Surgical approach to lobectomy for non-small cell lung cancer: a narrative review of open, thoracoscopic, and robotic techniques

Introduction

Lung cancer remains the leading cause of cancer-related mortality in the United States (U.S.) (1), with non-small cell lung cancer (NSCLC) accounting for approximately 85% of cases. Increased adoption of low-dose computed tomography screening and recent advances in systemic therapy, particularly immunotherapy, have transformed the landscape of early detection and management of NSCLC (1-5). Surgical resection remains the cornerstone of management for early NSCLC; over time, practice has shifted from highly invasive procedures such as pneumonectomy to more parenchymal-sparing techniques, including lobectomy and, more recently, sublobar resections (6,7). Currently, lobectomy remains the standard for the majority of patients with adequate lung reserve (6).

Although numerous reviews have compared perioperative and long-term outcomes across open, VATS, and RATS lobectomy, their conclusions often differ, particularly regarding lymph node assessment, cost, and short-term mortality (8-11). Long-term survival, in particular, remains an area with sparse randomized evidence (9,10,12). Interpretation of the existing literature is further complicated by the absence of randomized controlled trials directly comparing all three operative approaches. As a result, current comparisons must rely on studies that predominantly examine two modalities at a time (e.g., open vs. VATS or VATS vs. RATS), limiting the ability to draw definitive conclusions.

Objective

In this review, we synthesize the available evidence comparing the three major operative approaches to lobectomy, focusing on perioperative outcomes, survival outcomes, oncologic outcomes, impact on quality of life (QOL) and cost considerations. We also aim to highlight the advantages, limitations, and existing knowledge gaps across techniques to help guide surgical decision-making.

Although prior reviews have explored aspects of this topic, the present review provides a broader and more integrative scope than previously attempted. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-45/rc).

Methods

A literature search was conducted within PubMed, searching for studies/articles between January 1, 2015 and September 1, 2025. The date of search was between September 2, 2025 and September 16, 2025. Search terms included “non-small cell lung cancer”, “lobectomy”, “narrative review”, “review of non-small cell lung cancer”, “surgical approaches lobectomy NSCLC”, “VATS, RATS, OPEN, NSCLC”, “video-assisted thoracoscopic surgery”, “robotic assisted thoracic surgery”. “Outcomes, cost, VATS, RATS, OPEN, NSCLC”, “systematic review”, “meta-analysis”. Boolean operators (AND, OR) were used to refine results. Inclusion criteria included peer-reviewed studies, meta-analyses, randomized controlled trials, retrospective/prospective cohort studies, and review articles addressing lobectomy outcomes in adult NSCLC. Exclusion criteria included studies not focused on surgical management of NSCLC. Our methods are summarized in Table 1.

Overview of surgical approaches to lobectomy

Lobectomy involves the surgical removal of an entire lobe of the lung and remains the standard of care for NSCLC in operable patients, as endorsed by the American Association for Thoracic Surgery (13). Adequate nodal dissection is a key component of oncologic resection and should include at least 1 hilar and 3 mediastinal lymph node stations (13). Approaches to lobectomy span from open thoracotomy to minimally invasive approaches, including video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS) via small incisions.

Open thoracotomy

Traditionally, lobectomies are performed through an open, rib-spreading thoracotomy requiring a rib retractor. This technique provides exposure to the pulmonary hilum and provides space for two-handed exposure, retraction, and dissection. Most common thoracotomy sites include postero-lateral (excellent exposure but requires transection of large muscles, increased potential for blood loss and post-thoracotomy pain), lateral (excellent exposure with retained latissimus dorsi integrity but cannot extend to upper ribs) and anterior (excellent access to upper lobe, right middle lobe or anterior hila with superior cosmetic results but limits exposure to posterior pleural space) (4).

Technical advantages of open lobectomy include maximal ability to manage complex hilar anatomy, dense adhesions or challenging vascular anatomy as it allows for two-handed dissection and manual palpation of the lung which can allow for identification of additional nodules or assessing tumor extent.

VATS

VATS is a minimally invasive approach to anatomic pulmonary resection performed through small intercostal ports without rib spreading. The technique utilizes a high-definition thoracoscopic camera to provide magnified visualization of the pleural cavity, with long endoscopic instruments and staplers introduced through 2–4 ports or a single uniportal incision (4). Improvements in video technology, double-lumen endotracheal tubes, and endoscopic stapling platforms have substantially enhanced visualization and operative ergonomics, contributing to the broader adoption of VATS for lobectomy in the early 21st century. These refinements have expanded its feasibility for complex hilar dissection, fissure development, and systematic lymphadenectomy (14-17). The uniportal technique represents a further refinement of minimally invasive surgery; by consolidating all instruments through one incision, it reduces skin incisions and may lower the risk of intercostal nerve compression compared with standard multiport VATS (18). Technical advantages of VATS include reduced chest wall trauma due to the absence of rib spreading, high-definition visualization of hilar and mediastinal structures, and reproducible anatomic dissection under direct video guidance.

RATS

RATS is the newest minimally invasive technique for anatomic pulmonary resection and shares several foundational principles with VATS including video-based visualization and the use of non-rib spreading intercostal incisions. The operation is performed using a robotic platform in which the surgeon controls a three-dimensional, high-definition camera and wristed instruments from a remote console. The instruments are typically introduced through several 8 mm ports with procedural variations incorporating either a small utility thoracotomy or an entirely port-based approach with carbon dioxide insufflation to enhance the intrathoracic working space. Specimen extraction is accomplished through the utility incision or a widened assistant port (4).

Technical advantages of RATS include greater precision, enhanced instrument articulation with multiple degrees of freedom, and improved ergonomics supported by motion scaling and optical zoom capabilities. These platform features provide stable visualization and controlled instrument movement during thoracic procedures while allowing the surgeon to operate in a comfortable, ergonomically optimized position at the console. Contemporary U.S. practice reflects a notable shift toward RATS. According to the 2023 Society of Thoracic Surgeons General Thoracic Database, RATS accounted for 63% of lobectomies performed at participating centers, underscoring its expanding role within minimally invasive thoracic surgery (19).

Comparative outcomes across surgical approaches

A substantial body of literature has compared open, VATS, and RATS lobectomy across several clinically relevant domains. Building on the technical overview presented in the preceding sections, we summarize the evidence evaluating perioperative outcomes, oncologic adequacy, long-term survival, quality-of-life measures, and cost considerations associated with each surgical approach. Although the available studies differ in methodology and patient selection, these data collectively provide a framework for understanding the relative strengths and limitations of each technique in contemporary thoracic practice. The findings by outcome are summarized in Table 2.

Perioperative outcomes

Minimally invasive approaches differ fundamentally from open thoracotomy in their perioperative risk profile, offering advantages that have reshaped expectations for short-term outcomes after lobectomy. Across large comparative studies and meta-analyses, VATS is associated with several perioperative advantages over thoracotomy. Shorter hospital length of stay is consistently reported across multiple cohorts and pooled analyses (20-25). Lower perioperative complication rates are reported in some comparative studies and meta-analyses (20-22) while other cohorts demonstrate similar complication rates between approaches (23,25). Reduced intraoperative blood loss has been documented in select analyses (22,25) and shorter chest tube duration is primarily reported in meta-analytic data (22). A higher likelihood of discharge directly to home has been described in large database analysis (20). Additional multi-institutional studies further reported earlier recovery, improved delivery of adjuvant therapy, and reduced physiologic impact on pulmonary function with VATS, although these benefits are largely reported in high-volume centers with well-developed minimally invasive pathways (4,20). More recent analyses confirm these trends: one study demonstrated shorter hospitalization and trends toward reduced early complications (26), while another, using the National Cancer Database, found that minimally invasive lobectomy was associated with a significantly shorter postoperative length of stay—an important perioperative advantage—compared with open approaches (7.15 vs. 8.4 days), even among patients undergoing extended resections (27). Importantly, one matched analysis showed that the perioperative benefits of VATS—including reduced cardiovascular and thromboembolic complications and lower mortality—persist even after controlling for surgeon volume and specialty, underscoring the intrinsic advantage of the approach (21).

While most comparative data with open lobectomy are retrospective, emerging randomized trials provide corroborating evidence. Three randomized controlled trials—one conducted in Brazil, another across North America and Europe, and a third in Italy—compared RATS to VATS and offer additional insight. One trial found similar 90-day outcomes between groups, though RATS significantly reduced readmissions (28). Another multicenter randomized trial reported greater lymph node sampling with RATS and comparable early patient-reported health utility relative to VATS (29). A third reported reduced early postoperative pain, pleural effusion, and arrhythmias with RATS, although operative time was longer (30). These findings suggest that RATS may confer incremental early advantages over VATS in select domains but are not uniformly superior. Overall, while minimally invasive lobectomy appears to offer genuine short-term benefits over thoracotomy, particularly in high-experience centers, the strength of this evidence remains limited by the predominance of retrospective data and potential biases in patient selection and institutional protocols. More high-quality, prospective comparative trials remain needed to define the generalizability and magnitude of perioperative advantages across surgical platforms.

Comparisons between VATS and RATS show overlapping perioperative benefits but heterogeneous findings in several key outcomes. One randomized trial found no significant differences in perioperative complications, conversion-to-open rates, operative time, or length of stay, though it was underpowered (31). Across meta-analyses and retrospective studies, RATS has been associated with lower estimated blood loss compared with VATS (32,33). Reduced conversion-to-open rates have also been reported in several large series (33-35), whereas most studies show no significant differences in overall complications, length of stay, or short-term mortality between approaches (32,36,37). Propensity-matched analyses further refined these comparisons: RATS was associated with longer operative times and fewer dissected nodal stations, but perioperative outcomes—including chest tube duration, hospital stay, complications, readmissions, and 30-day mortality—remained similar between techniques (38). Collectively, these findings indicate that although RATS may offer modest advantages in blood loss and conversion rates, the consistency and magnitude of these differences depend heavily on study design, operator expertise, and institutional resources; perioperative outcomes are largely equivalent when examined in randomized or rigorously matched analyses. Given this, RATS and VATS likely confer similar perioperative advantages due to their minimally invasive nature, but more high-quality data are needed to parse out differences in key areas such as blood loss, conversion rates, and nodal dissection.

Survival outcomes

Survival following lobectomy appears broadly comparable across surgical approaches, with most studies demonstrating that minimally invasive techniques achieve long-term oncologic outcomes equivalent to open thoracotomy. Multiple propensity-matched and retrospective studies (23,24,39,40). Found similar overall survival (OS) and recurrence-free survival (RFS) between VATS and open lobectomy, including in patients with locally advanced disease or those treated with induction therapy. Propensity-matched analyses (41,42) also showed no significant survival differences between open and VATS approaches, while the induction therapy cohort study reported similar survival outcomes after balancing clinical characteristics (22). Several studies suggested potential long-term survival advantages with VATS: Li [2024] demonstrated higher 5- and 10-year survival with VATS (64.9% vs. 57.7% at 5 years), and Hernandez-Vaquero [2021], in a large meta-analysis, found improved long-term survival with VATS [hazard ratio (HR) =0.88; 95% confidence interval (CI): 0.81–0.96] (42,43). Nonetheless, these observations must be interpreted with caution, as nearly all studies were retrospective and susceptible to selection bias, with potential confounders such as staging accuracy and surgical experience. Moreover, the majority of evidence is derived from high-volume centers with established minimally invasive expertise, limiting generalizability. While direct comparisons of RATS and open lobectomy are limited, available studies—including Tang [2020] and Shagabayeva [2023]—support comparable 5-year OS, reinforcing that both VATS and RATS can achieve long-term oncologic effectiveness similar to open approaches (40,41).

Comparisons between RATS and VATS similarly demonstrate no consistent differences in long-term survival. Multiple retrospective and propensity-matched studies—including Zhang [2025], Casiraghi [2022], Gallina [2021], Zhang [2022], and Shagabayeva [2023]—reported similar 5-year OS and RFS between the two techniques (41,44-47). The Niu [2024] randomized trial confirmed non-inferiority of RATS compared with VATS in terms of 3-year OS and disease-free survival (DFS), and a large meta-analysis by Hireche [2022] found no difference in 3-year OS or DFS between the two platforms (22,48). Montagne [2022] further reported similar 5-year DFS for lobectomy via RATS and VATS (52.7% vs. 60.9%, P=0.24) (12). While some studies, including Zhang [2025], Gallina [2021], and Aiolfi [2021], observed higher lymph node yields with RATS, these differences did not consistently translate into improved survival (44,45,49). Casiraghi [2022] similarly found comparable OS between VATS, RATS, and open lobectomy, though VATS exhibited a higher rate of local recurrence (46). Importantly, Zhang [2025] demonstrated that lymph node count—but not surgical approach—was independently associated with OS, underscoring the importance of nodal dissection quality over technique (44). Despite early enthusiasm for RATS, critical appraisal of the literature reveals key limitations: most studies are retrospective, vary in staging methods, and often reflect outcomes from high-volume centers with dedicated robotic programs. As a result, current evidence suggests that RATS and VATS both yield equivalent long-term survival outcomes, and any observed differences in survival likely reflect differences in institutional expertise, case selection, or technical execution rather than inherent superiority of one platform.

Oncologic outcomes

Minimally invasive approaches, including VATS and RATS, demonstrate oncologic adequacy comparable to open lobectomy, with consistent evidence showing similar rates of lymph node retrieval, pathological upstaging, margin status, and long-term survival. Across multiple propensity-matched national database studies, VATS yielded noninferior OS and RFS when compared with thoracotomy, with no significant differences in nodal upstaging or positive margin rates (23,24,39,40,50). Although open lobectomy often retrieved a greater number of lymph nodes, VATS demonstrated equivalent rates of pathologic N2 upstaging and recurrence patterns in both early- and advanced-stage cohorts (23,46). These findings were echoed in meta-analyses and pooled retrospective studies, which showed that VATS yields comparable oncologic outcomes even in post-induction or stage III settings (22,49). Recent prospective data have also confirmed noninferior 3-year DFS and OS between VATS and RATS, further supporting the oncologic validity of minimally invasive approaches (48). While these data affirm that VATS provides oncologic clearance equivalent to open lobectomy across a range of clinical scenarios, most supporting studies are retrospective, vary in staging accuracy, and differ in the definition and extent of mediastinal lymphadenectomy. Moreover, matching often controls for observed covariates only, limiting adjustment for surgical expertise or center-level protocols. Overall, although open lobectomy may yield higher lymph node counts in some cohorts, VATS does not appear to compromise oncologic resection or recurrence control when performed in appropriately selected patients.

Comparisons between RATS and VATS generally support oncologic equivalence, although several studies suggest that RATS may facilitate more extensive nodal assessment. Multiple propensity-matched, single-center, and pooled analyses have reported higher lymph node yields and more comprehensive mediastinal lymphadenectomy with RATS compared with VATS (45,47,49). Casiraghi et al. [2022] reported lower local recurrence with RATS compared with VATS, while 5-year overall and cancer-specific survival remained comparable across surgical approaches (46). Similarly, Gallina et al. [2021] observed higher nodal upstaging and more extensive lymphadenectomy with RATS, though recurrence and survival outcomes were largely similar, leaving the prognostic significance of enhanced nodal assessment uncertain (45). Prospective randomized data further suggest comparable long-term oncologic outcomes between RATS and VATS, although these studies were not powered to detect small differences in survival (48). Collectively, while the oncologic equivalence of RATS and VATS is well supported, the predominance of retrospective designs, single-institution cohorts, and limited adjustment for unmeasured confounders—such as tumor complexity and surgeon experience—warrants cautious interpretation when generalizing these findings.

QOL

QOL has become an important patient-centered metric in evaluating surgical approaches for early-stage NSCLC, and the available evidence generally supports minimally invasive techniques over thoracotomy. Global health QOL refers to a patient’s overall perception of their general health and well-being, while lung cancer-specific QOL assesses symptoms and limitations related directly to the disease and its treatment. A systematic review demonstrated that thoracoscopic approaches improved multiple QOL domains—including physical functioning, emotional and physical role performance, social functioning, and bodily pain—while only isolated studies favored thoracotomy in select areas (51). Retrospective data provide additional granularity: one analysis found no significant differences in postoperative pain among open, VATS, and RATS approaches (52). In contrast, another study reported reduced acute postoperative pain and lower rates of chronic numbness with minimally invasive surgery compared with open resection; however, objective pain measures were similar between RATS and VATS. Notably, patient perception differed, with a greater proportion of individuals attributing their pain to the robotic approach (53). Additional retrospective evaluations have shown mixed but informative findings. One propensity-matched cohort demonstrated lower early pain scores and higher short-term global QOL at 6 weeks following robotic surgery compared with VATS, driven largely by reduced postoperative pain (54). In contrast, a larger single-center registry examining RATS patients before and after surgery, and in comparison with VATS and thoracotomy, found that robotic patients achieved the highest global and functional QOL and the lowest symptom burden—including fatigue, dyspnea, and pain—although these findings were influenced by small sample size and cohort imbalance (55). Overall, the evidence suggests that minimally invasive approaches to lobectomy are associated with improved QOL—particularly in physical functioning and symptom burden—compared to thoracotomy, with some data indicating modest short-term advantages for robotic surgery over VATS.

Prospective investigations offer more detailed trajectories of postoperative recovery using validated, multidimensional instruments. One study comparing all three modalities showed that robotic surgery produced lower thoracic pain scores and higher overall well-being (global health) and lung cancer-specific QOL relative to thoracotomy, with only small and transient early differences between RATS and VATS (56). Another cohort demonstrated that although RATS patients experienced a sharper early decline in physical health, QOL converged between RATS and VATS by 1 year, accompanied by parallel improvements in anxiety (44). A separate prospective evaluation directly comparing VATS and RATS found that VATS patients consistently reported higher overall QOL summary scores, improved social and cognitive functioning, and fewer symptoms—including dyspnea, neuropathy, appetite loss, and chest pain—with no QOL or fear-of-recurrence domains favoring RATS (57). These prospective studies, however, are constrained by single-institution design, modest sample sizes, significant attrition at later time points, and incomplete adjustment for factors such as surgeon-specific technique and socioeconomic variables, limiting generalizability and leaving long-term trajectories beyond 12 months uncertain. These data suggest that minimally invasive approaches—both VATS and RATS—generally yield superior QOL compared with thoracotomy, while differences between robotic and video-assisted techniques appear modest, short-lived, and domain-specific, with VATS showing advantages in select functional and symptom measures during early postoperative recovery.

Cost-effectiveness

Cost remains a major differentiator among surgical approaches, with most available evidence demonstrating substantially higher expenditures associated with RATS compared with VATS. Multiple systematic reviews and retrospective analyses consistently show that RATS carries significantly greater operative and instrument-related costs without proportional reductions in postoperative resource utilization. A systematic review found that RATS lobectomy was, on average, 25–30% more expensive than VATS, driven primarily by higher supply and operative costs rather than differences in non-operative expenditures (58). Large U.S. database analyses have demonstrated higher per-case costs for RATS compared with VATS, with incremental increases of approximately $4,000–$4,700 (59). Although certain series suggested that accumulated proficiency and reduced conversions may narrow this gap over time, cost parity was not achieved, as overall expenditures remained higher for RATS even after surpassing the learning curve (60). In a multicenter cohort analysis, operative duration—a key driver of intraoperative resource utilization—remained significantly longer for RATS compared with VATS after rigorous adjustment for patient, procedural, and surgeon factors, highlighting the potential time cost associated with robotic lobectomy (61).

Economic modeling studies reinforce this pattern. A Chinese Markov model demonstrated that while RATS may be cost-effective relative to thoracotomy, it was not cost-effective compared with VATS across realistic willingness-to-pay thresholds due to higher upfront operative costs and only marginal quality-adjusted life year (QALY) gains (62). A U.S. decision-analytic model reached similar conclusions, showing that robotic lobectomy required substantial improvements in instrument cost, operative time, conversion rates, and hospital volume before becoming cost-competitive with VATS (63). Institutional cohort data from China also demonstrated similar total hospitalization costs between VATS and open surgery, but significantly lower non-surgical costs in the VATS group, further emphasizing its economic efficiency (64). The randomized BRAVO trial found comparable 90-day total costs between RATS and VATS, but robotic procedures still incurred higher instrument and stapler expenses, with cost neutrality achieved only because of fewer readmissions—a circumstance that may not generalize beyond a controlled trial setting (28). Given that several of these studies are from single countries, particularly China, further economic assessments are needed to evaluate the cost implications of robotic versus thoracoscopic lobectomy in diverse healthcare systems, including Western nations and resource-constrained settings.

Overall, these studies are limited by heterogeneity in costing methods, inconsistent inclusion of capital and maintenance expenses, variability in surgeon experience, and differences in national reimbursement structures. Nonetheless, the overarching signal across systematic reviews, cost-utility models, retrospective cohorts, and randomized data remains consistent: current evidence suggests that VATS is the more cost-efficient minimally invasive approach, as RATS persistently incurs higher procedural and equipment-related costs without demonstrating proportional economic benefit. However, given that RATS is a relatively newer and evolving technology, future analyses will be essential as equipment costs fluctuate, efficiency improves, and broader adoption potentially alters cost structures over time.

Conclusions

Minimally invasive techniques have fundamentally reshaped the surgical management of operable NSCLC, offering clear advantages over open thoracotomy in perioperative recovery and patient-centered outcomes. VATS is well established as a cost-effective and oncologically sound approach, supported by extensive evidence demonstrating equivalent long-term survival, adequate lymph node assessment, and favorable quality-of-life outcomes. RATS achieves comparable oncologic results and offers technical advantages—including enhanced visualization, instrument articulation, and lower conversion rates—that may facilitate more extensive lymph node dissection in some series. However, although several retrospective and propensity-matched studies report higher lymph node yields and greater nodal upstaging with RATS compared with VATS, these differences have not consistently translated into improved recurrence or survival outcomes. As a result, the clinical and prognostic significance of enhanced nodal assessment with robotic surgery remains uncertain. Furthermore, RATS is associated with higher procedural costs and, in many analyses, longer operative times, and remains less economically favorable than VATS in most healthcare settings.

Future high-quality randomized trials directly comparing open, VATS, and RATS lobectomy—with standardized definitions of lymphadenectomy, longer follow-up, and robust cost-effectiveness analyses—are needed to clarify the relative value of each approach. Until such data are available, selection of surgical technique should be individualized, guided by patient characteristics, surgeon expertise, and institutional resources, rather than presumed oncologic superiority of any single platform.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-45/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-45/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-25-45/coif). J.B.V. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from September 2025 to August 2027. The other authors have no 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. Alduais Y. Non-small cell lung cancer: risk factors, diagnosis, and treatment. Medicine (Baltimore) 2023. Available online:
2. Duma N, Santana-Davila R, Molina JR. Non-Small Cell Lung Cancer: Epidemiology, Screening, Diagnosis, and Treatment. Mayo Clin Proc 2019;94:1623-40. [Crossref] [PubMed]
3. Jeon H, et al. Lung cancer management updates in 2025. Lung 2025. Available online:
4. Mangiameli G, Cioffi U, Testori A. Lung Cancer Treatment: From Tradition to Innovation. Front Oncol 2022;12:858242. [Crossref] [PubMed]
5. Hendriks LEL, Remon J, Faivre-Finn C, et al. Non-small-cell lung cancer. Nat Rev Dis Primers 2024;10:71. [Crossref] [PubMed]
6. Kang MW, et al. Evolution of lung cancer surgery. J Chest Surg 2025. Available online:
7. Raman V, et al. Surgical treatment of early-stage NSCLC. J Thorac Dis 2018. Available online:
8. Syrigos KN, et al. Minimally invasive approaches for lung cancer: unresolved controversies. J Clin Med 2025. Available online:
9. Nath S, et al. Robotic-assisted thoracoscopic surgery versus VATS: a systematic review. J Thorac Dis 2022. Available online:
10. Karuppannan A, et al. Robotic thoracic surgery: current landscape. Video-Assisted Thoracic Surgery 2025. Available online:
11. Francis J, et al. Open versus VATS versus RATS: systematic review and meta-analysis. J Cardiothorac Surg 2024. Available online:
12. Montagne F, et al. Enhanced recovery after thoracic surgery. J Thorac Dis 2022. Available online:
13. Expert Consensus Panel, American Association for Thoracic Surgery. Guidelines for minimally invasive lung resection. J Thorac Cardiovasc Surg 2023. Available online:
14. Bendixen M, et al. Pain and quality of life after lobectomy by VATS versus thoracotomy. Lancet Oncol 2016. Available online:
15. Migliore M, et al. Intercostal nerve injury after thoracic surgery. Interact Cardiovasc Thorac Surg 2018. Available online:
16. Passera E, et al. Learning curve for thoracoscopic lobectomy. Eur J Cardiothorac Surg 2017. Available online:
17. Migliore M, et al. Uniportal VATS: technical considerations. Eur J Cardiothorac Surg 2020. Available online:
18. Gonzalez-Rivas D, et al. Advances in uniportal VATS. Thorac Surg Clin 2016. Available online:
19. Adult Cardiac Surgery Database, General Thoracic Surgery Database: 2023 Annual Report. The Society of Thoracic Surgeons; 2024. Available online:
20. Nwogu CE, et al. Outcomes of open versus minimally invasive lobectomy. Ann Thorac Surg 2015. Available online:
21. Ezer N, et al. Postoperative outcomes after VATS versus thoracotomy. Ann Am Thorac Soc 2018. Available online:
22. Hireche K, et al. VATS versus open lobectomy after induction therapy. J Surg Res 2022. Available online:
23. Hireche K, et al. Minimally invasive lobectomy for stage III NSCLC. Cancers 2023. Available online:
24. Yun J, et al. VATS versus open lobectomy in large tumors. J Cardiothorac Surg 2022. Available online:
25. Cao J, et al. Surgical outcomes after neoadjuvant therapy. Clin Lung Cancer 2024. Available online:
26. Kim D, et al. Open thoracotomy versus MIS: meta-analysis. Cancers 2023. Available online:
27. Chen D, et al. NCDB analysis of minimally invasive lobectomy. Clin Lung Cancer 2024. Available online:
28. Mingarini Terra R, et al. BRAVO trial: cost-effectiveness of robotic lobectomy. Ann Surg 2025. Available online:
29. Patel YS, Baste JM, Shargall Y, et al. Robotic Lobectomy Is Cost-effective and Provides Comparable Health Utility Scores to Video-assisted Lobectomy: Early Results of the RAVAL Trial. Ann Surg 2023;278:841-9. [Crossref] [PubMed]
30. Catelli C, Corzani R, Zanfrini E, et al. Robotic-assisted (RATS) versus video-assisted (VATS) lobectomy: a monocentric prospective randomized trial. European Journal of Surgical Oncology 2023;49:107256.
31. Veronesi G, et al. Robotic approach versus manual videothoracoscopic resection (ROMAN). Front Oncol 2021. Available online:
32. Ma J, et al. Robotic versus thoracoscopic lobectomy: meta-analysis. BMC Cancer 2021. Available online:
33. Ueno H, et al. Robotic versus thoracoscopic lobectomy outcomes. Surg Today 2025. Available online:
34. Liang H, et al. Robotic versus thoracoscopic lobectomy outcomes. Ann Surg 2018. Available online:
35. Kent MS, et al. Pulmonary Open, Robotic, and Thoracoscopic Lobectomy (PORTaL). Ann Surg 2023. Available online:
36. Guo F, et al. Prognostic comparison of RATS and VATS. Medicine (Baltimore) 2019. Available online:
37. Otorkpa MJ, et al. Perioperative outcomes of RATS versus VATS. Cardiothorac Surg 2025. Available online:
38. Lampridis S, et al. Propensity-matched RATS versus VATS analysis. Cancers 2023. Available online:
39. Yang CJ, et al. Stage II NSCLC survival outcomes. Ann Surg 2021. Available online:
40. Tang A, et al. Nodal upstaging after robotic lung resection. Ann Thorac Surg 2020. Available online:
41. Shagabayeva L, et al. Outcomes after open, VATS, and robotic lobectomy. Ann Thorac Surg 2023. Available online:
42. Li Y, et al. Ten-year survival after lobectomy. Transl Lung Cancer Res 2024. Available online:
43. Hernandez-Vaquero D, et al. Survival after VATS versus open lobectomy. Ann Thorac Surg 2021. Available online:
44. Zhang J, Yip R, Taioli E, et al. Quality of life outcomes after robotic-assisted and video-assisted thoracoscopic surgery for early-stage non-small cell lung cancer. JTCVS Open 2025;24:383-93. [Crossref] [PubMed]
45. Gallina FT, et al. Nodal upstaging after robotic lobectomy. Front Surg 2021. Available online:
46. Casiraghi M, et al. Long-term oncologic outcomes across approaches. J Clin Med 2022. Available online:
47. Zhang F, et al. Lymph node dissection in RATS versus VATS. Front Oncol 2022. Available online:
48. Niu Z, et al. Robotic versus video-assisted lobectomy (RVlob): randomized trial. EClinicalMedicine 2024. Available online:
49. Aiolfi A, et al. Network meta-analysis of open, VATS, and RATS. Surgery 2021. Available online:
50. Yang CJ, et al. Long-term survival after minimally invasive lobectomy. Ann Surg 2019. Available online:
51. Singer ES, et al. Operative approach and quality of life. J Thorac Dis 2020. Available online:
52. van der Ploeg A, et al. Postoperative pain after robotic and thoracoscopic surgery. J Robotic Surg 2020. Available online:
53. Kwon ST, et al. Acute and chronic pain outcomes after lobectomy. J Thorac Cardiovasc Surg 2017. Available online:
54. Zheng L, et al. Quality-of-life comparison of RATS and VATS. J Thorac Dis 2022. Available online:
55. Asemota N, et al. Patient-reported outcomes after lung surgery. J Clin Med 2023. Available online:
56. Novellis P, et al. Pain and recovery after minimally invasive lung surgery. J Clin Med 2021. Available online:
57. Cannon J, Win T. Long-term quality of life after lung resection. Thorac Surg Clin 2008;18:81-91. Retraction in: Thorac Surg Clin 2008;18:xiii.
58. Keeney-Bonthrone T, et al. Cost-effectiveness of robotic lung resection. Video-Assisted Thoracic Surgery 2020. Available online:
59. Sbeih D, et al. Cost considerations in robotic thoracic surgery. J Clin Med 2025. Available online:
60. Harrison OJ, et al. Learning curve and cost in robotic thoracic surgery. Front Surg 2023. Available online:
61. Tupper K, et al. Operative duration and economic impact of robotic surgery. J Thorac Cardiovasc Surg 2024. Available online:
62. Chen D, et al. Cost-effectiveness modeling of robotic lung surgery. Lung Cancer 2021. Available online:
63. Heiden BT, Mitchell JD, Rome E, et al. Cost-effectiveness of robotic lobectomy. The Annals of Thoracic Surgery 2022;114:265-72.
64. 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]