Approaching lobectomy in a VIOLET tinted world: video-assisted thoracoscopic surgery (VATS) vs. open thoracotomy for lobectomy

Introduction

Over the past three decades, discussions in thoracic surgery have surrounded the use and importance of minimally invasive surgery (MIS). This all began with the introduction of thoracoscopy in the 1990s. Following evidence in the early 2000s proving comparable oncological outcomes with open surgery, MIS became an accepted option for lung cancer surgery (1). More than 30 years later, the debate between open and MIS lobectomy—including both video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS)—has been continuously revisited with no clear consensus. While there are multiple contributing factors, there have been few randomized controlled trials (RCTs) designed to answer this question and fewer with sufficient power. However, with the publication of the VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy (VIOLET) trial results, the call for an RCT comparing VATS and open thoracotomy for lobectomy in early-stage lung cancer was finally answered (2). In this review, we discuss the VIOLET trial in the context of the prevailing literature on thoracoscopic versus open lobectomy. We hope to emphasize prevailing trends in this field of research and point out the strengths and weaknesses of the VIOLET study itself. Finally, we hope to close the book on the question of VATS versus open lobectomy and recommend a future direction for research.

Approaching our understanding of surgical approach

We must begin by revisiting why we began asking the question of VATS vs. open thoracotomy for lobectomy in the first place. This should be obvious. As a field, we have always aimed to treat, if not cure, early-stage lung cancer, and we began to wonder if VATS would lead to improvements in long term survival. So, primary outcomes in studies comparing these surgical approaches often focus on all-cause survival, recurrence-free survival, and/or operative mortality. The other benefits VATS may pose cannot be ignored. When compared to the large incision associated with thoracotomy, the three smaller incisions along with high definition thoracoscopy in VATS may decrease operating time, reduce surgical complications, shorten length of stay, reduce post-operative pain, and lead to greater patient satisfaction. Though the questions remain, do the theoretical benefits of VATS actually translate to clinical outcomes? And if so, are minimally invasive approaches actually better operations?

While retrospective studies and meta-analyses have evaluated these topics for years, they are regularly accompanied by calls for a RCT (3). But, in order to demonstrate the superiority of VATS, these trials must display a clear advantage in clinical outcomes, pain, and length of stay in addition to fewer complications, lower mortality, and longer overall or recurrence free survival (4).

However, in articles touting the benefits of VATS, the requirements to establish its superiority are often forgotten. The most recent reviews argue that oncologic outcomes and long-term oncological survival are agnostic to surgical approach, even despite some short-term benefits that have been shown for MIS (5). Kim et al. argue in their systematic review and meta-analysis that even though VATS is accepted as the new standard of care, the data does not establish that MIS offers a benefit in patient safety or survival. They conclude that we must not forget the primary value of lung cancer surgery: to treat the cancer and improve survival (6).

The American Association for Thoracic Surgery (AATS) 2023 consensus guidelines for the management of patients with early-stage non-small cell lung cancer (NSCLC) leave the decision of operative approach to surgeon preference, given that oncologic principles are not comprised (7). With the question of VATS vs. thoracotomy for lobectomy unanswered, it remains necessary that thoracic surgeons understand the impact of surgical approach for lobectomy. We aim to clarify the implications of the VIOLET trial and put them in the context of the 30-year experience with VATS.

The VIOLET colored question

To date the VIOLET trial is the largest RCT to compare VATS and open lobectomy (2). The publication made waves simply by showing that a randomized study of this magnitude could even be performed. However, in order to appreciate the significance of the VIOLET trial, we must first explore its structure and conclusions.

The VIOLET study was a double arm, multicenter, randomized trial that investigated the impact of surgical approach (VATS or thoracotomy) for lobectomy in early-stage lung cancer patients (2). Lim et al. designed the VIOLET study with the uncommon primary outcome of physical function at 5 weeks post-lobectomy. This was quantified by the European Organization for Research and Treatment of Cancer core health-related quality of life questionnaire (EORTC QLQ-C30). Using this validated questionnaire, a self-reported physical function score of 0–100 was generated based on five multi-scale questions intended to gauge a patient’s physical status (e.g., difficulty taking a short walk on a scale of 1–4) (8). A value of 5 points on this 100-point scale was defined as the threshold for a clinically significant difference (9). Secondary outcomes included clinical efficacy, safety, and oncologic outcomes to 1 year. In order to be able to qualify for the study, participants needed to have a suspected or confirmed primary lung cancer, with a clinical tumor stage of 1–3 (cT) and regional lymph node involvement stage of 0–1 (cN) with no metastases [based on the 8^th edition of the tumor, node, metastasis (TNM) staging criteria by the International Association for the Study of Lung Cancer]. The disease had to be considered suitable for both VATS and open lobectomy. Once recruited, participants were randomly assigned to an operative cohort. Both the participant and research nurses were ostensibly blinded to the surgical approach until time of discharge.

Without a primary endpoint focused on survival or oncologic outcome, it becomes clear that this trial was not designed to argue the superiority of VATS over open lobectomy. With a focus on self-reported physical function at 5 weeks post-lobectomy, the study goal appears to be investigating the impact of lobectomy approach on short-term surgical recovery.

A total of 503 patients were included in this trial, with 247 randomized to VATS and 256 to open lobectomy. Greater than 50% of patients in both cohorts had a clinical T stage of 1. At the conclusion of the trial, Lim et al. (2) showed no difference in overall in-hospital mortality, serious adverse events, or progression or recurrence of lung cancer between the two groups with short-term 12-month follow-up.

There was a lower incidence of in-hospital adverse events in the VATS group (32.8%) compared to the open (44.3%); ostensibly reflecting a 25% decrease. Based on data in the supplementary appendix, the major contributors to this difference are infections and renal complications. The rate of “infections and infestations” was 16.2% in the VATS group and 27.8% in the open group and the rate of “renal and urinary disorders” was 2% in the VATS group and 6% in the open group. However, given that the randomized patients were presumably healthy enough for either operation, it is not clear why patients in the open cohort were more likely to develop infections, infestations, or renal complications. Further, in the case of “infections and infestations”, the major contributor to in-hospital complications, it should be noted that these were better handled in the open cohort. Only 5 of 71 (7%) patients with infections and infestations were classified as having a severe adverse event (SAE) in the open cohort, while 9 of 40 (22.5%) patients with infections and infestations were classified as having a SAE in the VATS cohort. Additionally, 2 patients died from pneumonia in the VATS group while there were no pneumonia-related deaths in the open group. It is also worth acknowledging where patients in the VATS cohort did poorly, as in the case of pulmonary air leakage. Nearly 2× more VATS patients experienced air leaks (15% vs. 8%). Critical analysis of the supplemental data leads us to further question whether the claim of fewer in-hospital adverse effects could possibly be a consequence of the surgical approach and if it truly indicates that patients randomized to VATS performed better post-operatively. Importantly, there was no difference in in-hospital SAE between the two groups [risk ratio 0.98 (95% confidence interval: 0.59 to 1.63]. Overall, the data does not illustrate a clear benefit to VATS surgery. Instead, several outcomes appear to identify hazards to a minimally invasive approach.

Unfortunately, if there is an advantage to VATS surgery, this study appears to suggest they are limited to the short term. There was a 1-day shorter hospital stay in the VATS group and a statistically significant improvement in physical function at 5 weeks post-surgery. However, with 4.65 greater points on the self-reported questionnaire, this did not achieve the predefined five-unit “minimally important difference”. The difference was also not significant at 6 months and 1 year.

The conclusion of a shorter hospital stay in the VATS cohort should be interpreted with caution. This statistic is often cited by proponents of VATS. However, while the median hospital stay was shorter by 1 day in patients receiving VATS, it is not necessarily clear why. Despite the claim by Lim et al. that this is a result of fewer in-hospital complications, it may simply be a result of a difference in surgeon management of VATS vs. thoracotomy patients. In practice, surgeons will often place two chest tubes in patients undergoing thoracotomy and one in patients undergoing VATS. These chest tubes are often removed on separate days, and patients may simply be kept in the hospital an extra day for this reason. With no standardization or discussion on the use of chest tubes for post-operative drainage in the study methodology, the possibility that this may be the reason for the difference on the duration of patients’ hospital stay should not be disregarded (9).

While not discussed extensively in the publication, it is important to acknowledge that bleeding as a result of vascular injury that prolonged hospital stay occurred in 4.7% of participants in the VATS group (6 of 129) compared to only 0.8% (1 of 127) in the open thoracotomy group. This specific serious adverse event was only added partway through the study and therefore not documented for all participants. It is surprising that this was not reported for the entire patient population, given bleeding as a result of vascular injury is an important concern with VATS and is major reason surgeons will convert from VATS to thoracotomy. This is consistent with the VIOLET study population, where 15 of the 247 patients randomized to VATS (6.1%) underwent an open thoracotomy, and 14 of these were converted intraoperatively for adhesions and bleeding (2).

It is important to highlight that surgeon decision-making is notably absent from the main text of the trial results. Since the trial involved randomization, inclusion criteria required that patients be candidates for both VATS and an open approach. However, the authors did not discuss patient factors that would have resulted in exclusion from VATS. For example, previous surgery, aberrant anatomy, obstructed views, significant medical history, or inability to maintain single lung ventilation. Of particular note, patient body mass index (BMI) often contributes to deciding operative approach. With the importance of this factor, it is surprising to see that BMI is not included in the table of patient characteristics.

With their results, the VIOLET trialists conclude that VATS lobectomy for early-stage lung cancer is associated with a better recovery of physical function 5 weeks after surgery compared to open surgery (2). It should be noted, that nowhere does this article conclude superiority of VATS to open lobectomy. Further, while there was a significant difference in physical function 5 weeks after surgery between the two groups, this did not meet their a priori standard of clinical significance.

Further, patients were “blinded” to the surgical approach during their hospital stay by covering the thoracotomy or VATS incisions with “a wound dressing sufficiently large to conceal a thoracotomy incision”. We assume this means a dressing covering the entire chest wall since a 3- or 4-incision VATS approach requires intercostal incisions in both higher (usually 3^rd or 4^th) and lower spaces (usually 7^th or 8^th) spaces. A dressing that is designed to only cover a thoracotomy incision in a single intercostal space (usually 5^th or 6^th) would fail to obscure a thoracoscopic incision strategy as it is commonly performed. While blinding participants to their treatment is a strength of this article, patients were alerted to the operation they received at discharge. Therefore, only outcomes related to the hospital stay, which is under 5 days on average, should be considered blinded (10).

Perhaps most importantly, the blinding appears to disprove the greatest purported strength of thoracoscopy: post-operative pain. On the day of discharge, only 51.2% of patients in VATS groups were able to correctly guess they had MIS, and only 45.74% in the thoracotomy group guessed that they had open surgery. A correct response rate of 50% would suggest random chance: meaning that neither group of patients were able to guess their procedure. In fact, more than half of thoracotomy patients thought they had small incisions. These results are worse for advocates of VATS lobectomy. More than half of open surgery patients guessed that they had MIS. If most patients in a group of 208 who receive a significantly larger, rib-spreading (often rib-breaking), muscle dividing incision think they had VATS incisions, this effectively disproves the theoretical pain advantage of thoracoscopic MIS. The authors note that “prolonged incisional pain”—defined as the need for pain medications >5 weeks—was noted in 59.6% of VATS patients and 72.3% of thoracotomy patients with a similar trend in pain scores. However, there were no significant differences in performance metrics on the quality of life questionnaire during this same time period. Further, the type and quantity of medication is not specified, and this finding was only observed after patients were no longer blinded to their surgery. The only performance outcome that was statistically significantly was at 5 weeks, and did not achieve pre-established study thresholds for a minimally clinically important difference. Paradoxically, this appears to suggest that there may not be a pain advantage to performing VATS surgery.

Overall, this study still provides a much-requested randomized trial comparing VATS and open lobectomy. However, we should be careful of the conclusions we make based on this study. In the case where lobectomy and VATS can both be performed for a patient with early-stage lung cancer, both procedures have similar oncologic outcomes. Given differences in short-term patient outcomes, VATS may be considered. However, the data does not suggest that VATS should be the standard of care. Patient comfort and pain should be a priority, but only secondary to the ability to safely treat the patient.

While the VIOLET trial seemed to support the underlying belief that VATS is better tolerated by patients, the data did not support this conclusion. As was described by Rizk et al. in their 2014 prospective study hoping to codify VATS’s superiority with regards to pain and quality of life, the choice of surgeon operative approach needs to reflect the reality of the data, not “our own prejudices” (11). VATS may offer short term benefits, but these may not be clinically significant or reproducible—in the case of incisional pain—and we should be careful to not overstate the benefits of this approach. Given this perspective, we don’t believe that this paper will change the practice of surgeons that are already comfortable with both VATS and open thoracotomy for lobectomy. However, Lim et al. subsequently published a much lengthier article discussing the results of VIOLET for the United Kingdom’s (UK) National Health Service (NHS) (12). This publication, with an added cost-effective analysis, was written to provide support for the adoption of VATS by the NHS and may allow for national-level policy change and increased access to VATS across Great Britain.

Zooming out to see the rainbow: a broad perspective on VATS vs. thoracotomy

An in-depth review of the VIOLET data makes it clear that there is much more to the question of whether VATS or open surgery should be performed. VIOLET’s conclusions are limited to cases of early-stage lung cancer where both VATS and open thoracotomy are considered viable options. However, this is often not the case. The question is more often which approach maximizes patients’ safety. Therefore, even despite the publication of VIOLET, non-randomized studies discussing the use of MIS for more complex resections provide important insight (13). It is overzealous to think we can arrive at a one-size-fits-all recommendation for lobectomy. Each patient is different and a safety-focused, bespoke approach should be considered in the context of clinical condition, anatomy, and surgeon judgement.

Numerous reviews of MIS versus open surgery have been conducted in the literature. Frequently, authors publish that VATS lobectomy offers similar long-term outcomes, with improved short-term outcomes with regards to in-hospital complications, pain, length of stay, and improved physical functioning (14). Previous concerns regarding differences in lymph node retrieval between VATS and open surgery have been shown to not significantly differ (15). Nodal retrieval appears to be, in large part, a result of surgeon effort, instead of operative approach. Generally, the conclusion seems consistent: when VATS is feasible, the short-term benefits lead many surgeons experienced in MIS to favor VATS over thoracotomy.

However, in some patients VATS is simply not optimal, not safe, or not possible. Unfortunately, judgment underlying the decision to perform a thoracotomy over VATS is the factor that is most often not discussed. Compounding this issue, since most studies are retrospective—and neither randomized nor blinded—patient choice and surgeon judgement become sources of inherent selection bias (16). Combined with flawed data-gathering and limitations in study methodology, this leads to further publication bias that culminate in studies that over promise the benefits of VATS (17). We must recognize that the decision to perform VATS over thoracotomy is often not an equal one. Unfortunately, a clear answer may never reach consensus. Given this inherent difficulty to compare surgical approaches without bias, maybe we should conclude that instead the question is a poor one. The argument that VATS offers a new and therefore better approach compared to thoracotomy is inappropriate (6). Rather than evaluating which technique, our questions should focus on why: what criteria lead a surgeon to select VATS over thoracotomy, or vice versa?

Studies have shown that many factors contribute to the decision of surgical approach. Phillips et al. previously conducted a retrospective analysis and found that patient factors, including age and Hispanic ethnicity, and surgeon training were predictors of operative approach (18). In another large retrospective analysis, Wolf et al. showed that undergoing VATS was associated with lower comorbidity index, private insurance, older age, and hospitals with a higher annual lung surgery value. Thus, they show that patient- and hospital-related factors that impact morbidity and mortality also affect the decision of whether a patient undergoes VATS or open surgery (19). These publications highlight that factors ranging from patient characteristics to institutional preference impact the decision of a patient’s lobectomy approach. This further supports our argument that with selection bias taking place at every level of the decision of VATS vs. thoracotomy, even the most rigorous retrospective studies are unable to truly gauge the sole impact of surgical approach on lobectomy outcomes (20). However, unfortunately, it also makes it clear that we cannot understand how surgeons decide upon surgical approach based on review of retrospective databases. This provides more reason why surgeon discussion regarding selection criteria for VATS vs. open thoracotomy in the case of lobectomy needs to be published.

It is possible that there are specific cases where VATS is better indicated than thoracotomy, and vice versa. Unfortunately, these situations may be difficult to define. For example, in geriatric patients, is a VATS approach safer with smaller incisions, or an open approach that may shorten the operative time? Even if these questions go unanswered, publications that highlight how surgical approaches can be optimized to ensure patient safety may prove useful. In their narrative review, Matern and Bao do this for the case of VATS in geriatric patients, highlighting perioperative, intraoperative, and postoperative measures that can be undertaken to optimize overall recovery following surgery (21).

It is also worth considering that in the current landscape, surgical approach for lobectomy may matter less. Thanks to staplers, the incision for thoracotomy is not as large as it once was (17). Further, outcomes from both procedures have been fortified by enhanced recovery protocols (ERPs). Krebs et al. showed that in the case of both VATS and open lobectomy, in the setting of a comprehensive ERP program, short-term outcomes were similar (22). In a subsequent study, this group showed that ERPs can have sustained impacts. Up to 3 months post-operatively, ERP implementation was associated with decreased opioid use (23). With optimization of thoracotomy and improvements in post-operative care, it is possible surgical approach is not the defining factor for the patient experience.

When VATS fails: contraindications

With improvement in VATS technology and growing surgical experience, the contraindications for VATS have evolved. From a technical perspective, contraindications for VATS are more dependent on surgeon experience and comfort (24). In terms of tumor characteristics, surgeons agree that certain factors, including large tumor size and centrality, may contraindicate VATS (25). In terms of patient characteristics, the only de facto contraindication of VATS that has endured is the inability of a patient to tolerate single-lung ventilation; which might also preclude lung surgery in any form (26).

In our institution (Mount Sinai, New York), the indications for planned thoracotomy or non-emergent conversion include a list of high-risk features when open surgery offers a safety advantage. These include; obesity, obstructed views, elevated diaphragm, small chest volume, dense adhesions, asbestosis, aberrant anatomy that complicates surgical approach, inability to maintain single lung ventilation, injury, bleeding, a high standard uptake value on positron emission tomography that may increase the risk of locoregional spread with excessive manipulation, or a significant medical history where open surgery may be faster. We refer to this guideline as a “three-strikes list” but will also perform an open procedure when surgeon judgement dictates.

Even if a lobectomy is planned with a VATS approach, it is important to remember that the decision is not final. Most procedures begin with a diagnostic thoracoscopy. This helps to evaluate for advanced disease, the anatomy of the lung, and the patient’s overall candidacy. Though the intention to perform VATS has become the standard, surgeons should feel comfortable performing thoracotomy to reduce operative risk, limit time on the table, or optimize surgical outcomes. Reports of catastrophic complications have also been documented in hopes of educating others on how to handle them. Flores et al. reported 12 patients who had catastrophic complications during VATS lobectomy over an 8-year period at a single institution, with conversion to thoracotomy taking place in nine of these cases. These complications included pulmonary arterial/venous transections requiring reanastomosis, injuries requiring unplanned further parenchymal resection (pneumonectomy or bilobectomy), tracheoesophageal fistula, membranous airway injury to the bronchus intermedius, injury requiring subsequent splenectomy, injury to the pulmonary vein, and injury to the azygos/superior vena cava junction (27). Decaluwe et al. analyzed intraoperative complications and conversions in the case of VATS anatomical lung resections across six European institutions. In their patient cohort, conversion to thoracotomy took place in 170/3,076 patients, with 50 of these happening for technical reasons and 83 for complications. These complications, similarly, consisted of transections of bronchovascular structures, injuries to gastrointestinal organs or proximal airways, and complications that were immediately life-threatening or required additional unplanned major surgery. Interestingly, Decaluwe et al. found that the probability of conversion for non-oncological reasons independently correlated with surgeon experience (defined as having 10 or more surgeries as experience) but not to vascular injuries or major complications (28). It is important to acknowledge that complications can and will happen in VATS lobectomy, regardless of surgical experience. Therefore, more discussion of complications is necessary to improve our outcomes and provide continuous learning opportunities.

Perhaps most importantly, the perception of thoracotomy must change: the need to convert should not be viewed as a failure. No significant difference has been shown in outcomes for converted thoracoscopic lobectomy vs. upfront thoracotomy lobectomy (29,30). And, even the VIOLET trial appears to suggest that there is no difference in long term post-operative pain or functional outcomes (2). As a field, we must not fear the need to convert. With patient safety and treatment as a priority, preparations to convert should be standard and surgeons should be trained to handle complications that are bound to occur. For this reason, further development of better ways for surgeons to prepare for the likelihood of conversion is needed. One possible approach includes the development of reliable scoring systems for conversion risk (31). Approaches like these can improve preoperative surgical planning and prepare surgeons for the possibility of intraoperative complications requiring thoracotomy.

Teaching to VATS

There is no doubt that MIS is generally preferred and VATS is the modern standard of thoracic surgery (32). Recognizing the need for experience with MIS, the American Board of Thoracic Surgery mandated that thoracic track trainees conduct 10 MIS anatomic resections in 2012 (33). With the rise in the use of VATS across the US and acknowledgement of the need of trainee experience with MIS lobectomy specifically, the board now mandates that thoracic track trainees complete 25 MIS lobectomies as a part of their training (34). In addition to these requirements, surgeons have described how they teach thoracoscopic lobectomy, building educational content (35).

With this focus on education, it is important to appreciate that, as with any surgical skill, there is a learning curve associated with minimally invasive approaches. Haidari et al. review the existing literature on VATS lobectomy training approaches and recommend a multifaceted educational approach, consisting of theory, simulation, supervised clinical training, and independent clinical practice (36). While ideal training approaches seem clearer, the question of what constitutes sufficient training is difficult to answer. Yao et al. analyzed cases of one surgeon in their institution to determine the number of cases necessary to overcome the learning curve of VATS. Using moving average and the cumulative sum method, they found that the peak point for operation time took place at the 26^th case, suggesting that the learning curve for VATS requires ~26 cases (37). This is nearly consistent with the 25 cases mandated by the American Board of Thoracic Surgery.

However, competency and proficiency are two different things. Learning curve analysis may reveal the amount of training needed for a surgeon to be competent, demonstrating safety and efficacy. Proficiency on the other hand, a metric of efficiency and consistency, requires much more experience. Li et al. analyze two surgeons’ experience with VATS lobectomy to provide insight to this question. They found that between 100 and 200 cases were needed for these two surgeons to develop efficiency in terms of operative time and blood loss. However, consistency was not achieved at the 200-case endpoint in their study, suggesting that further experience is necessary to achieve that (38). Further work in this space is necessary to clearly understand the amount of training necessary for surgeons to confidently, safely, and consistently conduct VATS lobectomy.

In addition to training residents and fellow in the basics of thoracoscopic approach, it is essential that education covers handling conversions of MIS to thoracotomy (5). There is robust enthusiasm in the literature for robotic training among thoracic surgery trainees (39). Unfortunately, few articles, if any, with regards to thoracic surgery warn of the potential loss of open skills with a decreased focus on thoracotomy, despite similar concerns in other surgical disciplines (40). Only with this training can we ensure the next generation of thoracic surgeons will be prepared to handle the complexity of thoracic cases, be ready to handle complications, and not solely be dependent on a minimally invasive approach.

The rise of the robots

A discussion of MIS in the case of thoracic surgery would be incomplete if it did not include a discussion of RATS. RATS, with its increased degrees of freedom and 3D visualization, can largely be used in any case that VATS can be, and in some cases may offer advantages. However, for RATS to supersede VATS as the optimal MIS approach, questions with regards to the benefit the robotic approach offers with regards to operative time, incision size, post-operative pain, and cost must be addressed (3). Existing review articles offer a more in-depth analysis of the literature comparing VATS and RATS (5,41,42). Overall, the conclusions seem to be consistent: RATS offers a reasonable alternative to VATS for lobectomy, with limited differences in patient short-term outcomes. There are of course drawbacks. RATS routinely uses 1 to 2 more incisions than VATS, has a steeper learning curve, eliminates tactile feedback, and requires the uses of a limited inventory of proprietary instrumentation.

Even if the reasonable benefits offered by RATS hold true, the conversation regarding the cost of RATS remains an important one. In a recently published cost analysis, Harrison et al. demonstrate that, following surgeon experience with RATS, there is no significant difference in operating room cost between VATS and RATS. However, we must understand that this is in the case of a hospital with the highest volume of lung cancer resection in the UK NHS (43). While their center may have a sufficient volume to offset the up-front cost of establishing RATS, this may not be generalizable for smaller hospitals. Further work is necessary to determine in what cases RATS offers a similar cost to VATS and when it might be practical for a smaller system to consider investing in RATS.

Our discussion of the training of VATS and how it compares to thoracotomy holds for RATS as well. With regards to addressing complications and the need for conversion to open surgery, VATS and RATS may be viewed under the same MIS umbrella when compared to open thoracotomy. Similarly, to the case of VATS, it is in the case of handling complications that more work is necessary. Cerfolio et al. describe their experience with converting from RATS to thoracotomy in the case of major vascular injury and approaches to handling these situations when they occur. They describe management of bleeding and preparation for a non-hurried, elective thoracotomy to repair injuries (44). Publications like these that highlight surgical pitfalls and recovery techniques are necessary if RATS is to replace VATS as the premier option for MIS.

Conclusions

Overall, MIS, whether it be VATS or RATS, is an important approach for lobectomy. The data is clear, VATS is a safe and oncologically sound approach for lobectomy. However, when it comes to its superiority over open thoracotomy, we argue that the question is flawed. Surgical approach for lobectomy is a difficult decision with many factors. Surgical decision making cannot be generalized, and given the most recent AATS guidelines to leave the decision of surgical approach for lobectomy to the operating surgeon, our reasoning seems to fall in line. There is no doubt, VATS is an important approach in thoracic surgery. Now, nearly three decades of work and the publication of VIOLET, the largest RCT begging the question of VATS vs. thoracotomy to date, support the fact that VATS is an essential approach to conducting a lobectomy. However, this does not mean VATS is always going to be the perfect approach. That conclusion cannot be made. Due to the inherent bias, it is practically impossible to compare these two surgical approaches in all cases and arrive at a one-size-fits-all conclusion. The only broad conclusion we can draw is that surgeon priority for patient safety and treatment should apply 100% of the time. Where the literature on MIS and open thoracotomy could benefit is from discussions of contraindications and indications for both surgical approaches in the case of lobectomy. It is with this information that surgeons can continue to make educated decisions regarding their own approach to lobectomy.

MIS may be the new standard of care for lobectomy, but thoracotomy remains the benchmark for safety. We cannot forget where we came from. In a crisis we convert to thoracotomy, and it is essential we retain the skillset to do so. Thoracic surgical education must further stand in line with this need to reinforce training of open thoracotomy, conversions, and techniques to avoid complications. MIS has changed the field, but we must remember why we do these cases, and it is not just for the sake of making smaller incisions with no pain. We do lobectomies to treat cancer, and thus, patient safety and survival should remain our north star.

Acknowledgments

Funding: None.

Footnote

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-23-76/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-23-76/rc). R.F. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from March 2022 to February 2026. 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/.

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