer death in the United States and worldwide.¹ Non-small cell lung cancer (NSCLC) is the most common subtype, accounting for about 85% of all lung cancers.² The medical treatment of NSCLC has evolved tremendously in recent years with the discovery of novel therapeutic targets triggering advancements in the development of pharmaceuticals. However, surgery remains a cornerstone in the treatment of early-stage NSCLC and has also seen great advancements in the past several decades. Most notably there has been a shift in practice patterns toward minimally invasive approaches with the widespread adoption of video-assisted thoracoscopic surgery (VATS) as the standard of care for lung cancer resection.

In the wake of novel techniques for laparoscopic surgery, VATS quickly became an attractive minimally invasive alternative for thoracic surgeons in the early 1990s. By using videoscopes and modified instruments, surgeons can treat a variety of thoracic pathologies via small incisions, sparing patients from the large incisions and painful rib-spreading associated with conventional approaches, including thoracotomy and median sternotomy.³ The benefits of VATS were immediately apparent in the treatment of a variety of thoracic pathologies, with surgeons reporting a reduction in patients’ postoperative pain, shorter hospital stays, and faster recovery.^4,5 However, many were initially hesitant to apply VATS techniques for lung cancer operations as it was believed to restrict the adherence to the well-established principles of oncological surgery.⁵

The first VATS lobectomy was performed in October of 1991 by Roviaro and colleagues. In their case published in 1992, they described a successful videoendoscopic right lower lobectomy in a 71-year-old male with a right lower lobe adenocarcinoma.⁶ Several case series describing VATS lobectomy closely followed, confirming the observed benefits of VATS over conventional techniques and demonstrating it was a safe and feasible alternative for early-stage NSCLC.^4,7–9 Since then, the procedure has continued to evolve. Technological advancements have helped optimized VATS procedures, making them safer and helping expand their application.¹⁰ For example, in some of the first cases of patients undergoing VATS lobectomy for lung cancer resection, additional concomitant procedures such as mediastinoscopy or mediastinotomy were required for the completion of mediastinal lymph node dissection, a crucial part of oncological surgery.^5,7,11 However, advancements in thoracoscopic cameras and equipment yielded safer dissections, allowing for mediastinal lymph node dissection to be performed concomitantly with primary tumor resection via VATS.⁸ Since its inception, numerous studies demonstrating the favorable surgical and oncological outcomes of VATS have been published, which has led to more wide-spread adoption of the technique and its acceptance as the current standard of care.^12–14 This review aims to describe the evolution of VATS lobectomy and its role in the surgical treatment of early-stage (stage I and II) NSCLC, its indications, contraindications, technical aspects, and outcomes.

Indications for VATS Lobectomy

Current guidelines recommend a multidisciplinary team approach to determining the appropriate treatment strategy for each patient, considering tumor characteristics, disease stage, and patient risk profile.¹³ The indications for VATS lobectomy are generally the same as those for conventional lobectomy via thoracotomy. Upfront curative-intent resection is indicated for patients with known or presumed early-stage NSCLC, namely stages I and II as described by the 8th edition of TNM staging classification for lung cancer published by the American Joint Committee on Cancer.^13,15 Tumors should be completely resectable without mediastinal node involvement observed on preoperative workup, and patients must be considered medically operable.^16,17 For smaller, peripheral tumors, the decision between lobectomy and lesser resection should be individualized based on patient factors (such as age, comorbid conditions, and lung function), anatomical tumor location, and surgeon experience. For larger or more central tumors, lobectomy remains the standard of care.

Preoperative risk assessment with pulmonary function tests and cardiac evaluation is a crucial aspect in identifying surgical candidates, but one of the major advantages of using a VATS technique for lobectomy is that it can be performed in those with higher surgical risk profiles who would otherwise not tolerate traditional thoracotomy approaches.^17,18 Therefore proper staging becomes increasingly more important in determining appropriate surgical candidates. Determining the presence of metastasis to mediastinal lymph nodes is crucial in determining optimal treatment strategies. This is done as part of the initial lung cancer workup by means of imaging and follow-up sampling procedures in some cases. Nodal involvement has profound effects on patient prognosis and those with more advanced stages should not be offered surgery as an initial treatment modality, if at all.^13,19

Contraindications

In general, there are no absolute contraindications to VATS lobectomy. Prior to surgery, patients should undergo testing for risk stratification in an effort to mitigate intraoperative complications and determine which individuals will have anatomy or comorbid conditions that could affect a VATS approach.^20,21 By performing thorough preoperative evaluations surgeons can plan a safe resection based on the individual patient characteristics, the technical components of the case, and the radiographical appearance of the target lung. Typically this includes combined positron emission tomography and computed tomography imaging (PET-CT), endobronchial ultrasound (EBUS) lymph node staging (unless it is a peripheral T1 lesion), and pulmonary function testing.²² There is some evidence that patients with poor lung function have better outcomes with a VATS approach versus open thoracotomy.²³

Initially, VATS was considered an unsuitable approach in individuals who had undergone prior ipsilateral thoracic surgery, had been treated with induction chemotherapy, or had an endobronchial mass.²⁴ These criteria have been challenged with time and technical advancements, in concert with the development of higher resolution preoperative imaging.^10,25 However, there remain a number of anatomical criteria that do present a relative contraindication to VATS. An inability to achieve an adequate resection with VATS will render it an unfavorable technique. Relative contraindications for VATS also include T4 tumors and large specimens that are not able to be removed without rib spreading or a thoracotomy.²⁶ Although some have suggested a tumor size cutoff of 4 cm, there is no definitive size that precludes VATS resection.²⁵

Anatomically, an inability to enter the pleural space due to severe adhesions or pleural symphysis will naturally preclude a VATS approach should the surgeon appreciate an inability to safely complete a lysis of adhesions.²⁷ Fusion of fissures or incomplete fissures will present a challenge in dissection but do not preclude VATS as long as the pulmonary vasculature and contributing bronchus is divided prior to fissurectomy.²⁷ VATS also represents a viable tool in the resection of tumors involving the chest wall, as it can be used to complete the lung resection and also assess appropriate margins prior to thoracotomy and chest wall resection.²⁸ Tumors that are adherent to the vasculature, central tumors, and induction radiation may present technical challenges but are in and of themselves not absolute contraindications to VATS as long as the surgeon feels technically able to offer a patient a safe and complete oncological resection.²⁸

Preoperative nodule localization

Improved protocols in lung cancer screening have led to the detection of lung cancer at earlier stages, when the lung lesions are still small and may be difficult to localize at the time of VATS. When planning a lobectomy, there is not a mandate to palpate the tumor prior to resection, as resection will be guided by the anatomical constraints of the involved lobe. As described earlier, small peripheral tumors may be treated effectively with a sublobar resection, which requires that the lesion can be accurately located at the time of surgery to ensure adequate resection. Earlier detection has made the intraoperative localization of these lesions increasingly challenging, especially when the lesions are deep in the lung parenchyma and with the limited ability for surgeons to palpate during VATS procedures to localize nodules intraoperatively. In some cases of early-stage NSCLC, there may be minimal solid or palpable components. In fact, inability to localize nodules is the reported cause for conversion to open thoracotomy in over half of VATS cases.²⁹ Furthermore, inability to localize nodules can make obtaining adequate resection margins increasingly difficult, potentially compromising oncological outcomes. Hence several operative adjuncts have been developed to facilitate the intraoperative localization of lung nodules. These adjuncts include a variety of preoperative interventional procedures using implants or dyes to mark nodules, intraoperative radiographical adjuncts such as fluoroscopy or EBUS, and newer tumor-targeting intravenous dyes administered preoperatively.

Hookwires are the oldest localization technique with a nodule localization rate of up to 98%.³⁰ These are typically placed percutaneously under CT guidance, but because a portion of the wire remains extracorporeal after placement, they are uncomfortable for the patient and are at risk of becoming dislodged at any point in the perioperative period, with dislodgment happening in up to 13% of cases.³¹ Additionally, this technique has the highest rates of pneumothorax and hemorrhage when compared to others.³⁰ In contrast, microcoil or fiducial placement, which are also implanted percutaneously under CT or bronchoscopic guidance, is more comfortable for patients and has a similar localization rate of up to 98.4%.³⁰ However, they require use of intraoperative fluoroscopy with a C-arm for intraoperative localization, exposing the patient and operating team to radiation. Microcoils can also migrate in 3%–10% of cases or embolize, with significant clinical sequelae.³⁰ Additionally, they also carry risk of hemorrhage and pneumothorax, and their application is limited by nodule location.³²

Injectable solutions such as contrast medium, dyes, and radiotracers have also been used for lesion marking. Contrast mediums such as barium and lipiodol can be injected directly into the nodule and can be visualized intraoperatively with use of fluoroscopy. But, as previously described, use of a C-arm increases radiation exposure. Additionally, barium can cause a local inflammatory response that can affect the pathological diagnosis after resection.³² Dyes such as methylene blue have been used for visual detection intraoperatively, sparing the patient and operative team from additional radiation, but the dye diffuses rapidly into the surrounding parenchyma and requires nodule marking to be done immediately prior to resection.³² Finally, injection of a gamma-emitting radioisotopes as radiotracers can guide surgeons in detection of lung nodules by use of a gamma ray detecting probe intraoperatively. However, this technique also increases radiation exposure and is highly operator and facility dependent.^30,32 As tumor-targeting therapies have evolved in recent years, newer dyes have been developed for use in intraoperative molecular imaging (IMI). IMI consists of using a dye composed of a tumor-targeting component bound to a fluorophore that emits fluorescent light when exposed to near-infrared (NIR) light. The dye is injected preoperatively and binds to tumor cells in the lung parenchyma. Specialized camera equipment is then used intraoperatively to emit NIR light and simultaneously detect the fluorescent light emitted by the tumor-bound dye. This allows the surgeon to localize the nodule intraoperatively and determine appropriate resection margins. Additionally, the use of microscopes with similar technology to analyze the extracted specimen during surgery can help in determining if the margins are free of disease in real time.³³

To minimize procedural risks related to preoperative nodule marking, less invasive techniques such as electromagnetic navigation bronchoscopy (ENB) have gained popularity in high-volume centers. In short, ENB combines uploaded CT images and real-time bronchoscopy to reconstruct a virtual bronchoscopy with a 3D map and intended navigational route to guide clinicians to target lesions real time. A locatable probe is used to advance further into distal airways where conventional bronchoscopy cannot, allowing for biopsy or dye injection into peripheral lung nodules that were previously identified on imaging.^30,32,34 The use of ENB is safe and effective with reported rates of pneumothorax and bleeding of 2% and 1%, respectively.^32,34 The procedure can also be done in the operating room just prior to resection and it allows for additional procedures to be performed at the same time, including EBUS-guided fine-needle aspiration (EBUS-FNA), if needed.^30,32 Several other nodule localization and biopsy techniques are currently in development and are expected to improve rates of intraoperative nodule localization while minimizing procedural risks to patients.

Operative Techniques for VATS Lobectomy

There is no single standardized approach to VATS lobectomy. The surgical principles of lobectomy remain consistent to the original approach described by Blades et al. in their original description of the individual ligation technique.³⁵ As the procedure gained popularity in its early days, surgical techniques evolved considerably, and a variety of approaches have been described in the literature. The procedure’s evolution has been largely due to the development of more advanced technologies that have facilitated improvements in camera equipment and surgical instruments, consequently improving efficiency and safety within the limited operative field of VATS. Most of the techniques described differ in number of ports used and their anatomical positions, which is largely dictated by surgeon preference or tumor location. However, the surgical principles of VATS lobectomy are the same regardless of the techniques used. Importantly, avoidance of rib spreading is one of the defining aspect of VATS as it reduces trauma to the intercostal neurovascular bundles and helps mitigate postoperative pain.¹⁶

In general, VATS lobectomy requires single-lung ventilation and anesthesia by use of a dual-lumen endotracheal tube or bronchial blocker.^3,36–38 The patient is placed in a lateral decubitus position (some recommend a slight posterior rotation so that the anterior axillary line is presented towards the ceiling), with slight flexion of the hips to allow for improved thoracoscopic access by splaying the ribs and widening the intercostal spaces.³ The use of a 5 mm or 10 mm 30-degree angled endoscope and angled instruments for dissection and retraction is recommended to allow for panoramic visualization and to decrease collisions between instruments in the limited working space.^3,38 The procedure can be performed with anywhere from one to four ports, with specific anatomical locations chosen to optimize angles for retraction while allowing sufficient degrees of freedom for ease and safety of dissection while minimizing instrument fencing.^3,38 Port location will also depend on the intended total number of ports to be used during the procedure.

Multiport technique

Most VATS lobectomies are performed via multiple ports as it provides flexibility in instrument positioning to achieve more angles for retraction and dissection. An initial incision for the camera port is usually made at the 7th or 8th intercostal space in the mid-axillary line. A thoracoscopic sleeve port is used in this incision for ease of entry and manipulation of the endoscope, but it is generally not used in other working ports as it limits the instruments that can be used and applies increased pressure on adjacent intercostal nerve bundles with instrument manipulation.³⁸ Once multiple port incisions have been created, it may be useful to reposition the camera between ports to improve visualization for different portions of a lung resection. Unlike in laparoscopy, the rigidity of the chest wall dictates that carbon dioxide insufflation is not necessary for VATS surgery. It may have a role in facilitating initial exposure, although care must be taken to minimize the associated increase in intrathoracic pressure to avoid decreased venous return to the heart and associated hypotension.

Once the endoscope is introduced through the first access incision, subsequent incisions are made under direct visualization, which helps the surgeon select optimal port placement based on patient-specific anatomy. When obtaining access into the thoracic cavity, it is important to start with the minimum number of incisions necessary to allow for an initial thoracoscopic exploration. Only after confirming the location of the tumor and ruling out evidence of unresectable disease should additional incisions be made to proceed with resection.^3,38 In a three-port technique, a second 1–2 cm incision is generally made anteriorly at the 5th or 6th intercostal space. After inspection of the hilum, a third “utility” incision measuring 4–6 cm is made starting at the anterior border of the latissimus muscle and extending anteriorly at the intercostal space closest to the level of the upper lobe vein for upper lobectomies, or one intercostal space below for middle and lower lobectomies.³⁸ It is useful to place a soft tissue spreader such as the Alexis wound retractor (Applied Medical Corporation, Rancho Santa Margarita, CA, USA) through this utility incision, which greatly facilitates the simultaneous use of multiple instruments through this incision. An optional fourth incision over the auscultatory triangle can be helpful for those with limited VATS experience as it provides additional freedom of movement, another point of retraction, and a direct axis approach to all hilar structures.³⁸ In a two-port technique, the camera port is maintained and the anterior incision is made just posterior to the breast or pectoralis major muscle extending about 4–6 cm. At this anatomical location the intercostal spaces are widest, allowing sufficient space for dissection and specimen retrieval regardless of the target lung lobe.³

Uniport technique

The association between minimally invasive approaches and improved postoperative outcomes has pushed surgeons to further reduce operative trauma. The development of thinner, more advanced instruments made a single-port or “uniport” technique possible with placement of the scope and instruments through a single incision in one intercostal space without significant fencing.^39–44 The uniport technique was initially used for simpler diagnostic and therapeutic procedures such as lung biopsies and treatment of spontaneous pneumothorax, which did not require extensive dissection. However, Gonzalez and colleagues reported using a uniport approach for lower-lobe VATS lobectomy in a case report published in 2011.⁴⁰ The technique has subsequently been employed for upper and middle lobectomies without compromising hilar exposure or procedural ergonomics.^42,43 The incision is typically about 4 cm in length at the 4^th or 5^th intercostal space at the anterior axillary line.⁴² As described previously, this anatomical location is where intercostal spaces are widest, maximizing room for instruments and specimen extraction. Notably, this technique has also been facilitated by advancements in endostaplers, which have ushered in thinner, more efficient versions with articulations allowing for larger flexion ranges to achieve difficult angles even within the confines of a uniport approach.⁴⁴

A technical principle that improves instrument ergonomics is keeping the camera positioned at the posterior portion of the incision and introducing the working instruments and staplers through the anterior portion of the wound, with the assistant and surgeon both positioned in front of the patient.^45,46 With this technique, the trocar sleeve is not utilized. Instead, some surgeons will use an anchoring suture on the chest wall, wrapped around the scope to help the surgical assistant maintain the camera position during the case.⁴⁵ Overall uniport VATS is a technically challenging approach given the limited dissection angles, space constraints, and restrictions in instrument selection. However, postoperative outcomes may be improved with this technique. A metanalysis published in 2021 looked at 20 studies, including 2 randomized controlled trials (RCTs), and showed that patients who underwent uniport VATS had less postoperative pain, shorter chest tube duration, and shorter length of stay when compared with those who underwent multiport VATS.⁴⁷ Additional studies have shown reported significantly shorter operative times as surgeon experience increases.^48–50 Although more evidence is needed to fully evaluate the oncological outcomes of uniport VATS, studies have shown the number of lymph nodes resected with this technique is the same as that in multiport VATS.⁴⁷ Furthermore, some studies have published favorable short-term and mid-term oncological data after uniport VATS, which are comparable with those of traditional thoracotomy and multiport VATS technique.⁵¹ Two-year disease-free survival and overall survival rates vary depending on disease stage, but for those with stage 1 disease they have been reported to be as high as 96% and 100%, respectively.^52,53 Based on these findings, uniport VATS has been recommended by some as the preferable technique over conventional approaches and multiport VATS.⁴⁷ Ultimately, the number of ports used will largely depend on surgeon comfort level, as the hilar dissection and steps in performing a lobectomy will generally be the same regardless of the approach.

Role of Sublobar Resection

Widespread interest in lung resections less than a lobectomy for NSCLC was tempered by the results from the Lung Cancer Study Group in the 1990s, noting sublobar resection for T1N0 NSCLC resulted in a 300% increase in local recurrence in concert with a 50% increase in cancer-related death in comparison to anatomical lobectomy.⁵⁴ Consequently, lobectomy was maintained as the standard of care. Subsequent imaging advancements have resulted in the diagnosis of earlier-stage NSCLC, and the viability of sublobar resection as an oncological alternative to lobectomy in early-stage NSCLC has been reconsidered.⁵⁵

A query of the Society of Thoracic Surgeons Database evaluating the survival of 14,286 patients who underwent segmentectomy versus lobectomy for clinical stage IA disease by Onatis et al. noted that ∼11.6% of these individuals underwent segmentectomy.⁵⁶ They noted that overall survival was similar between the two techniques (hazard ratio [HR] 1.04, 95% confidence interval [CI] 0.89–1.20). In 1995, when the Lung Cancer Study Group described above confirmed lobectomy as the standard of care, patients were diagnosed via chest X-ray with pathological upstaging being greater than 25%.⁵⁴ Currently, PET-CT has a negative predictive value exceeding 90% in evaluation of lymph node involvement, resulting in accurate preoperative staging.⁵⁷ The study concluded that in individuals over 65 with stage 1A NSCLC, there is no difference in long-term survival between lobectomy and segmental resection.⁵⁶

No randomized trials evaluating the role of sublobar resection were published until the release of JCOG0802. The study evaluated 1106 individuals who were randomized 1:1 to receive either lobectomy or segmentectomy.⁵⁸ Overall survival at 5 years was 94.3% (92.1–96.0) for segmentectomy and 91.1% for lobectomy (95% CI 88.4–93.2).⁵⁸ Disease-free survival at 5 years was 88.0% (95% CI 85.0–90.4) for segmentectomy and 87.9% (84.8–90.3) for lobectomy (HR 0.998; 95% CI 0.753–1.323; P = .9889).⁵⁸ Finally, it was noted that locoregional recurrence was higher for segmentectomy at 10.5% versus 5.4% for lobectomy. Given this, the study concluded that segmentectomy in patients with peripheral NSCLC demonstrated improved overall survival.⁵⁸

The CALGB 13053 study in 2023 evaluated the role of sublobar resection (nonanatomical wedge resection or anatomical segmentectomy) in T1aN0 NSCLC. The trial included 697 randomized patients with a tumor on the outer third of the lung parenchyma, no personal history of malignancy in the preceding 3 years, and no history of chemoradiation.⁵⁹ After a 7-year follow-up period, they found that sublobar resection was noninferior in regard to disease-free survival (HR 1.01; 90% CI 0.83–1.24).⁵⁹ Disease-free survival at 5 years was 63.6% for sublobar resection, compared with 64.1% following lobectomy. Overall survival was found to be 80.3% (95% CI, 75.5–84.3) after sublobar resection and 78.9% (95% CI, 74.1–82.9) after lobectomy, with no difference in recurrence rates. At 6 months postoperatively, there was a slight advantage in FEV1 in patients who underwent sublobar resection over those that underwent lobectomy.⁵⁹ The study concluded that sublobar resection was overall noninferior to lobectomy in the management of peripheral T1aN0 NSCLC.⁵⁹

Potential advantages of sublobar resection include preservation of lung parenchyma, improved overall survival, and less impact on postoperative pulmonary function.⁵⁹ Postoperative mortality and disease-free survival appear to be similar between the two techniques.⁶⁰ In summary, it is clear that there is a role for sublobar resection in the management of T1aN0 NSCLC that are anatomically amenable to this technique.

Nodal Staging

Imaging modalities for staging include high dose CT, PET, and magnetic resonance imaging (MRI). Each of these modalities has different limitations as it pertains to clinical staging and are often combined to improve diagnostic yield. CT scans provide information on the primary tumor size, location, involvement of adjacent structures, and detection of distant metastasis, but CT is less reliable in detecting mediastinal lymph node metastasis. A lymph node larger than 10 mm on its short axis on CT is typically considered suspicious for malignancy, but the sensitivity and specificity is only about 55% and 81%, respectively.⁶¹ CT is also unable to detect microscopic lymph node involvement. The addition of PET imaging has improved the detection of local and distal metastases during lung cancer workup significantly.⁶² Integrated PET-CT has a reported sensitivity of mediastinal lymph node involvement of 98%.⁶³ Despite its low specificity (reported at 44%), the low rate of false negatives and high negative predictive value (91%) has made PET-CT the gold-standard imaging technique for staging in NSCLC.⁶³ Finally, whole-body MRI has also been used in staging of lung cancer. Although it is the most accurate modality in detecting brain and hepatic metastasis, it has been shown to be nonsuperior to PET-CT in assessing the T, N, and M descriptors of lung cancer staging.^63,64

If a patient has lymph node enlargement on imaging, additional procedures for nodal tissue sampling should be pursued to confirm the clinical stage and determine the appropriateness of upfront surgery. The type of sampling procedure performed will be dependent on the size and location of the target lymph nodes. Traditionally, cervical mediastinoscopy has been the gold-standard procedure for mediastinal lymph node staging. However, it requires general anesthesia and several lymph node stations are inaccessible via this procedure, including inferior mediastinal stations (posterior paratracheal, paraesophageal, and inferior pulmonary ligament stations), aortic nodal stations (aortopulmonary window and paraaortic stations), and hilar stations.⁶³ Other procedures have been developed that are less invasive than mediastinoscopy and provide access to a larger range of lymph node stations. These include EBUS-FNA and endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA). Additionally, procedures used for biopsy of parenchymal lung lesions can also be used for mediastinal lymph node sampling, including CT-guided percutaneous biopsy and ENB.^34,65 ENB specifically is a less invasive diagnostic procedure that has been reported to have a diagnostic yield of up to 94%.³³

Benefits of VATS

Early adopters of VATS reported its advantages over traditional thoracotomy in several case series. These included decreased postoperative pain, shorter hospital stays, faster recovery times, and improved cosmetic appearance.^4–6 Many studies showed the technique was feasible and safe to perform, but skeptics argued that the direct benefits of VATS that were endorsed by many were anecdotal and had not been proven.⁵ One of the first randomized trials performed in the United States was published in 1995 by Kirby and colleagues and compared short-term outcomes between VATS lobectomy and lobectomy by muscle-sparing thoracotomy for lung cancer. They showed that there was no difference in operative time, intraoperative complications, blood loss, postoperative pain, length of chest tube drainage, or length of hospital stay. However, they reported that thoracotomy had increased postoperative complications, most of which were prolonged air-leaks lasting longer than 7 days.⁹ But additional studies since then, including RCTs performed in Europe and Asia, showed that VATS is associated with significantly less postoperative pain and improved quality of life when compared to thoracotomy.^66,67 Additionally, patients who undergo VATS have been shown to have improved recovery of physical function postoperatively.⁶⁸ A retrospective study published in 2009 reported that VATS was associated with less postoperative complications including atrial fibrillation, atelectasis, pneumonia, transfusion, prolonged air leak, sepsis, renal failure, and death. The study showed that 69% of VATS patients had no postoperative complications compared with 51% of patients who underwent thoracotomy (P = .0001).⁶⁹

As the procedure became more accepted, additional studies revealed the benefits of VATS lobectomy in high-risk populations. This allowed surgeons to offer a VATS procedure to patients who otherwise would not be surgical candidates given their inability to tolerate a thoracotomy. One study showed that patients older than 70 had fewer and less severe complications and shorter hospital stays when undergoing VATS when compared with lobectomy by thoracotomy.⁷⁰ As previously mentioned, VATS has also been shown to be associated with reduced postoperative pulmonary complications in those with poor preoperative pulmonary function.^71,72 These benefits seem to improve as surgeons gain experience performing VATS. Studies suggest that as VATS becomes more frequently performed for lung resection surgeries, patients overall tend to do better with progressively lower rates of postoperative complications.⁷³ Despite these benefits, the largest critics of the techniques were concerned about the application of VATS in oncological surgery as they feared it would usher in poor outcomes.

Conversion Rates and VATS Complications

Rates of conversion to open thoracotomy have been reported anywhere from 3% to 25%, with individuals who have higher stage or more advanced NSCLC being more likely to undergo conversion. Globally, causes for conversion may be classified into technical complications, bleeding, anatomical constraints, or oncological presentation. A meta-analysis of 72,000 cases found that the median conversion rate was 9.6% (95% CI 6.6%–13.9%) and that 27.9% were due to vascular injury/bleeding, 26.2% due to difficult lymph node dissection, and 19% due to adhesions.⁷⁴ Conversion rates due to oncological reasons have been described as being approximately 8%, including centrally located tumors requiring vascular control, chest wall involvement, and diaphragm invasion.⁷⁴ Bleeding from pulmonary vessels is a dreaded complication during lobectomy, and will often necessitate conversion to thoracotomy. It is important to note, however, that with experience it may be possible for surgeons to manage these injuries thoracoscopically. Additional causes for conversion include failure of equipment, namely video cameras and lighting, which is unique to VATS. Therefore it is recommended that an individual with experience in the management of equipment failure be immediately available during VATS procedures.⁷⁵

The number of patients undergoing resection via VATS has continued to increase, and concomitantly conversion rates have continued to fall in recent years. This may be attributed to technical competence and accurate patient assessment using a standardized evaluation to predict which individuals may require conversion and working to either mitigate those risk factors or opt for thoracotomy. Interestingly, some studies have shown that surgeon experience with VATS is not associated with lower conversion rates but that the highest predictor of conversion was clinical nodal involvement.⁷⁶

Oncological and Long-Term Outcomes

Initial concerns regarding VATS for lung cancer surgery stemmed from the notion that the procedure limited lymph node dissection, preventing a proper oncological resection from being performed.⁵ Initially, some studies did show that surgeons harvested less lymph nodes during VATS than during a thoracotomy, which correlated with the decreased rate of pathological upstaging initially observed for patients who underwent VATS.⁷⁷ However, subsequent analyses demonstrated that as facilities and surgeons performed more VATS, the number of lymph nodes resected increased, suggesting that the number of lymph node stations sampled and total lymph nodes harvested was more a direct result of surgeon experience rather than an intrinsic technical flaw of VATS lobectomy.¹⁹ Later studies showed that the number of lymph node stations sampled and total number of harvested lymph nodes did not vary between VATS and open thoracotomy resections.^78–80 Additionally, Watanabe and colleagues demonstrated that the rates of upstaging in individuals with NSCLC were not different between VATS and thoracotomy, and the outcomes were similar in individuals who were ultimately upstaged regardless of the approach.^81,82

There is still a need for high-level evidence comparing long-term oncological outcomes between VATS and conventional thoracotomy, but several studies have been published suggesting that VATS is noninferior and sometimes even superior to conventional thoracotomy for lung cancer surgery. A Japanese prospective study in 2000 followed 100 patients undergoing either conventional lobectomy via thoracotomy or VATS lobectomy for stage 1A (T1N0M0) NSCLC. In their study, the incidence of recurrence and 5-year survival rates were not significantly different between both groups. Five-year survival rates were reported at 85% for those who underwent conventional open lobectomy and 90% for those who had VATS lobectomy.⁸⁰ Other studies have shown similar results.^51,83 As previously mentioned, some studies on uniportal VATS have shown 2-year disease-free survival and overall survival rates as high as 96% and 100% for those with stage 1 disease, respectively.^52,53 Other studies have suggested improved oncological outcomes with VATS. A meta-analysis by Yan and colleagues reported no significant difference in postoperative complications, mortality or locoregional recurrence, but improved systemic recurrence rate and 5-year mortality rates in those who undergo VATS lobectomy when compared to open lobectomy.⁸⁴ Additionally, a retrospective study using data from over 29,000 patients in the Society of Thoracic Surgeons’ General Thoracic Surgery Database showed that patients who undergo VATS lobectomy had improved long-term survival when compared to thoracotomy.⁸⁵ However, given the paucity of data, more high-level evidence is needed to evaluate any potential oncological superiority of VATS over thoracotomy for lung cancer.

An interesting link between postoperative stress response and immune surveillance has also led some to believe VATS could have a benefit on oncological outcomes by virtue of being less invasive. A study out of Scotland found that patients who underwent VATS lobectomy had less changes in perioperative acute phase reactants, indicating a decreased postoperative stress response which is thought to have important implications in postoperative tumor immune surveillance in lung cancer patients.⁸⁶ Similar results have been published in other studies, though the direct effects on oncological outcomes are yet to be proven.⁸⁷

Although there is a lack of RCTs comparing oncological outcomes between VATS and conventional lobectomy, the majority of studies published have led to the generally accepted notion that VATS lobectomy is noninferior to conventional lobectomy.¹⁷ Considering the added benefits for VATS lobectomy previously discussed, it has become the preferred approach to surgical resection of early-stage lung cancer, with societal guidelines recommending strong consideration of VATS for patients with medically operable disease.^13,88

Future Role of VATS

In the same vein as the innovations that brought about VATS for thoracic surgery, surgeons continue to devise ways of reducing the impact of thoracic surgery while improving postoperative outcomes and providing comparable, if not superior, oncological outcomes. Recently, there have been cases reported in which VATS is performed without intubation. The first VATS lobectomy in a nonintubated patient was reported in 2014 by Gonzalez-Rivas et al. who performed a right middle lobectomy and lymphadenectomy in a 46-year-old patient with spontaneous ventilation during the case.⁸⁹ This represents an even less invasive technique for VATS with the benefit of reduced complications from mechanical ventilation, including barotrauma and atelectasis of the dependent lung.⁴³

VATS is now increasingly being used for more complex procedures such as tracheal and carinal resections, with some reports of shorter operative times and faster recovery.^90,91 As VATS has asserted its place in thoracic surgery, emerging technologies such as robotic assisted thoracic surgery have also garnered support as an alternate minimally invasive approach. As they continue to evolve, continued research will help optimize these techniques to provide patients with safer and more efficient procedures.

Footnotes

Acknowledgment

We would like to thank all authors for their contributions to this review.

Authors’ Contributions

G.R.R.: Investigation; writing—original draft; writing—reviewing and editing. J. K.: Investigation; writing—original draft; writing—reviewing and editing. J. L. A.: Conceptualization; project administration; supervision; writing—reviewing and editing. P. S. M.: Writing—reviewing and editing. G. D. T.: Conceptualization; project administration; supervision; writing—reviewing and editing.

Author Disclosure Statement

The authors have no conflicts of interest to disclose.

Funding Information

No funding was received for this article.

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