Conventional video-assisted thoracic surgery (VATS) vs. robotassisted lobectomy: where is the money?

The past 20 years have seen growing evidence for minimally invasive thoracic surgery, namely the widespread adoption of video-assisted thoracic surgery (VATS). The pinnacle of this procedure is the VATS lobectomy, which has thus far spawned multiple adaptations, such as robot-assisted, single-port and subxiphoidal approaches to mention only a few (1-3). Despite much higher adoption rate and more advanced technology, boundaries to conducting safe, efficient, reliably reproducible, minimally invasive surgery persist. Currently, the single-port approach offers no reported benefits over the conventional VATS lobectomy (4,5). Likewise, the robot-assisted VATS approach is reportedly non-inferior to that of conventional VATS (6). Debate about the rationality of the robot-assisted VATS approach is ongoing, as many surgeons feels the costs do not yet offset the benefits of this approach, as direct costs were significantly higher (robot-assisted surgery cost $25,040.70 vs. $20,476.60 for VATS) (7,8). Single-center reports have described higher incidence rates of laryngeal nerve palsy and chylothorax with robot-assisted VATS than with conventional VATS (9). These reports confirm that all of the approaches mentioned here are non-inferior to the conventional multiport VATS approach, and use of these alternative approaches remains the prerogative of the experienced surgeon.