Minimally Invasive Lung Resection: When Is a VATS Not a VATS?

November 15, 2016

Lung resection is gaining momentum among thoracic surgeons because it allows the operating surgeon the convenience of performing a dissection that in many ways is similar to open surgery, yet that has the advantages of a minimally invasive approach. Hopefully, surgical robotics, along with VATS, will make it possible for the thoracic surgery community to offer minimally invasive lung resection to nearly all early-stage lung cancer patients.

Drs. White and Swanson have written a lucid assessment of minimally invasive anatomic lung resection for early-stage lung cancer.[1] They explain how the subtle details of video-assisted thoracic surgery (VATS) resection make it superior to open surgery. They convincingly make the point that lung cancer patients benefit from a minimally invasive surgical approach, similar to patients with many other tumor types.

Traditionally, lung resection has been a more difficult operation for patients to tolerate than other cancer operations-not necessarily because of the lung parenchyma resected, but rather because of the debilitating nature of a thoracotomy incision. As the authors describe, a thoracotomy is rife with difficulties and potential complications. The rigors of recovering from a thoracotomy also make patients less able to tolerate adjuvant chemotherapy in those cases where unanticipated nodal disease is discovered, and this may lead to lower survival rates in this group.[2]

White and Swanson also include an important discussion of the relative merits of stereotactic ablative radiotherapy (SABR) compared with surgical resection for early-stage lung cancer. Many small studies have made specious assertions that radiation can offer local control and survival rates similar to those seen with lung resection. The authors adroitly point out that these data are incomplete and, in many cases, unconvincing.[3] Anatomic sublobar resection, or segmentectomy, offers an excellent alternative to SABR in those patients with insufficient pulmonary reserve to tolerate a lobectomy. Furthermore, anatomic segmentectomy can be performed with VATS techniques similar to those used for lobectomy and offers the crucial benefit of complete and accurate staging because it includes segmental, hilar, and mediastinal lymph node sampling.

While White and Swanson document the above points well, there are several important aspects of minimally invasive lung resection that were not included in their review but deserve mentioning.

Proper credit for VATS owed to Dr. Robert McKenna

The authors discuss the origins of VATS lobectomy, but perhaps it would be useful to include special mention of the most significant innovator of this technique, Dr. Robert J. McKenna, Jr. Dr. McKenna performed his first VATS lobectomy in 1992 and was the most prodigious practitioner and assertive early proponent of the technique. He published his first series of 45 patients in 1994[4] and was the first to show that the main advantage of a VATS lobectomy was a significantly shorter length of stay. He also demonstrated that the minimally invasive approach allowed lobectomy to be offered to elderly patients who might not have been considered suitable candidates for traditional thoracotomy.[5] Dr. McKenna’s impressive series of 1,100 patients, published in 2006, convincingly showed that the VATS approach was an oncologically equivalent operation and allowed the median length of stay to be decreased to 3 days.[6]

Lack of a standardized definition of VATS lobectomy

While the authors clearly demonstrate the advantages of VATS resection, it should be mentioned that the thoracic surgery community at large has failed to standardize the definition of VATS lobectomy.[7] The authors discussed the Cancer and Leukemia Group B 39802 study that attempted to standardize the definition of VATS lobectomy, yet there remains tremendous variation among thoracic surgeons regarding the technique of VATS lobectomy.[8] There is no standard definition of VATS to this day, and many thoracic surgeons continue to use large incisions and rib spreading in their VATS resections; such practices likely preclude many of the advantages of the VATS approach.

Difficulty in mastering VATS

Despite the clear advantages of VATS lobectomy, it is interesting to note that, to date, only 45% of lobectomies are performed utilizing this preferred technique.[9] This fact should make it clear that VATS is difficult to master. To be performed effectively, it requires dedicated and focused training, and experience with a relatively large volume of cases.[10,11] Therefore, it should be performed by dedicated general thoracic surgeons with focused training in minimally invasive techniques. Furthermore, the authors suggest-convincingly-that VATS anatomic segmentectomy may be a better option than VATS lobectomy for patients with compromised pulmonary function.[12] However, VATS segmentectomy is even more difficult from a technical standpoint than VATS lobectomy. Without subspecialty focus and experience with an appropriate volume of cases, it may be impossible for surgeons to perform VATS segmentectomy efficiently and safely.[13]

The contribution of robotics to minimally invasive lung surgery

Lastly, the authors convincingly elaborate on the benefits of minimally invasive lung resection via VATS. However, it should be noted that perhaps the most important recent contribution to minimally invasive lung surgery is surgical robotics. Over the past 8 years, the role of surgical robotics in minimally invasive lung resection has become increasingly significant. Surgeons such as Dr. Robert Cerfolio and Dr. Bernard Park have developed techniques for robotic-assisted lung resection that are predictable, safe, and oncologically effective.[14,15] Although controversial in terms of cost-effectiveness compared with VATS, robotic resection represents a technique that is similar in execution to open surgery, and which therefore may be amenable to wider adaptation and implementation. Surgical robotics may enable more thoracic surgeons to offer a minimally invasive approach and thus may allow many more patients access to it.[16] Furthermore, the industry push behind robotic lung resection has been strong and innovative. The latest-generation surgical robot allows the operating surgeon to fire the stapler from the robotic console, thus relieving the assistant of the vital responsibility of division of the pulmonary vessels and bronchi. Also, the latest design of the equipment has the robotic arms hanging from a boom positioned above the patient, allowing the anesthesiologist to assume a more natural position at the head of the patient rather than competing for space with the base of the robot.


Drs. White and Swanson correctly point out that minimally invasive lung resection has replaced thoracotomy as the standard of care for early-stage lung cancer. The early pioneers of this technique have accomplished their goal of establishing a safe and predictable method for minimally invasive lung resection that allows patients a much faster recovery with equivalent oncologic effectiveness. Furthermore, the authors’ assertion that minimally invasive anatomic segmentectomy may offer patients more accurate staging and, potentially, improved survival when compared with SABR is important to consider. A crucial point for the physician caring for lung cancer patients to be clear on is whether the thoracic surgeon is utilizing all the advantages of VATS resection: no rib spreading, no large incisions, thorough lymph node sampling, and complete anatomic dissection/division of the hilar structures. Finally, robotic-assisted lung resection is gaining momentum among thoracic surgeons because it allows the operating surgeon the convenience of performing a dissection that in many ways is similar to open surgery, yet that has the advantages of a minimally invasive approach. Hopefully, surgical robotics, along with VATS, will make it possible for the thoracic surgery community to offer minimally invasive lung resection to nearly all early-stage lung cancer patients.

Financial Disclosure:The author has no significant financial interest or other relationship with the manufacturers of any products or providers of any service mentioned in this article.


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14. Cerfolio RJ. Total port approach for robotic lobectomy. Thorac Surg Clin. 2014;24:151-6.

15. Park BJ. Robotic lobectomy for non-small cell lung cancer: long-term oncologic results. Thorac Surg Clin. 2014;24:157-62.

16. Wei B, Eldaif SM, Cerfolio RJ. Robotic lung resection for non-small cell lung cancer. Surg Oncol Clin N Am. 2016;25:515-31.