Cost-effectiveness and clinical utility of video-assisted thoracoscopic surgery (VATS) in hemodynamically stable thoracic trauma: a narrative review

Introduction

Background

Thoracic trauma accounts for 25–35% of trauma-related deaths in the United States and includes a broad spectrum of injuries ranging from rib fractures and pulmonary contusions to life-threatening hemothorax and tracheobronchial injuries (1). These injuries can be managed non-operatively, with tube thoracostomy, or through operative intervention such as thoracotomy (1). Over the past few decades, video-assisted thoracoscopic surgery (VATS) has emerged as a minimally invasive alternative for selected trauma patients, offering both diagnostic and therapeutic potential. Its adoption has been driven by several advantages: reduced postoperative pain, shorter hospital stays, improved intrathoracic visualization, and fewer wound complications compared to open thoracotomy (1,2).

Rationale and knowledge gap

Despite its growing adoption, high-quality data on the efficacy, outcomes, and cost-effectiveness of VATS in trauma remain limited. Most evidence arises from retrospective series or institutional experiences, and indications vary widely across trauma centers (2). In particular, the role of VATS in the management of retained hemothorax, diaphragmatic injuries, persistent air leaks, and suspected esophageal or bronchial injury continues to evolve (2,3).

Importantly, few studies have directly addressed the cost-effectiveness of VATS compared to open thoracotomy in trauma populations.

Objective

In this narrative review, we focus on the comparative cost-effectiveness of VATS versus traditional thoracotomy in adult thoracic trauma patients, including clinical outcomes, economic implications, and resource utilization. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-17/rc).

Methods

We performed a narrative review of the literature to assess the role of VATS in the management of thoracic trauma and the resulting several common thoracic injuries. This review aimed to synthesize available evidence regarding its indications, outcomes, and cost-effectiveness compared to traditional open thoracotomy.

A structured search of the PubMed database was conducted in March 25^th, 2025. Search terms included combinations of “video-assisted thoracoscopic surgery”, “VATS”, “thoracic trauma”, “thoracic injury”, “hemothorax”, “diaphragm injury”, “rib fractures”, “flail chest”, “persistent air leaks”, and “thoracotomy”. Boolean operators (“AND”, “OR”) were used to optimize search sensitivity. Additional references were identified through manual searches of bibliographies in relevant review articles and guideline documents. The search strategy summary was shown in Tables 1,2.

Given the narrative nature of this review, we did not apply formal systematic review protocols such as PRISMA or structured bias assessment tools. The goal was to provide a thematic synthesis of relevant evidence, prioritizing clinical relevance and interpretability.

Inclusion criteria were as follows: studies published in English from inception through March 2025, involving human patients who sustained thoracic trauma and underwent evaluation or treatment with VATS or VATS versus thoracotomy. We included randomized controlled trials, prospective cohort studies, and retrospective analyses in addition to any published meta-analysis. Animal studies, conference abstracts without full data, and single case reports were excluded.

From approximately 100 studies initially identified, 17 relevant articles were selected after screening (details provided in Table 3). Study selection was guided by relevance to thoracic trauma and the review’s primary focus on clinical outcomes and economic implications.

To align with the aims of this review, data extraction and synthesis were structured around three domains: (I) clinical outcomes such as length of stay (LOS), complication rates (e.g., infection, empyema, persistent air leak), pain control/the need for postoperative analgesia, and conversion to open surgery; (II) economic implications, including comparative cost analyses and perioperative expenditure; and (III) resource utilization, including intensive care unit (ICU) needs, operative time, and return to function or discharge disposition.

Due to the heterogeneity in study design and reporting across the literature, a meta-analysis was not performed. This narrative approach was chosen to better accommodate the variability in clinical protocols, surgical expertise, and trauma systems worldwide. Formal bias assessment tools (e.g., Cochrane Risk of Bias or GRADE) were not applied, as this was not a systematic review. However, we prioritized high-quality studies with larger cohorts and clear methodology when drawing conclusions.

Key content and findings

This section summarizes the current clinical and economic evidence supporting the use of VATS in trauma care. We present findings grouped into three thematic domains: (I) clinical outcomes; (II) economic implications; and (III) resource utilization.

A summary of key studies that provide clinical and economic justification for the use of VATS in trauma care was provided in Table 4.

Clinical outcomes

The introduction of VATS has significantly improved clinical outcomes in the management of both hemothorax/retained hemothorax and multiple rib fractures including flail chest. In hemothorax, early VATS—especially within the first 24 to 72 hours—allows for rapid evacuation of blood clots before pleural adhesions form, leading to improved lung re-expansion, reduced morbidity and mortality, and prevention of complications such as empyema, fibrothorax, and pneumonia (4,11). It is especially valuable in retained hemothorax, where traditional methods like repeated tube thoracostomy often fail, necessitating open thoracotomy which carries higher morbidity (4,6).

Similarly, in the context of rib fractures and flail chest, VATS-assisted surgical stabilization of rib fractures (SSRF), also known as rib osteosynthesis, has emerged as a superior alternative to conservative treatment or open thoracotomy, providing increased chest wall stability, reduced pain, better pulmonary function, and prevention of chronic deformities or paradoxical respiration (5,8). Unlike traditional open surgery, which is associated with high rates of postoperative complications such as infection, chronic pain, and upper limb dysfunction, thoracoscopic techniques minimize tissue damage and enhance recovery (5). These improvements collectively underscore VATS as a safer and more effective clinical intervention for traumatic thoracic injuries.

Furthermore, early intervention with VATS may substantially improve clinical results. Smith et al. demonstrated that VATS performed within 5 days of thoracic injury significantly reduced the conversion rate to open thoracotomy and shortened hospital LOS (6). Importantly, none of the patients who underwent early VATS developed persistent empyema, underscoring the clinical advantage of early operative timing in preventing infectious complications (6) (Table 5).

Economic implications

Ramos et al. compared the costs of VATS lobectomy to open thoracotomy and found that, although equipment costs were higher for VATS (€1,800±560.46 vs. €901±328), the overall hospital expenditure was lower (€11,934 vs. €14,145) due to reduced hospital stays and complications. While this study was conducted in the context of early-stage lung cancer, it underscores the broader economic potential of minimally invasive thoracic approaches when applied appropriately in clinical practice (16).

In trauma-specific contexts, the economic benefits of VATS are increasingly evident. Studies have shown that VATS reduces post-procedural complications, hospital LOS, and the need for intensive interventions, all of which contribute to lower overall costs. For example, in the management of rib fractures and flail chest, VATS has been associated with reduced intraoperative blood loss, shorter durations of chest tube placement, and decreased postoperative complication rates—factors that facilitate faster recovery and discharge, thereby improving cost-efficiency (5).

In contrast, conventional open thoracotomy for multiple rib fixation incurs higher indirect costs due to prolonged recovery, increased analgesic requirements, and potential for long-term disability and functional impairment (5).

Likewise, in retained hemothorax, the earlier use of VATS avoids expensive complications such as empyema and fibrothorax, which would otherwise require prolonged antibiotic therapy, additional surgeries, or intensive care (4).

By enabling faster recovery and minimizing the need for further interventions, VATS contributes to a more cost-effective approach in both emergency and elective thoracic trauma care settings (Table 5).

Resource utilization

VATS offers a more efficient use of healthcare resources in both hemothorax and rib fracture management. In patients with retained hemothorax, timely VATS use—ideally within 3 to 10 days post-injury—not only improves outcomes but also reduces the burden on healthcare facilities by preventing complications that require prolonged ICU stays or repeated surgical interventions (4,11). Moreover, VATS enables clear visualization of the pleural space, making it more effective than inserting additional thoracostomy tubes, which often fail to fully evacuate clotted blood and may necessitate further procedures (4). For rib fractures and flail chest, VATS facilitates internal fixation with smaller incisions, reduced surgical time, and faster postoperative recovery, minimizing the need for extended pain control or respiratory support (5). This technique is especially useful for fractures in anatomically complex regions like the scapular or breast areas, which are difficult to expose through traditional methods. Altogether, the minimally invasive nature of VATS reduces hospital resource consumption, shortens hospital stays, and enables more efficient allocation of surgical and postoperative care services (Tables 4,5).

Discussion

VATS has gained substantial recognition for its superiority over traditional open thoracotomy in enhancing postoperative outcomes across various thoracic procedures. Numerous studies have demonstrated that VATS is associated with shorter hospital LOS, lower infection rates, reduced postoperative pain, diminished need for analgesia, and earlier discharge—all of which reflect its minimally invasive nature and facilitation of faster recovery (7).

Trauma-specific clinical outcomes

In thoracic trauma settings, VATS has shown clear advantages over thoracotomy. For instance, Ben-Nun et al. demonstrated that trauma patients managed with VATS experienced significantly fewer pulmonary and wound-related complications, reduced reliance on narcotic analgesia, and faster return to daily activities. Long-term follow-up further revealed better patient satisfaction in terms of health status, cosmetic results, and overall quality of life (9).

However, not all interventions yield the same benefit. Meyer et al. noted that SSRF may not result in significant short-term improvements in quality of life, highlighting the importance of proper patient selection when considering rib osteosynthesis with VATS (17).

To better illustrate the comparative benefits of VATS over open thoracotomy in trauma care, a summary of clinical, economic, and procedural outcomes is presented in Table 5, highlighting key metrics and supporting studies.

Trauma-specific economic evidence and remaining gaps

Emerging trauma-specific data are beginning to shed light on the economic implications of VATS. For example, Uma et al. [2024] evaluated the timing and cost-effectiveness of VATS in 617 patients with unilateral traumatic hemothorax. Their findings revealed that operative intervention before hospital day 4 was associated with significantly higher costs without a reduction in hospital LOS, while delayed VATS beyond day 4 increased the failure rate of nonoperative management. These results suggest that timing is a critical determinant of cost-efficiency, underscoring the need for a balanced, patient-specific approach when deploying VATS in trauma care (18).

Despite such valuable contributions, there remains a notable gap in the literature regarding comprehensive, head-to-head economic evaluations comparing VATS to open thoracotomy in trauma populations. Existing studies are limited in scope, and often focus on isolated injuries or retrospective data. Additionally, variability in trauma systems, injury severity, and perioperative care further complicate standardized cost comparisons. More robust, prospective economic analyses are needed to establish the true cost-effectiveness of VATS across broader trauma settings.

Elective surgery literature as analogy

In the absence of robust trauma-specific cost analyses, limited insights can be drawn from elective thoracic surgery. For instance, Chen et al. reported that in lung cancer patients undergoing lobectomy, VATS significantly reduced rates of blood transfusion and postoperative pulmonary infections, while also shortening LOS. Although total hospitalization costs were comparable between the VATS and open groups, non-surgery-related expenditures were significantly lower in the VATS cohort (7).

Furthermore, Fang et al. demonstrated the potential cost-effectiveness of VATS within one year of surgery from a payer’s perspective in Taiwan, even when accounting for higher upfront procedural costs. This was supported by willingness-to-pay thresholds, suggesting that VATS may offer economic viability in the short term despite initial expenses (10).

However, it is important to note that these findings are derived from elective oncologic settings and not trauma populations. To our knowledge, cost-effectiveness analyses of VATS lobectomy specifically in trauma populations remain unavailable. As such, we referenced studies from lung cancer surgery to offer analogies in terms of resource utilization and economic trends for minimally invasive thoracic approaches. These comparisons, while informative, should be interpreted with caution due to the differing clinical scenarios, instrumentation, and cost drivers between elective and emergency thoracic surgery.

Patient selection and contraindications

It is important to emphasize that VATS is not suitable for all trauma patients. In cases of hemodynamic instability, ongoing intrathoracic bleeding, or penetrating chest trauma such as gunshot or stab wounds, emergent thoracotomy remains the gold standard. The benefits of VATS are primarily observed in stable patients who can tolerate minimally invasive evaluation and management (4).

Quality and limitations of included studies

While this review synthesizes current evidence on the clinical and economic outcomes of VATS in trauma care, it is important to acknowledge the variability in the quality of included studies. Most available literature comprises retrospective analyses or single-center case series, with relatively small sample sizes and heterogeneous patient populations. For instance, while Uma et al. [2024] offers valuable insights due to its large cohort and multicenter design, other studies such as Ben-Nun et al. and Fang et al. are more limited in scope and generalizability. In many cases, important confounders such as associated injuries, timing of intervention, or concurrent procedures were not consistently reported, which may affect the reliability of outcome comparisons. Additionally, several studies lack standardized definitions for complications or cost components, further complicating cross-study interpretation. These limitations highlight the need for cautious interpretation of findings and reinforce the importance of future prospective, controlled investigations to validate and refine the observed trends.

Review limitations and future directions

This narrative review offers a focused and structured assessment of VATS in thoracic trauma, with particular attention to its clinical outcomes, economic implications, and resource utilization. A key strength lies in its clinical relevance, offering practical insights into the growing role of minimally invasive approaches in trauma care. The review highlights the benefits of early VATS intervention and integrates both clinical and cost-effectiveness perspectives, providing a balanced understanding that is valuable for surgical decision-making.

We acknowledge that many patients undergoing thoracic trauma care often present with polytrauma and complex injury patterns, which may confound outcomes such as LOS and procedural cost. Our review is limited in its ability to differentiate the effects of VATS in isolation from those of associated interventions. This limitation is inherent to narrative reviews and highlights the need for well-controlled prospective studies in the future.

However, as a narrative rather than systematic review, it is subject to inherent limitations such as potential selection bias and lack of formal risk of bias assessment. The heterogeneity of included studies—with differences in injury patterns, timing of intervention, and outcome definitions—may limit generalizability. Additionally, while economic findings from elective thoracic surgery offer valuable analogies, trauma-specific cost analyses remain limited. The absence of quantitative synthesis further restricts the ability to draw definitive comparative conclusions. Nonetheless, this review contributes meaningfully to a nuanced understanding of VATS in trauma and identifies important areas for future research.

Future research should also focus on clarifying the role of VATS in hemodynamically unstable patients and establishing stratification criteria to guide its use across different trauma profiles. Larger cohort studies and prospective trials will be essential to define appropriate indications and ensure safe implementation in this high-risk population.

Conclusions

VATS has emerged as a transformative modality in the management of thoracic trauma, providing a minimally invasive alternative to conventional open thoracotomy. In diverse clinical scenarios—including retained hemothorax, multiple rib fractures, and persistent air leaks—VATS has consistently demonstrated benefits such as reduced postoperative complications, shorter hospital stays, decreased opioid requirements, and accelerated recovery.

Economically, VATS is associated with reduced overall healthcare expenditures, primarily due to fewer complications and shorter lengths of stay, making it a cost-effective strategy in both acute and long-term trauma care. These advantages are most evident when VATS is employed early, ideally within 3 to 5 days post-injury.

Although challenges remain, including a steep learning curve and the need for careful patient selection, VATS represents a clinically effective and economically sustainable option for managing hemodynamically stable thoracic trauma patients. Future research should focus on validating its cost-effectiveness across broader trauma populations and refining criteria for optimal timing and surgical indication.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the Guest Editors (Savvas Lampridis and Andrea Bille) for the series “The Role of VATS in Thoracic Trauma Management” published in Video-Assisted Thoracic Surgery. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-17/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-17/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-17/coif). The series “The Role of VATS in Thoracic Trauma Management” was commissioned by the editorial office without any sponsorship or funding. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. 2023 May 23. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025.
2. Goodman M, Lewis J, Guitron J, et al. Video-assisted thoracoscopic surgery for acute thoracic trauma. J Emerg Trauma Shock 2013;6:106-9. [Crossref] [PubMed]
3. Mert Ü, Andruszkow H, Hildebrand F. Chest Trauma: Classification and Influence on the General Management. In: Pape HC, Borrelli J Jr, Moore EE, editors. Textbook of Polytrauma Management: A Multidisciplinary Approach. Springer International Publishing; 2022:161-84.
4. Chou YP, Lin HL, Wu TC. Video-assisted thoracoscopic surgery for retained hemothorax in blunt chest trauma. Curr Opin Pulm Med 2015;21:393-8. [Crossref] [PubMed]
5. Wang J, Sun Z, Liu Y, et al. Clinical effect of the internal fixation for rib fracture with single utility port complete video-assisted thoracoscopic surgery. J Cardiothorac Surg 2024;19:59. [Crossref] [PubMed]
6. Smith JW, Franklin GA, Harbrecht BG, et al. Early VATS for blunt chest trauma: a management technique underutilized by acute care surgeons. J Trauma 2011;71:102-5; discussion 105-7. [Crossref] [PubMed]
7. Chen W, Yu Z, Zhang Y, et al. Comparison of cost effectiveness between video-assisted thoracoscopic surgery (vats) and open lobectomy: a retrospective study. Cost Eff Resour Alloc 2021;19:55. [Crossref] [PubMed]
8. Zhang J, Hong Q, Mo X, et al. Complete Video-assisted Thoracoscopic Surgery for Rib Fractures: Series of 35 Cases. Ann Thorac Surg 2022;113:452-8. [Crossref] [PubMed]
9. Ben-Nun A, Orlovsky M, Best LA. Video-assisted thoracoscopic surgery in the treatment of chest trauma: long-term benefit. Ann Thorac Surg 2007;83:383-7. [Crossref] [PubMed]
10. Fang HY, Hsiao FY, Huang HC, et al. Cost and effectiveness of video-assisted thoracoscopic surgery for clinical stage I non-small cell lung cancer: a population-based analysis. J Thorac Dis 2014;6:1690-6. [Crossref] [PubMed]
11. Ziapour B, Mostafidi E, Sadeghi-Bazargani H, et al. Timing to perform VATS for traumatic-retained hemothorax (a systematic review and meta-analysis). Eur J Trauma Emerg Surg 2020;46:337-46. [Crossref] [PubMed]
12. Paliouras D, Barbetakis N, Lazaridis G, et al. Video-assisted thoracic surgery and pneumothorax. J Thorac Dis 2015;7:S56-61. [Crossref] [PubMed]
13. Duggan J, Rodriguez G, Peters A, et al. Video-assisted thoracoscopic surgery (VATS) in trauma: a narrative review. Video-Assist Thorac Surg 2024;9:8.
14. Divisi D, Barone M, Zaccagna G, et al. Video-assisted thoracoscopic surgery lobectomy learning curve: what program should be offered in a residency course? J Vis Surg 2017;3:143. [Crossref] [PubMed]
15. Ng CS, Lee TW, Wan S, et al. Video assisted thoracic surgery in the management of spontaneous pneumothorax: the current status. Postgrad Med J 2006;82:179-85. [Crossref] [PubMed]
16. Ramos R, Masuet C, Gossot D. Lobectomy for early-stage lung carcinoma: a cost analysis of full thoracoscopy versus posterolateral thoracotomy. Surg Endosc 2012;26:431-7. [Crossref] [PubMed]
17. Meyer DE, Harvin JA, Vincent L, et al. Randomized Controlled Trial of Surgical Rib Fixation to Nonoperative Management in Severe Chest Wall Injury. Ann Surg 2023;278:357-65. [Crossref] [PubMed]
18. Uma CV, Risinger WB, Nath S, et al. Not So Vats: How Early Is Too Early in the Operative Management of Patients with Traumatic Hemothorax? Am Surg 2024;90:2149-55. [Crossref] [PubMed]