The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer

*Güntuğ Batihan and Kenan Can Ceylan*

## **Abstract**

Lobectomy plus regional lymph node dissection remains the gold standard treatment method in early-stage lung cancer. However, with the demonstration of the safety and efficacy of minimally invasive approaches, the expression of surgery in this statement, replaced by thoracoscopic anatomical lung resection. Clinical studies have demonstrated the superiority of VATS in terms of postoperative pain, drainage time, length of hospital stay, and complications, moreover, long-term oncologic results are similar or better than thoracotomy. Therefore, VATS lobectomy is the preferred surgical method in early-stage lung cancer. Different surgical techniques are available in VATS and can be modified according to the surgeon's personal experience. Uniport can be applied as well as two or three port incisions. In this book section, I plan to focus on VATS lobectomy, technique-related tricks, complication management, and long-term oncologic results in early and locally advanced lung cancer.

**Keywords:** Lobectomy, minimally invasive surgery, robotic surgery, video-assisted thoracic surgery

### **1. Introduction**

Lung cancer is the most common cancer and the leading cause of cancer death in both genders [1]. Its high frequency and high mortality increase the importance of early diagnosis and treatment in this disease. Despite promising recent advances in diagnosis and treatment methods, only a minority of patients have a cure chance. Resection of the primary tumor and mediastinal lymph node dissection/sampling is the gold standard treatment method in this group of patients. However, in these patients, lung resection was performed by open thoracotomy until the end of the '90s, regardless of the size of the tumor and the extent of cancer. Severe postoperative pain and long hospitalization and drainage periods could prolong the recovery period of the patients [2].

Following the technological developments include high-definition video monitors, robot-assisted technology, specialized thoracoscopic surgical instruments, and endomechanical stapling devices, the emergence of modern imaging systems and the use of appropriate surgical equipment has created the concept of "minimally invasive surgery". In the early 2000s, patient series including Video-assisted thoracic surgery (VATS) applications began to be published. This and many subsequent studies have demonstrated the superiority of VATS over a thoracotomy in terms of less postoperative pain and minimize complications hasten recovery and improve postoperative quality [3–6]. With the positive results of VATS, it has found a wide application area for the diagnosis and treatment of benign and malignant lung diseases.

In this section, the role and application areas of VATS in the diagnosis and treatment of lung cancer will be discussed rather than technical details.

## **2. Surgical technique**

Although "tubeless" or "awake" VATS has been described and performed successfully by several authors, single-lung ventilation, which may be accomplished with either double-lumen endobronchial tubes or with single-lumen tubes and bronchial blockers, is often required for thoracoscopic lobectomy [7, 8].

The patient is positioned in full lateral decubitus position with slight flexion of the table at the level of the mid-chest, which allows slight splaying of the ribs to improve exposure in the absence of rib spreading.

The instruments and surgical technique used vary according to the number, location, and width of the port incisions. Although the number of port incisions and locations are the surgeon's preference, different applications and techniques have emerged over time.

### **2.1 Posterior approach**

The posterior approach was first described by Walker WS in 1992. The main components of this approach include [6, 9]:


The main advantages of the posterior approach include:


However, the interlobar fissure is incomplete in a considerable number of patients, and fissure dissection may cause parenchymal damage and prolonged air leak in the postoperative period. If the posterior approach is preferred, the interlobar fissure should be carefully dissected. Tissue glues, absorbable patches, or fibrin sealants can be used in the repair of injuries and air leaks that may occur in the parenchyma.

**13**

**Figure 1.**

*Port incisions in the 3-port VATS technique.*

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer*

endoscopic staplers and the lobe is removed from the thorax.

The anterior approach, also known as the fissureless technique, was applied firstly in open thoracotomy in 1999. The application of this technique to VATS has been described recently [10–12]. In this technique, the surgeon stands anterior to the patient, and the camera port is placed at the anterior axillary line. The hilar structures are dissected from the anterior to the posterior. After the dissection of the bronchovascular structures is completed, the interlobar fissure is divided with

This approach aims to prevent postoperative air leaks due to fissure dissection.

In this technique, the camera port-anterior port is located in the 7th or 8th intercostal space in the anterior axillary line, and the posterior port is located in the posterior axillary line in the same intercostal space. The utility port was usually placed in the anterior axillary line 4th intercostal space for an upper lobectomy or 5th intercostal space for a lower lobectomy (**Figure 1**). While the posterior port was

*DOI: http://dx.doi.org/10.5772/intechopen.97348*

**2.2 Anterior approach**

**2.3 3-port VATS**

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.97348*

## **2.2 Anterior approach**

*Lung Cancer - Modern Multidisciplinary Management*

improve exposure in the absence of rib spreading.

components of this approach include [6, 9]:

• The surgeon stands posterior to the patient.

The main advantages of the posterior approach include:

**2. Surgical technique**

have emerged over time.

**2.1 Posterior approach**

simus dorsi muscle.

anterior axillary line;

pulmonary arterial branches.

• Easy access to the posterior hilum.

artery and bronchial branches.

• Easy access to subcarinal lymph nodes.

postoperative pain and minimize complications hasten recovery and improve postoperative quality [3–6]. With the positive results of VATS, it has found a wide application area for the diagnosis and treatment of benign and malignant lung diseases. In this section, the role and application areas of VATS in the diagnosis and

Although "tubeless" or "awake" VATS has been described and performed successfully by several authors, single-lung ventilation, which may be accomplished with either double-lumen endobronchial tubes or with single-lumen tubes and

The patient is positioned in full lateral decubitus position with slight flexion of the table at the level of the mid-chest, which allows slight splaying of the ribs to

The instruments and surgical technique used vary according to the number, location, and width of the port incisions. Although the number of port incisions and locations are the surgeon's preference, different applications and techniques

The posterior approach was first described by Walker WS in 1992. The main

• The utility incision is made at the 6th or 7th intercostal space anterior to latis-

• The camera port is made through the auscultatory triangle, instead of the lower

• The aim is to dissect the hilar structures from the posterior to the anterior. For this purpose, the interlobar fissure must be opened first to identify and isolate

• A clear view of the posterior hilum allows safe dissection of the segmental

However, the interlobar fissure is incomplete in a considerable number of patients, and fissure dissection may cause parenchymal damage and prolonged air leak in the postoperative period. If the posterior approach is preferred, the interlobar fissure should be carefully dissected. Tissue glues, absorbable patches, or fibrin sealants can be used in the repair of injuries and air leaks that may occur in the

treatment of lung cancer will be discussed rather than technical details.

bronchial blockers, is often required for thoracoscopic lobectomy [7, 8].

**12**

parenchyma.

The anterior approach, also known as the fissureless technique, was applied firstly in open thoracotomy in 1999. The application of this technique to VATS has been described recently [10–12]. In this technique, the surgeon stands anterior to the patient, and the camera port is placed at the anterior axillary line. The hilar structures are dissected from the anterior to the posterior. After the dissection of the bronchovascular structures is completed, the interlobar fissure is divided with endoscopic staplers and the lobe is removed from the thorax.

This approach aims to prevent postoperative air leaks due to fissure dissection.

## **2.3 3-port VATS**

In this technique, the camera port-anterior port is located in the 7th or 8th intercostal space in the anterior axillary line, and the posterior port is located in the posterior axillary line in the same intercostal space. The utility port was usually placed in the anterior axillary line 4th intercostal space for an upper lobectomy or 5th intercostal space for a lower lobectomy (**Figure 1**). While the posterior port was

**Figure 1.** *Port incisions in the 3-port VATS technique.*

previously placed from the upper and rear levels, it was modified over time, and the localization we described became more frequently applied [13].

## **2.4 2-port VATS**

Since the additional contribution of the posterior port is not essential, VATS has become applied with two ports in some centers. The need for surgical retraction and manipulation can be provided by using another instrument via the utility port (**Figure 2**). However, apart from providing retraction, another feature of the posterior port that makes it useful is the introduction of the endoscopic stapling devices. Therefore, the absence of the posterior port should be compensated by appropriate maneuver and retraction of the lung.

## **2.5 Uniportal VATS**

Uniportal VATS is firstly described by Dr. Gaetano Rocco for minor thoracic procedures include lung biopsies and pneumothorax operations [14]. Dr. Diego

**15**

usage area.

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer*

Gonzalez Rivas shared his single port VATS lobectomy experience and became a pioneer in this regard [15, 16]. It has become preferred by many surgeons due to its

Moreover, Gonzales Rivas successfully performed extended lung resections include bronchial, arterial, and double sleeve resections and raised the bar in uniportal VATS lobectomy [17]. Despite favorable surgical results, whether uniportal

The main goal of this technique is to reduce the size of the incisions rather than the number of ports. It was aimed to minimize intercostal nerve damage and achieve better cosmetic results with the use of instruments and ports with a diam-

The placement of the ports and the direction of the vision are the same as the 3-port VATS technique, and the utility port has to remain at 3–5 cm to extract the resection material. Surgeons who have appropriate instruments include 3 mm trocar, 3 mm 30° video-thoracoscope, and needlescopic grasper and do not prefer

Advances in technology have enabled robots to be used in surgical procedures, and some authors started to share their first experiences in robotic thoracic surgery

It is thought that robotic surgery, which provides 3-dimensional vision and has articulated modern instruments, may allow the surgeon a safer dissection. With increasing experience, many thoracic surgery procedures are successfully per-

However, its use has not become widespread worldwide due to the system's higher cost, the time-consuming installation, and the lack of tactile feedback during surgery. It is possible to achieve similar surgical results with much less expense

Despite advances in imaging technology techniques, including positron emission tomography (PET), integrated PET/computed tomography (CT) scans, PET/ magnetic resonance imaging (MRI), multi-slice computed tomography, invasive diagnostic procedures continue to play an essential role in the management of the

VATS provides the opportunity to evaluate for solitary pulmonary nodules, mediastinal or chest wall invasion by the primary tumor, pleural effusions/ nodules, and mediastinal lymph nodes. Especially in the recent period, the use of targeted treatment methods has increased the need for tissue for mutation analysis. This situation has increased the diagnostic value of VATS and has widened its

**3. Diagnostic performance of VATS in patients with lung cancer**

advantages, such as causing less tissue damage and providing direct vision. 3–5 cm uniport incision is placed in the 5th intercostal in the anterior axillary line. A 5 mm diameter 30° video-thoracoscope is inserted through the same incision. Thus, the assistant and the surgeon share the same vision of direction. Although this is beneficial in terms of team cooperation, the working environment

VATS has an additional benefit over traditional VATS is still controversial.

eter of 3–5 mm instead of 10 mm ones used in conventional VATS [18].

*DOI: http://dx.doi.org/10.5772/intechopen.97348*

of the surgeon is somewhat limited.

the uniportal VATS may prefer this technique.

**2.7 Robot-assisted thoracic surgery**

formed with robotic surgery [20].

without sacrificing minimal invasiveness.

in the early 2000s [19].

patient with lung cancer.

**2.6 Needlescopic VATS**

**Figure 2.** *Port incisions in the 2-port VATS technique.*

#### *The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.97348*

Gonzalez Rivas shared his single port VATS lobectomy experience and became a pioneer in this regard [15, 16]. It has become preferred by many surgeons due to its advantages, such as causing less tissue damage and providing direct vision.

3–5 cm uniport incision is placed in the 5th intercostal in the anterior axillary line. A 5 mm diameter 30° video-thoracoscope is inserted through the same incision. Thus, the assistant and the surgeon share the same vision of direction. Although this is beneficial in terms of team cooperation, the working environment of the surgeon is somewhat limited.

Moreover, Gonzales Rivas successfully performed extended lung resections include bronchial, arterial, and double sleeve resections and raised the bar in uniportal VATS lobectomy [17]. Despite favorable surgical results, whether uniportal VATS has an additional benefit over traditional VATS is still controversial.

## **2.6 Needlescopic VATS**

*Lung Cancer - Modern Multidisciplinary Management*

maneuver and retraction of the lung.

**2.4 2-port VATS**

**2.5 Uniportal VATS**

localization we described became more frequently applied [13].

previously placed from the upper and rear levels, it was modified over time, and the

Since the additional contribution of the posterior port is not essential, VATS has become applied with two ports in some centers. The need for surgical retraction and manipulation can be provided by using another instrument via the utility port (**Figure 2**). However, apart from providing retraction, another feature of the posterior port that makes it useful is the introduction of the endoscopic stapling devices. Therefore, the absence of the posterior port should be compensated by appropriate

Uniportal VATS is firstly described by Dr. Gaetano Rocco for minor thoracic procedures include lung biopsies and pneumothorax operations [14]. Dr. Diego

**14**

**Figure 2.**

*Port incisions in the 2-port VATS technique.*

The main goal of this technique is to reduce the size of the incisions rather than the number of ports. It was aimed to minimize intercostal nerve damage and achieve better cosmetic results with the use of instruments and ports with a diameter of 3–5 mm instead of 10 mm ones used in conventional VATS [18].

The placement of the ports and the direction of the vision are the same as the 3-port VATS technique, and the utility port has to remain at 3–5 cm to extract the resection material. Surgeons who have appropriate instruments include 3 mm trocar, 3 mm 30° video-thoracoscope, and needlescopic grasper and do not prefer the uniportal VATS may prefer this technique.

#### **2.7 Robot-assisted thoracic surgery**

Advances in technology have enabled robots to be used in surgical procedures, and some authors started to share their first experiences in robotic thoracic surgery in the early 2000s [19].

It is thought that robotic surgery, which provides 3-dimensional vision and has articulated modern instruments, may allow the surgeon a safer dissection. With increasing experience, many thoracic surgery procedures are successfully performed with robotic surgery [20].

However, its use has not become widespread worldwide due to the system's higher cost, the time-consuming installation, and the lack of tactile feedback during surgery. It is possible to achieve similar surgical results with much less expense without sacrificing minimal invasiveness.

## **3. Diagnostic performance of VATS in patients with lung cancer**

Despite advances in imaging technology techniques, including positron emission tomography (PET), integrated PET/computed tomography (CT) scans, PET/ magnetic resonance imaging (MRI), multi-slice computed tomography, invasive diagnostic procedures continue to play an essential role in the management of the patient with lung cancer.

VATS provides the opportunity to evaluate for solitary pulmonary nodules, mediastinal or chest wall invasion by the primary tumor, pleural effusions/ nodules, and mediastinal lymph nodes. Especially in the recent period, the use of targeted treatment methods has increased the need for tissue for mutation analysis. This situation has increased the diagnostic value of VATS and has widened its usage area.

#### **3.1 Mediastinal staging**

Evaluate the mediastinal and hilar lymph node status is essential for accurate staging of the lung cancer and to choose the appropriate treatment modality.

Noninvasive mediastinal staging methods include CT and PET/CT provide valuable clinical information however sensitivity, specificity, and negative predictive values insufficient to guide treatment decisions [21–23].

Abnormal lymph node (LN) is described as an LN with a short-axis diameter ≥ 1 cm). The median sensitivity and specificity of CT for identifying mediastinal lymph node metastasis are 55% and 81% [21].

PET can provide more accurate information about the differentiation of malignant and benign lymph nodes than CT. The median sensitivity and specificity of PET/CT for detecting lymph node metastases is ranges 80%- 88%, PET is successfully used in clinical staging and monitoring response to treatment in patients with lung cancer. However, the risk of false negativity is relatively high in lesions smaller than 1 cm and tumors with low metabolic activity (e.g. well-differentiated adenocarcinoma) [22, 23].

Cervical mediastinoscopy is the gold standard method for preoperative mediastinal lymph node staging in patients with lung cancer. The 2nd, 4th, and 7th station lymph nodes can be sampled by mediastinoscopy [24, 25]. Nowadays, cervical mediastinoscopy is performed with the help of a videomediastinoscope and it is named "video-assisted mediastinoscopy (VAM)" or "video-assisted mediastinal lymphadenectomy (VAMLA)" depending on the application technique [26].

Endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS), which are parts of minimally invasive procedures, are successfully applied with high sensitivity and specificity for mediastinal staging. Combined application of EBUS and EUS allows sampling of lymph node stations numbered 2R, 2 L, 4R, 4 L, 7, 8, and 9 with the sensitivity of 86% (95% CI, 82–90%) [21, 24, 27].

VATS is very useful in the evaluation of lymph nodes as well as the evaluation of the T factor of the tumor. It allows for access to almost every mediastinal lymph node station and total mediastinal lymphadenectomy can be applied [28]. With the right-sided VATS, lymph node stations numbered 2,4,7,8 and 9 can be sampled (**Figures 3** and **4**). Left-sided VATS is an ideal approach for sampling the 5th and 6th lymph node stations that cannot be reached by EBUS and mediastinoscopy.

Although the awake/tubeless VATS procedure has been described, general anesthesia and intubation with a double-lumen tube are usually required and it can only evaluate one side of the mediastinum. In conclusion, it is an approach that offers

**17**

planned.

**Figure 4.**

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer*

high specificity and sensitivity values, especially in patients who require sampling of 5th and 6th lymph node stations or in whom complete lymph node dissection is

*VATS is also an effective method in the diagnosis and treatment of undiagnosed lesions located in the mediastinum. Para-aortic large mass resected and diagnosed as ectopic mediastinal thyroid.*

With the widespread use of radiological imaging methods, patients with newly

According to the recommendations of the Fleischner Society, solitary pulmonary nodules larger than 8 mm are recommended for further examination include tissue sampling regardless of cancer risk status [29]. CT-guided percutaneous transthoracic needle aspiration or transbronchial biopsy can be applied to pulmonary nodules with appropriate location and size. However, regardless of the location or size of the pulmonary nodule, sufficient material cannot always be obtained for

VATS is a useful approach for pulmonary nodules that cannot be sampled with minor diagnostic procedures. However, probe or digital palpation is very difficult for ground-glass opacity (GGO) lesions and nodules smaller than 1 cm. To solve this problem several pre-operative and perioperative marking techniques were

• Pleural dye marking using electromagnetic navigation bronchoscopy with or

Each of the methods listed above has advantages and disadvantages and it is controversial which is the best method for marking the pulmonary nodules. We use the "CT-guided injection of methylene blue" method for marking the pulmonary nodules in our clinic (**Figure 5**). It is a simple, safe and effective procedure.

• Gamma probe assessment after marking with Technetium-99 [34].

detected pulmonary nodules constitute an important part of daily practice.

cytopathological examination by transthoracic and transbronchial biopsy.

• Preoperative CT-guided injection of methylene blue [30].

• CT-guided positioning of a metal wire [31].

• CT-guided placement of a micro coil [32].

• The intrathoracic stamping method [35].

without radial endobronchial ultrasound [33].

*DOI: http://dx.doi.org/10.5772/intechopen.97348*

**3.2 Investigation of the pulmonary nodules**

described in the literature:

**Figure 3.** *Intraoperative image of the lung parenchyma after the CT-guided methylene blue labeling.*

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.97348*

**Figure 4.**

*Lung Cancer - Modern Multidisciplinary Management*

values insufficient to guide treatment decisions [21–23].

nal lymph node metastasis are 55% and 81% [21].

the sensitivity of 86% (95% CI, 82–90%) [21, 24, 27].

Evaluate the mediastinal and hilar lymph node status is essential for accurate staging of the lung cancer and to choose the appropriate treatment modality.

Abnormal lymph node (LN) is described as an LN with a short-axis diameter ≥ 1 cm). The median sensitivity and specificity of CT for identifying mediasti-

PET can provide more accurate information about the differentiation of malignant and benign lymph nodes than CT. The median sensitivity and specificity of PET/CT for detecting lymph node metastases is ranges 80%- 88%, PET is successfully used in clinical staging and monitoring response to treatment in patients with lung cancer. However, the risk of false negativity is relatively high in lesions smaller than 1 cm and tumors with low metabolic activity (e.g. well-differentiated adeno-

Cervical mediastinoscopy is the gold standard method for preoperative mediastinal lymph node staging in patients with lung cancer. The 2nd, 4th, and 7th station lymph nodes can be sampled by mediastinoscopy [24, 25]. Nowadays, cervical mediastinoscopy is performed with the help of a videomediastinoscope and it is named "video-assisted mediastinoscopy (VAM)" or "video-assisted mediastinal lymphadenectomy (VAMLA)" depending on the application technique [26].

Endobronchial ultrasound (EBUS) and endoscopic ultrasound (EUS), which are parts of minimally invasive procedures, are successfully applied with high sensitivity and specificity for mediastinal staging. Combined application of EBUS and EUS allows sampling of lymph node stations numbered 2R, 2 L, 4R, 4 L, 7, 8, and 9 with

VATS is very useful in the evaluation of lymph nodes as well as the evaluation of the T factor of the tumor. It allows for access to almost every mediastinal lymph node station and total mediastinal lymphadenectomy can be applied [28]. With the right-sided VATS, lymph node stations numbered 2,4,7,8 and 9 can be sampled (**Figures 3** and **4**). Left-sided VATS is an ideal approach for sampling the 5th and 6th lymph node stations that cannot be reached by EBUS and

Although the awake/tubeless VATS procedure has been described, general anesthesia and intubation with a double-lumen tube are usually required and it can only evaluate one side of the mediastinum. In conclusion, it is an approach that offers

*Intraoperative image of the lung parenchyma after the CT-guided methylene blue labeling.*

Noninvasive mediastinal staging methods include CT and PET/CT provide valuable clinical information however sensitivity, specificity, and negative predictive

**3.1 Mediastinal staging**

carcinoma) [22, 23].

mediastinoscopy.

**16**

**Figure 3.**

*VATS is also an effective method in the diagnosis and treatment of undiagnosed lesions located in the mediastinum. Para-aortic large mass resected and diagnosed as ectopic mediastinal thyroid.*

high specificity and sensitivity values, especially in patients who require sampling of 5th and 6th lymph node stations or in whom complete lymph node dissection is planned.

## **3.2 Investigation of the pulmonary nodules**

With the widespread use of radiological imaging methods, patients with newly detected pulmonary nodules constitute an important part of daily practice.

According to the recommendations of the Fleischner Society, solitary pulmonary nodules larger than 8 mm are recommended for further examination include tissue sampling regardless of cancer risk status [29]. CT-guided percutaneous transthoracic needle aspiration or transbronchial biopsy can be applied to pulmonary nodules with appropriate location and size. However, regardless of the location or size of the pulmonary nodule, sufficient material cannot always be obtained for cytopathological examination by transthoracic and transbronchial biopsy.

VATS is a useful approach for pulmonary nodules that cannot be sampled with minor diagnostic procedures. However, probe or digital palpation is very difficult for ground-glass opacity (GGO) lesions and nodules smaller than 1 cm. To solve this problem several pre-operative and perioperative marking techniques were described in the literature:


Each of the methods listed above has advantages and disadvantages and it is controversial which is the best method for marking the pulmonary nodules. We use the "CT-guided injection of methylene blue" method for marking the pulmonary nodules in our clinic (**Figure 5**). It is a simple, safe and effective procedure.

**Figure 5.**

*The paratracheal lymph node, which could not be diagnosed by EBUS, was totally excised with VATS (VCS: Superior vena cava, T: Trachea, asterisk indicates paratracheal lymph node).*

However, in order to ensure optimal labeling, the radiologist and the surgeon must be in good collaboration and the time between labeling and operation must be kept as short as possible.

## **4. The role of VATS in the surgical treatment of the lung cancer**

Surgical resection in lung cancer has a relatively long history. First successful en bloc pneumonectomy reported by Graham and Singer in 1933 for the treatment of lung cancer. Lobectomies and segmentectomies were reported in the 1940s and 1950s and the first successful sleeve resection with right upper lobectomy for carcinoma in 1952 by Allison [36–38].

Today, anatomic pulmonary resection remains the best curative option in patients with early-stage lung cancer. The first VATS lobectomy series was reported in 1992 by Lewis [39].

In the following years, different surgeons defined unique techniques and pioneered the development of VATS however, the variability in the technique and the skeptical approach to published results prevented VATS from being widely accepted until the 2000s [40–42].

In addition to being technically feasible, superior postoperative results compared to thoracotomy have been effective in the general acceptance of VATS (**Figure 5**).

Long et al. conducted a prospective randomized trial comparing the quality of life after VATS vs. open lobectomy for clinically early-stage NSCLC [42]. It was stated that a month after operation both dyspnea and pain score were significantly lower in the VATS group.

In another study, Andretti et al. documented the results of 145 patients and compared the postoperative pain of patients who underwent VATS and mini thoracotomy. It was stated that significantly less pain was observed in the VATS group at the 1st, 12th, 24th and 48th postoperative hours [43].

The advantages of VATS over thoracotomy have also been revealed in other studies conducted with large patient groups:

McKenna Jr. et al. published experiences of 1,100 cases and reported 0.8% mortality and 15.3% morbidity [4].

In another study, Boffa et al. analyzed data of 9033 pulmonary resections for primary lung cancer by using the database of the Society of Thoracic Surgeons. In this study, VATS resection was performed in 2429 of 9033 patients. In the VATS group, the mortality rate was 2% and the overall morbidity was 32% [44].

**19**

**Figure 6.**

*endoscopic stapler.*

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer*

lymph node dissection between VATS and thoracotomy groups [47].

patients; the 5-year OS rates of the two groups were similar [48].

Laursen et al. analyzed the results of 1379 patients who underwent lobectomy. In this study minor and major complications were found significantly lower in the

Compared to the mortality (%1–2) and morbidity (%32–37) of open lobectomies from large series in the literature, the results are highly satisfactory [46].

The risk of compromising the oncological principles in VATS has been a matter of debate for a long time. However, in the retrospective large-scale studies, no significant difference was found between VATS and thoracotomy in terms of oncological results. Watanabe et al. reported no differences in the total number of lymph nodes, nodal stations, mediastinal nodes, and stations sampled during systematic

Moreover, Yang et al. reported the long-term results of VATS and open lobectomy based on the National Cancer Data Base of the U.S. About three thousand patients with stage I NSCLC was matched with propensity score from >7,000

*A case of right upper lobectomy performed using the anterior approach. In the hilum, the upper lobe vein, artery and bronchus were dissected and divided sequentially from anterior to posterior. a. the asterisk indicates the vein of the right upper lobe and triangle indicates the middle lobe vein. b. the arrow indicates pulmonary vein stump. The asterisk and triangle indicate pulmonary arterial branches. c. after the dissection of the arterial branch of the right upper lobe, upper lobe bronchus was seen (asterisk). d. after dividing the vascular and bronchial structures belonging to the upper lobe, the interlobar fissure is finally divided with the help of* 

*DOI: http://dx.doi.org/10.5772/intechopen.97348*

VATS group [45].

#### *The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.97348*

*Lung Cancer - Modern Multidisciplinary Management*

as short as possible.

**Figure 5.**

in 1992 by Lewis [39].

until the 2000s [40–42].

lower in the VATS group.

(**Figure 5**).

carcinoma in 1952 by Allison [36–38].

However, in order to ensure optimal labeling, the radiologist and the surgeon must be in good collaboration and the time between labeling and operation must be kept

*The paratracheal lymph node, which could not be diagnosed by EBUS, was totally excised with VATS (VCS:* 

Surgical resection in lung cancer has a relatively long history. First successful en bloc pneumonectomy reported by Graham and Singer in 1933 for the treatment of lung cancer. Lobectomies and segmentectomies were reported in the 1940s and 1950s and the first successful sleeve resection with right upper lobectomy for

Today, anatomic pulmonary resection remains the best curative option in patients with early-stage lung cancer. The first VATS lobectomy series was reported

In the following years, different surgeons defined unique techniques and pioneered the development of VATS however, the variability in the technique and the skeptical approach to published results prevented VATS from being widely accepted

In addition to being technically feasible, superior postoperative results compared to thoracotomy have been effective in the general acceptance of VATS

Long et al. conducted a prospective randomized trial comparing the quality of life after VATS vs. open lobectomy for clinically early-stage NSCLC [42]. It was stated that a month after operation both dyspnea and pain score were significantly

In another study, Andretti et al. documented the results of 145 patients and compared the postoperative pain of patients who underwent VATS and mini thoracotomy. It was stated that significantly less pain was observed in the VATS group at

McKenna Jr. et al. published experiences of 1,100 cases and reported 0.8%

group, the mortality rate was 2% and the overall morbidity was 32% [44].

In another study, Boffa et al. analyzed data of 9033 pulmonary resections for primary lung cancer by using the database of the Society of Thoracic Surgeons. In this study, VATS resection was performed in 2429 of 9033 patients. In the VATS

The advantages of VATS over thoracotomy have also been revealed in other stud-

the 1st, 12th, 24th and 48th postoperative hours [43].

ies conducted with large patient groups:

mortality and 15.3% morbidity [4].

**4. The role of VATS in the surgical treatment of the lung cancer**

*Superior vena cava, T: Trachea, asterisk indicates paratracheal lymph node).*

**18**

Laursen et al. analyzed the results of 1379 patients who underwent lobectomy. In this study minor and major complications were found significantly lower in the VATS group [45].

Compared to the mortality (%1–2) and morbidity (%32–37) of open lobectomies from large series in the literature, the results are highly satisfactory [46].

The risk of compromising the oncological principles in VATS has been a matter of debate for a long time. However, in the retrospective large-scale studies, no significant difference was found between VATS and thoracotomy in terms of oncological results. Watanabe et al. reported no differences in the total number of lymph nodes, nodal stations, mediastinal nodes, and stations sampled during systematic lymph node dissection between VATS and thoracotomy groups [47].

Moreover, Yang et al. reported the long-term results of VATS and open lobectomy based on the National Cancer Data Base of the U.S. About three thousand patients with stage I NSCLC was matched with propensity score from >7,000 patients; the 5-year OS rates of the two groups were similar [48].

#### **Figure 6.**

*A case of right upper lobectomy performed using the anterior approach. In the hilum, the upper lobe vein, artery and bronchus were dissected and divided sequentially from anterior to posterior. a. the asterisk indicates the vein of the right upper lobe and triangle indicates the middle lobe vein. b. the arrow indicates pulmonary vein stump. The asterisk and triangle indicate pulmonary arterial branches. c. after the dissection of the arterial branch of the right upper lobe, upper lobe bronchus was seen (asterisk). d. after dividing the vascular and bronchial structures belonging to the upper lobe, the interlobar fissure is finally divided with the help of endoscopic stapler.*

Nowadays, the indications of VATS have expanded with the increasing experience. It can be successfully applied in cases with neoadjuvant therapy, tumor larger than 5 cm, chest wall invasion, need of sleeve resection, which was previously considered as a relative or absolute contraindication.

Park BJ et al. analyzed 428 patients who underwent induction chemotherapy for lung cancer and compared thoracotomy and minimally invasive surgical approaches in this patient group. There were not seen any differences in disease-free and overall survival between minimally invasive surgery and thoracotomy groups [49].

Huang et al. presented the results of 118 patients who underwent VATS bronchial sleeve lobectomy and postoperative complications were reported in only 2 patients.

In a study, we conducted in our clinic, which included 60 patients with tumors larger than 5 cm, mean drainage time and postoperative length of hospital stay were significantly shorter [50] (**Figure 6**).

## **5. Contraindications for VATS anatomic lung resection**

With the widespread use of the VATS technique, many contraindications related to the procedure have been described [51]. However, these contraindications have changed over time, thanks to the increasing experience in VATS and the needoriented developments and diversity of thoracoscopic instruments.

Many conditions such as the presence of endobronchial lesions, history of neoadjuvant treatment, pleural adhesions, and tumor larger than 3 cm, which were previously contraindicated for VATS, are not considered as contraindications by many surgeons today.

Sleeve resections with VATS can be successfully applied in patients with endobronchial lesions.

Moreover, many studies have demonstrated that VATS can be applied with low complication rates after neoadjuvant therapy or in cases with large tumors [49–52].

Large mediastinal vessel, pericardium, carina, and chest wall invasions can be considered relatively contraindicated for VATS. These kinds of major resections must be performed in high-volume institutions and by experienced surgeons.

## **6. Learning curve for VATS**

Mc Kenna has been suggested that the length of the VATS lobectomy learning curve should consist of 50 lobectomies however, there are several personal and environmental factors that affect the learning curve associated with VATS lobectomy [53]. If we put aside personal factors such as instrument use, anatomy mastery and 3-dimensional thinking ability, there are 2 main factors affecting the learning curve: The size of the center and the presence of experienced surgeons who can supervise [51, 53, 54].

The prolongation of the time between the two cases will adversely affect the learning process. In centers where there are not many cases, this deficiency can be partially eliminated with VATS videos or simulators.

#### **7. Conclusions**

Minimally invasive thoracic surgery has made great progress in the past 20 years and today it has an important role in both diagnosis and treatment of lung cancer. However, VATS lobectomy is a relatively young technique and is still evolving.

**21**

**Author details**

Güntuğ Batihan\* and Kenan Can Ceylan

provided the original work is properly cited.

Surgery Training and Research Center, İzmir, Turkey

\*Address all correspondence to: gbatihan@hotmail.com

University of Health Sciences Turkey, Dr. Suat Seren Chest Diseases and Chest

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer*

The search for a less invasive technique is not specific to thoracic surgery and is a process that occurs in all surgical specialties. Fortunately, advancing technology

*DOI: http://dx.doi.org/10.5772/intechopen.97348*

supports this search in the best possible way.

The author declares no conflict of interest.

**Conflict of interest**

**Acronyms and abbreviations**

VCS Superior vena cav

CT Computed tomography EBUS Endobronchial ultrasound EUS Endoscopic ultrasound MRI Magnetic resonance imaging NSCLC Non-small cell lung cancer PET Positron emission tomography VATS Video-assisted thoracic surgery *The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.97348*

The search for a less invasive technique is not specific to thoracic surgery and is a process that occurs in all surgical specialties. Fortunately, advancing technology supports this search in the best possible way.

## **Conflict of interest**

*Lung Cancer - Modern Multidisciplinary Management*

considered as a relative or absolute contraindication.

significantly shorter [50] (**Figure 6**).

many surgeons today.

**6. Learning curve for VATS**

partially eliminated with VATS videos or simulators.

bronchial lesions.

patients.

Nowadays, the indications of VATS have expanded with the increasing experience. It can be successfully applied in cases with neoadjuvant therapy, tumor larger than 5 cm, chest wall invasion, need of sleeve resection, which was previously

Park BJ et al. analyzed 428 patients who underwent induction chemotherapy for lung cancer and compared thoracotomy and minimally invasive surgical approaches in this patient group. There were not seen any differences in disease-free and overall

Huang et al. presented the results of 118 patients who underwent VATS bronchial sleeve lobectomy and postoperative complications were reported in only 2

In a study, we conducted in our clinic, which included 60 patients with tumors larger than 5 cm, mean drainage time and postoperative length of hospital stay were

With the widespread use of the VATS technique, many contraindications related to the procedure have been described [51]. However, these contraindications have changed over time, thanks to the increasing experience in VATS and the need-

Many conditions such as the presence of endobronchial lesions, history of neoadjuvant treatment, pleural adhesions, and tumor larger than 3 cm, which were previously contraindicated for VATS, are not considered as contraindications by

Sleeve resections with VATS can be successfully applied in patients with endo-

Moreover, many studies have demonstrated that VATS can be applied with low complication rates after neoadjuvant therapy or in cases with large tumors [49–52]. Large mediastinal vessel, pericardium, carina, and chest wall invasions can be considered relatively contraindicated for VATS. These kinds of major resections must be performed in high-volume institutions and by experienced surgeons.

Mc Kenna has been suggested that the length of the VATS lobectomy learning curve should consist of 50 lobectomies however, there are several personal and environmental factors that affect the learning curve associated with VATS lobectomy [53]. If we put aside personal factors such as instrument use, anatomy mastery and 3-dimensional thinking ability, there are 2 main factors affecting the learning curve: The size of the center and the presence of experienced surgeons who can supervise [51, 53, 54]. The prolongation of the time between the two cases will adversely affect the learning process. In centers where there are not many cases, this deficiency can be

Minimally invasive thoracic surgery has made great progress in the past 20 years and today it has an important role in both diagnosis and treatment of lung cancer. However, VATS lobectomy is a relatively young technique and is still evolving.

survival between minimally invasive surgery and thoracotomy groups [49].

**5. Contraindications for VATS anatomic lung resection**

oriented developments and diversity of thoracoscopic instruments.

**20**

**7. Conclusions**

The author declares no conflict of interest.

## **Acronyms and abbreviations**


## **Author details**

Güntuğ Batihan\* and Kenan Can Ceylan University of Health Sciences Turkey, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Center, İzmir, Turkey

\*Address all correspondence to: gbatihan@hotmail.com

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer DOI: http://dx.doi.org/10.5772/intechopen.97348*

other complex resections. J Thorac Dis. 2014;6(Suppl 6):S674-S681.

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[25] Lemaire A, Nikolic I, Petersen T, et al. Nine-year single center experience with cervical mediastinoscopy: Complications and false negative rate. Ann Thorac Surg. 2006;82:1185-90.

[26] Leschber G, Holinka G, Linder A. Video-assisted mediastinoscopic lymphadenectomy (VAMLA)--a method for systematic mediastinal lymphnode dissection. Eur J Cardiothorac Surg. 2003 Aug;24(2):192-5

[27] Dong X, Qiu X, Liu Q, et al. Endobronchial ultrasound-guided transbronchial needle aspiration in the mediastinal staging of non-small cell lung cancer: A meta-analysis. Ann Thorac Surg.

[28] Hiebinger A, and Velano D, Bodner. VATS-lymph node dissection, staging and restaging in advanced malignancy/ the Munich experience. Video-assist Thorac Surg 2018;3:29.

[29] MacMahon H, Naidich DP, Goo JM et al. "Guidelines for management of incidental pulmonary nodules detected on CT images: from the Fleischner Society 2017," Radiology, vol. 284, no. 1, pp. 228-243, 2017.

[30] Wang YZ, Boudreaux JP, Dowling A, Woltering EA. Percutaneous localisation of pulmonary nodules prior to video-assisted thoracoscopic surgery using methylene blue and TC-99. Eur J Cardiothorac Surg. 2010 Jan;37(1):237-8.

[31] Wang T, Ma S, Yan T, Song J, Wang K, He W, Bai J. [Computed Tomography Guided Hook-wire Precise Localization and Minimally Invasive Resection of Pulmonary Nodules]. Zhongguo Fei Ai Za Zhi. 2015 Nov;18(11):680-5. Chinese.

[32] Alharbi SR. Computed Tomography-guided Pulmonary Nodule Microcoil Localization Technique, Misplacement Errors, and Complications: A Pictorial Essay. J Clin Imaging Sci. 2018 Mar 9;8:8.

[33] Ozgul G, Cetinkaya E, Ozgul MA, et al. Efficacy and safety of electromagnetic navigation bronchoscopy with or without radial

**22**

*Lung Cancer - Modern Multidisciplinary Management*

[1] Ferlay J, et al. GLOBOCAN 2012v1.0,

Surg. 2014;3(2):183-191. doi:10.3978/j.

[10] Temes RT, Willms CD, Endara SA, et al. Fissureless lobectomy. Ann Thorac

[11] Cerfolio RJ, Bryant AS, Singh S, Bass CS, Bartolucci AA. The

[12] Stamenovic D, Bostanci K,

Cardiothorac Surg. 2016

[13] Sihoe AD. The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery. J Thorac Dis. 2014;6(Suppl 6):S604-S617.

[14] Rocco G, Khalil M, Jutley R. Uniportal video-assisted thoracoscopic surgery wedge lung biopsy in the diagnosis of interstitial lung diseases. J Thorac Cardiovasc Surg 2005;129:

[15] Gonzalez-Rivas D, Paradela M, Fernandez R, et al. Uniportal videoassisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg

[16] Gonzalez D, Paradela M, Garcia J, et al. Single-port video-assisted thoracoscopic lobectomy. Interact Cardiovasc Thorac Surg 2011;12:514-5.

[17] Gonzalez-Rivas D, Fieira E, Delgado M, de la Torre M, Mendez L, Fernandez R. Uniportal video-assisted thoracoscopic sleeve lobectomy and

Jul;50(1):118-23.

947-8.

2013;95:426-32.

management of chest tubes in patients with a pneumothorax and an air leak after pulmonary resection. Chest 2005;

Messerschmidt A, Jahn T, Schneider T. Fissureless fissure-last video-assisted thoracoscopic lobectomy for all lung lobes: a better alternative to decrease the incidence of prolonged air leak? Eur J

issn.2225-319X.2014.03.11

Surg 1998;65:282-4.

128:816-20.

[2] Lazdunski LL. Surgery for nonsmall cell lung cancer. Eur Respir Rev 2013;

[3] Roviaro G, Rebuffat C, Varoli F, et al. Videoendoscopic pulmonary lobectomy for cancer. Surg Laparosc Endosc

[4] McKenna RJ, Jr, Houck W, Fuller CB.

lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006;81:421-5;

[6] Walker WS, Codispoti M, Soon SY, et al. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 2003;23:397-402

[7] Gonzalez-Rivas D, Bonome C, Fieira E, et al. Non-intubated videoassisted thoracoscopic lung resections: the future of thoracic surgery? Eur J Cardiothorac Surg 2016;49:721-31.

[8] Cui F, Liu J, Li S, et al. Tubeless video-assisted thoracoscopic surgery (VATS) under non-intubated, intravenous anesthesia with spontaneous ventilation and no

J Thorac Dis 2016;8:2226-32.

[9] Yan TD. Surgical atlas of thoracoscopic lobectomy and segmentectomy. Ann Cardiothorac

placement of chest tube postoperatively.

Video-assisted thoracic surgery

[5] Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg

Cancer Incidence and Mortality Worldwide. IARC Cancer Base No. 11. Lyon, France: International Agency for

Research on Cancer (2013).

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[41] Walker W. VATS lobectomy: the Edinburgh experience. Semin Thorac Cardiovasc Surg 1998; 10:291-299

[42] Roviaro G. VATS major pulmonary resections: the Italian experience. Semin Thorac Cardiovasc Surg 1998; 10:313-320

[43] Andreetti C, Menna C, Ibrahim M, et al. Postoperative pain control: videothoracoscopic versus conservative mini-thoracotomic approach. Eur J Cardiothorac Surg 2014;46:907-12. 10.1093/ejcts/ezu092

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[45] Laursen LØ, Petersen RH, Hansen HJ, Jensen TK, Ravn J, Konge L. Video-assisted thoracoscopic surgery lobectomy for lung cancer is associated with a lower 30-day morbidity compared with lobectomy by thoracotomy. Eur J Cardiothorac Surg. 2016 Mar;49(3):870-5.

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**25**

*The Role of Minimally Invasive Surgery in the Treatment of Lung Cancer*

*DOI: http://dx.doi.org/10.5772/intechopen.97348*

[50] Batihan G, Ceylan KC, Usluer O, et al. Video-Assisted Thoracoscopic Surgery vs Thoracotomy for Non-Small Cell Lung Cancer Greater Than 5 cm: Is VATS a feasible approach for large tumors?. J Cardiothorac Surg

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*Lung Cancer - Modern Multidisciplinary Management*

[43] Andreetti C, Menna C, Ibrahim M, et al. Postoperative pain control: videothoracoscopic versus conservative mini-thoracotomic approach. Eur J Cardiothorac Surg 2014;46:907-12.

[44] Boffa DJ, Allen MS, Grab JD, Gaissert HA, Harpole DH, Wright CD. Data from The Society of Thoracic Surgeons General Thoracic Surgery database: the surgical management of primary lung tumors. J Thorac

10.1093/ejcts/ezu092

Cardiovasc Surg. 2008 Feb;135(2):247-54.

2016 Mar;49(3):870-5.

[45] Laursen LØ, Petersen RH,

with a lower 30-day morbidity compared with lobectomy by

Tsuchiya R. Recent results of postoperative mortality for surgical resections in lung cancer. Ann Thorac

Surg. 2004;78(3):999-1002.

[47] Watanabe A, Koyanagi T, Ohsawa H, et al. Systematic node dissection by VATS is not inferior to that

through an open thoracotomy: A comparative clinicopathologic retrospective study. Surgery

[48] Yang CJ, Kumar A, Klapper JA, et al. A National Analysis of Long-term Survival Following Thoracoscopic Versus Open Lobectomy for Stage I Non-small-cell Lung Cancer. Ann Surg

[49] Park BJ, Yang HX, Woo KM, et al. Minimally invasive (robotic assisted thoracic surgery and video-assisted thoracic surgery) lobectomy for the treatment of locally advanced non-small cell lung cancer. J Thorac Dis 2016;8:

2005;138:510-7.

2019;269:163-71.

S406-13.

Hansen HJ, Jensen TK, Ravn J, Konge L. Video-assisted thoracoscopic surgery lobectomy for lung cancer is associated

thoracotomy. Eur J Cardiothorac Surg.

[46] Watanabe S, Asamura H, Suzuki K,

endobronchial ultrasound for peripheral

[35] Kawada M, Okubo T, Poudel S, et al. A new marking technique for peripheral lung nodules avoiding pleural puncture: the intrathoracic stamping method. Interact Cardiovasc Thorac Surg.

[36] Kittle CF. The history of lobectomy and segmentectomy including sleeve resection. Chest Surg Clin N Am

[37] Evarts A, Graham MD, Singer JJ. Successful removal of an entire lung for carcinoma of the bronchus. JAMA 1984;

[39] Lewis RJ, Sisler GE, Caccavale RJ. Imaged thoracic lobectomy: should it be done? Ann Thorac Surg 1992; 54:80-83

[40] Lewis RJ, Caccavale RJ, Bocage JP, Widmann MD. Video-assisted thoracic

simultaneously stapled lobectomy: a more patient-friendly oncologic

[41] Walker W. VATS lobectomy: the Edinburgh experience. Semin Thorac Cardiovasc Surg 1998; 10:291-299

[42] Roviaro G. VATS major pulmonary resections: the Italian experience. Semin

Thorac Cardiovasc Surg 1998;

surgical non-rib spreading

resection. Chest. 1999 Oct;116(4):1119-24.

[38] Allison PR. Meeting of the Association of Thoracic Surgeons; quoted by Jones PH. Ann R Coll Surg

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**27**

treatment.

**1. Introduction**

**Chapter 3**

**Abstract**

Cell Lung Cancer

*Andrew X. Li and Justin D. Blasberg*

Robotic Surgery for Non-Small

Pulmonary resection has been a cornerstone in the management of patients with non-small cell lung cancer (NSCLC) for decades. In recent years, the popularity of minimally-invasive techniques as the primary method to manage NSCLC has grown significantly. With smaller incisions and a lower incidence of peri-operative complications, minimally-invasive lung resection, accomplished through keyhole incisions with miniaturized cameras and similarly small instruments that work through surgical ports, has been shown to retain equivalent oncologic outcomes to the traditional gold standard open thoracotomy. This technique allows for the safe performance of anatomic lung resection with complete lymphadenectomy and has been a part of thoracic surgery practice for three decades. Robotic-assisted thoracoscopic surgery (RATS) represents another major advancement for lung resection, broadening the opportunity for patients to undergo minimally invasive surgery for NSCLC, and therefore allowing a greater percentage of the lung cancer population to benefit from many of the advantages previously demonstrated from video assisted thoracoscopic surgery (VATS) techniques. RATS surgery is also associated with several technical advantages to the surgeon. For a surgeon who performs open procedures and is looking to adopt a minimally invasive approach, RATS ergonomics are a natural transition compared to VATS, particularly given the multiple degrees of freedom associated with robotic articulating instruments. As a result, this platform has been adopted as a primary approach in numerous institutions across the United States. In this chapter, we will explore the advantages and disadvantages of robotic-assisted surgery for NSCLC and discuss the implications for increased adoption of minimally invasive surgery in the future of lung cancer

**Keywords:** non-small cell lung cancer, pulmonary resection, minimally invasive

Surgical resection for early stage non-small cell lung cancer (NSCLC) (Stage I and II) is associated with the lowest risk for local and distant recurrence and the best 5-year survival compared to other available treatment options [1]. The preferred approach for the surgical management of resectable, early-stage NSCLC has shifted in recent years from open thoracotomy to minimally-invasive surgery (MIS). Although thoracotomy has evolved over several decades to utilize muscle sparing incisions and improved postoperative pain control using epidural and paravertebral catheter systems, this technique is associated with more significant muscle

surgery, robotic surgery, robotic-assisted thoracoscopic surgery

## **Chapter 3**
