Swanson et al. analyzed a large, nationally representative database including more than 600 hospitals that included a total of 3,961 patients underwent a lobectomy by a thoracic surgeon by an open (n = 2,907) or VATS (n = 1,054) approach. Hospital costs were higher for open ($21,016) versus VATS ($20,316) (p = 0.027). Adjustment for surgeon experience with VATS over the 6 months prior to each operation showed a significant association between surgeon experience and cost. Average costs ranged from $22,050 for low volume surgeons to $18,133 for high volume surgeons. For open lobectomies, cost differences by surgeon experience were not significant and both levels were estimated at $21,000. This indicates that VATS compared with an open technique offers economic advantages, particularly when an experienced surgeon performs the procedure [9].

Casali’s single-institution retrospective cost analysis confirmed that only the operating room related cost in VATS lobectomy is more expensive than a conventional thoracotomy, and this cost is counterbalanced by the significantly shorter hospital stay and the reduced length of stay related costs. The total cost of VATS lobectomy is less expensive than conventional lobectomy [13].

A number of studies have demonstrated that VATS lobectomy, as compared with open lobectomy, is associated with subjective and objective improvements in surgery-related quality-of-life [14]. Improved pain control seems to be the most commonly demonstrated benefit. The main cause of postoperative pain is direct injury to the chest wall and intercostal nerves. Rib spreading in a thoracotomy can cause uncontrolled rib fractures and impingement on intercostal nerves. The diminished surgical trauma to the chest wall from VATS lobectomy is reflected in diminished levels of postoperative pain. The shorter duration of chest tube drainage after VATS lobectomy may also contribute to the lower pain levels. More than 80 % of patients still require narcotic analgesics 3 weeks after an open lobectomy compared with fewer than 40 % patients after a VATS lobectomy. Reduced pain levels may contribute to the observed improved quality of life (QOL) after a VATS resection, and this drives secondary enhancements of QOL scores of performance and symptom control [15]. Tajiri et al. demonstrated that, compared with open lobectomy, VATS lobectomy is associated with lower analgesics requirements and less pain at 1 day, 2 weeks, 4 weeks, 6 months, and 1 year postoperatively [16]. A prospective study by Balduyck et al. analyzed 100 patients after lung cancer surgery and showed more favorable physical function for VATS over thoracotomy at 6 months (p < 0.01) [17].

Many studies have shown objective measurements to suggest that QOL is improved for VATS. Some effects are immediate, and others are more prolonged. Most of the literature has documented a substantial reduction in pain control measures and better physical recovery documented by faster return to work or other equivalents of preoperative functioning [15]. A retrospective study of 204 patients by Kaseda indicated that the postoperative to preoperative ratio of pulmonary function tests (vital capacity and forced expiratory volume in 1s(FEV1)) were better in video-assisted thoracic surgery lobectomy than in open thoracotomy(FEV1 0.848 vs 0.712) (p < 0.0001) [18].

Demmy provided a comprehensive review of subjective and objective QOL measures after VATS lobectomy. They reviewed 97 papers and concluded that QOL was improved after VATS compared with open surgery, and this improvement was demonstrated by better scores on standardized QOL instruments, improved physical activity after surgery, and an earlier return to work [15].

A meta-analysis by Cheng et al. indicated pain measured via visual analog scales (10-point VAS) was significantly reduced by <1 point on day 1, by >2 points at 1 week, and by <1 point at weeks 2–4. Similarly, analgesia requirements were significantly reduced in the VATS group. Postoperative vital capacity was significantly improved (weighted mean differences (WMD) 20, 95 % CI 15–25), and percent predicted forced vital capacity at 1 year was significantly greater for VATS versus open surgery (WMD 7, 95 % CI 2–12). The incidence of patients reporting limited activity at 3 months was reduced (OR 0.04, 95 % CI 0.00–0.82), and time to full activity was significantly reduced in the VATS versus open surgery group (WMD 1.5, 95 % CI 2.1–0.9), but was reported in only one trial [11].

Some patients with early-stage NSCLC, especially those with stage II disease, may require adjuvant chemotherapy. However, patients receiving lobectomy through conventional thoracotomy sometimes have delayed adjuvant therapy due to slow recovery, and not infrequently, discontinue treatment because of worsening of performance status. Because the advantages of VATS lobectomy include remission of post-operative pain, less releasing of inflammatory factor and less effect on pulmonary functions, fewer complications and rapid recovery, VATS lobectomy may increase compliance with planned adjuvant chemotherapy [19].

Through propensity score matching, Lee et al. indicated a higher percentage of VATS group received four cycles of the planned adjuvant chemotherapy (95.9 % versus 82.4 %, p = 0.015). There was a trend toward better compliance in VATS group with four cycles of adjuvant chemotherapy without reduced dose (83.8 % versus 73.0 %, p = 0.162), and four cycles of adjuvant chemotherapy without delayed or reduced dose (70.3 % versus 62.2 %, p = 0.385). The result showed thoracoscopy was associated with better compliance with adjuvant chemotherapy after pulmonary resection for NSCLC [20]. A possible explanation of this seems to be associated with lower postoperative pain, better performance status, and better preserved hematologic function before adjuvant chemotherapy.