The main criticism of the evidence in favor of VATS compared to open thoracotomy has been that the studies were biased because they were non-randomized observational retrospective studies and thus more favorable patients may have been selected for the new technique (3). To address this concern, the data of 7,739 unmatched non-small cell lung cancer (NSCLC) patients from 3 retrospective studies were analyzed, 5,636 open thoracotomy versus 2,094 VATS, as well as differences in propensity score matched patients in open thoracotomy versus VATS, 1,681 cases in each group (3). Mortality, prolonged airleak, and sepsis were significantly lower in the VATS unmatched comparison, but not significantly lower in the matched VATS comparison (3). Overall perioperative morbidity and length of hospital stay were consistently lower in VATS in both the matched and unmatched comparisons (3). While previous smaller studies have demonstrated the benefits of VATS compared to open thoracotomy, this review further contextualized those results for clinical practice (3).

Over the last decade there have been small reports of RVATS utilizing the $1 million US dollar master-slave robotic system (da Vinci, Intuitive Surgical, Sunnyvale, California), but there has been controversy regarding the actual benefits of this expensive technology (4). A systematic review of 941 patients (mostly NSCLC, some carcinoid and metastatic disease) from 12 institutions in 9 reports compared RVATS to VATS and open thoracotomy. They demonstrated equivalent oncologic outcomes to open thoracotomy, and the overall mortality ranged from 0-3.8%, overall morbidity from 0-39%, average operative time from 132-238 minutes, rates of conversion to open thoracotomy from 0-19%, average chest tube days from 1.5-7 days, and median length of hospital stay from 2-11 days. In contrast, our hybrid VATS series demonstrated an overall perioperative mortality of 4.3%, overall morbidity of 21.1%, mean operative time of 52 minutes, no conversions to open thoracotomy, mean chest tube days of 4.5 days, and mean length of hospital stay of 7 days (1). RVATS was on average $3,981 US dollars more expensive than VATS, but $3,988 US dollars cheaper than open thoracotomy (4). However, an extra $1,715 US dollars of amortized cost had to be accounted for utilizing the robot for each RVATS patient. Furthermore, although they demonstrated an improved quality of life score in the RVATS patients compared to open thoracotomy 3 weeks after operation, there was no difference at 4 months. Although they demonstrated the feasibility of this technology which has a well reported steep learning curve, the benefits of RVATS over VATS, especially considering the increased cost, have yet to be demonstrated.