Intuitively, a minimally invasive approach should provide considerable improvement in perioperative outcomes. Early in the VATS experience, two very small prospective trials comparing the initial VATS lobectomy experience to open lobectomy did not show a benefit of perioperative outcomes but reported a reduction in perioperative complications [5, 6]. There have been no recent randomized trials comparing the two approaches despite significant technical improvements in both MIS and open surgical approaches.

Non-randomized comparative published series have, however, repeatedly reported on the perioperative superiority of the MIS approaches to reduce early post operative pain, to lessen early pulmonary dysfunction, to shorten length of hospital stay and to allow an earlier return to usual activities of living [7, 8]. These advantages are particularly noted in the geriatric and/or frail populations where lesser perioperative pain translates in a significant reduction in needs for perioperative analgesia that often contributes to complications in these patient populations [9–11]. Similarly, MIS approaches are favored in patients with poor pulmonary function (defined as an FEV1 or DLCO <60 %) to reduce post operative respiratory complications including ARDS, pneumonia, need for bronchoscopy, ventilator support and reintubation [12]. Analysis from large administrative data sets have also suggested a lesser incidence of new onset post operative atrial dysrhythmias after MIS resections [7]. Finally, it has been suggested that the faster recovery seen after VATS lobectomy may translate in an improved ability to deliver adjuvant chemotherapy when indicated [13] though recent data from Denmark has questioned this assertion [14].

Overall modern day operative or 30 day mortality rates of lobectomy have significantly improved when comparing to historical data and some of this improvement may be related to a wider adoption of MIS techniques. In the voluntary and highly selected STS database, the operative mortality is reported at 2 % for all surgical approaches [15]. Comparatively, the Nationwide Inpatient Sample, which represents a broader cross section of the US, yielded a mortality rate of 3.1 % for thoracotomy compared to 3.4 % for VATS [16]. However, using a different statewide administrative database, Kent et al. showed an operative mortality rates of 1.1 % for VATS lobectomies and only 0.2 % for robotic lobectomies [3]. These very low mortality rates have also been suggested in a 4,312 patient review from Asia where an overall mortality rate of 1 % was reported (open 1.1 %; VATS 0.8 %) [17] and a nationwide Danish study of 1,513 patients with an overall rate of 2 % (open 2.9 %, VATS 1.1 %) [18].

Several recent large comparative analyses of VATS and open thoracotomy lobectomies have compared survival and cancer recurrences. The majority of these data relate to the surgical treatment of clinical stage I cancers and there is less comparative data with clinical cancers of higher clinical stages. A recent meta-analysis of 21 studies including 2,641 patients demonstrated reduced systemic recurrences and 5-year mortality rates that favored VATS for early stage lung cancer [19]. In comparison, a propensity matched multi-institutional study of 4,312 patients showed 5-year survival was 62 % regardless of approach [17]. These findings continue to be seen in two small and more recent comparisons with actuarial 5-year survivals of 77 % [20] and 60 % [18].