Video-assisted thoracic surgery (VATS) segmentectomy for early-stage non-small cell lung cancer: current evidence and future perspectives—a narrative review

Background and Objective: Segmentectomy has emerged as a lung-sparing alternative to lobectomy for patients with early-stage non-small cell lung cancer (NSCLC). Recent randomized trials have demonstrated that segmentectomy can achieve oncological outcomes comparable to, or even superior to, lobectomy while preserving pulmonary function. The widespread adoption of video-assisted thoracoscopic surgery (VATS) has further enhanced the feasibility and safety of anatomical sublobar resection. This narrative review aims to summarize current evidence, oncological and functional outcomes, technical advances, and future perspectives of VATS segmentectomy for early-stage NSCLC.

Methods: A comprehensive literature search was conducted using PubMed, Web of Science, and Google Scholar. The search included English-language publications from January 1995 to March 2026. Keywords included “lung cancer”, “segmentectomy”, “VATS”, and related terms. The review focused on major phase III clinical trials, retrospective analyses, and recent studies evaluating surgical outcomes and technological innovations.

Key Content and Findings: Evidence from pivotal trials (JCOG0802/WJOG4607L and CALGB/Alliance 140503) strongly supports the oncological validity and functional advantages of segmentectomy. Recent post-hoc analyses further suggest survival benefits even for radiologically pure-solid tumors, highlighting the importance of tailored patient selection based on the consolidation-to-tumor ratio (CTR). Furthermore, identifying preoperative predictors for spread through air spaces (STAS) is crucial for optimizing indications. Technically, the integration of preoperative 3D planning and intraoperative indocyanine green (ICG) fluorescence has significantly improved the precision of identifying intersegmental planes, allowing VATS to remain a highly practical and versatile standard compared to robotic platforms. Advances in simulation-based training and artificial intelligence will help overcome the steep learning curve.

Conclusions: VATS segmentectomy represents an evidence-based, function-preserving surgical option for selected early-stage NSCLC patients. Precise patient selection via radiological phenotyping, combined with ongoing technological innovations, will continue to refine its reproducibility and global applicability, reinforcing its role as a cornerstone of modern minimally invasive thoracic surgery.