Lung cancer is one of the greatest health problems in the world and is the major cause of death from cancer globally.[1] It was responsible for about 12.4% of the total cancer cases and 18.7% of cancer deaths globally.[2] Despite improvements in screening, imaging, systemic therapy, and targeted therapy, the burden of mortality remains significant, especially since a large number of patients still present with locally advanced or metastatic disease.[3] Although other risk factors, such as exposure to air pollution, occupational carcinogens, second-hand smoke, and other environmental factors, significantly contribute to the global burden, tobacco smoking is the main risk factor.[4]

Non-small cell lung cancer (NSCLC) accounts for the majority of the lung cancer population, and prognosis is vastly different if the disease is diagnosed early and is still treatable.[5] Anatomical lung resection with systematic lymph-node assessment is a mainstay of therapy for selected patients with resectable early-stage NSCLC.[6] The lobectomy has always been considered the gold standard surgical treatment for many patients because it offers the same oncological clearance as pneumonectomy while sparing more lung parenchyma.[7] The advantages of surgical resection must be weighed against the physiological implications of thoracic surgery, such as post-operative pain, changes in respiratory mechanics, increased hospital stay, pulmonary complications, and delayed rehabilitation.[8]

The advent of video-assisted thoracoscopic surgery (VATS) has revolutionized the surgical treatment of early-stage lung cancer, as an alternative to traditional open thoracotomy.[9] VATS lobectomy enables pulmonary resection through small thoracic incisions, without the need for the extensive rib spreading that is required during open surgery.[10] The potential benefits are decreased surgical trauma, decreased pain after surgery, earlier movement, decreased hospital length of stay, and quicker functional recovery.[11] Open thoracotomy (OT) remains a vital procedure, especially for technically challenging resections, in the presence of extensive adhesions, involvement of the vessels, and tumors which are too large or located centrally to be safely resected via a minimally invasive approach.[12] Previous reports evaluating the two techniques have indicated favourable perioperative results with VATS, but there are several issues to consider concerning operative duration, postoperative complications, lymph-node assessment, conversion to open surgery, and oncological long-term outcomes.[13,14] Despite those recent findings, it remains unclear to date whether the lobectomy procedure can be performed in a minimally invasive fashion without sacrificing completeness or oncologic outcomes.

Thus, the decision between VATS and OT cannot simply be viewed as understanding two different surgical approaches but a concept of balancing the trauma of the operation with the effectiveness of the treatment. Although VATS is gaining acceptance as a method of early-stage lung cancer surgery, variables such as patient selection, surgeon experience, tumor type, peri-operative support, and institutional practice can affect the reported results. Furthermore, the evidence from centers in high-resource areas may not be directly applicable in centers with less developed minimally invasive thoracic surgery.

A direct comparison of postoperative recovery, complications, hospital stay, operative parameters, and short-term outcomes can thus offer clinically relevant evidence that will help choose the most suitable surgical approach. The general purpose of this study was to evaluate the clinical and perioperative results of VATS versus OT in patients with early-stage lung cancer and lobectomy to assess whether the minimally invasive technique offers any advantages in terms of clinical outcome while providing adequate surgical results. The current study was designed to compare the perioperative and clinical outcomes in patients undergoing lobectomy for early-stage lung cancer with the use of VATS versus open thoracotomy.

A multicentered comparative analytical study was performed that compared the peri- and post-operative results of video-assisted thoracoscopic surgery (VATS) and open thoracotomy (OT) in patients who had lobectomy for early cancer of the lung. The study was conducted at Mayo Hospital, Arif Memorial Hospital, and Bahria International Hospital. Patients who met the eligibility criteria and had a clinically diagnosed early-stage non-small cell lung cancer (NSCLC) were recruited and divided into two groups based on surgical procedure: VATS group and OT Group. The study was conducted over a period of one year from 1st April 2025 to 31st March 2026 Sample size was determined from OpenEpi version 3.01 for comparison of two proportions. The calculation was based on the number of major complications reported in a previous comparative study by Berry et al., which reported a major complication rate of 20.0% in the VATS lobectomy group and 35.7% in the thoracotomy lobectomy group. A two-sided 95% confidence level, 80% statistical power, and expected complication proportions of 20.0% in the VATS group and 35.7% in the OT Group yielded a minimum sample size of about 127 patients per group, with a total sample size of 254 patients.[15] To account for potential incomplete records, loss to follow-up, and exclusions during analysis, a 10% contingency, for a total sample size of approximately 280 patients, 140 patients in each group, was added. A consequential sampling technique of non-probability sampling has been adopted. Each eligible patient presenting during the study period was consecutively evaluated and added to the study until the desired sample size was reached. Patients were divided into the VATS or OT Group depending on the surgical procedure performed by the surgical team of the thoracotomy. The treating surgeon did not change their approach to the surgery for study entry. Patients were eligible for the study if they were 18 years or older with a known or suspected histology diagnosis of resectable, early-stage NSCLC and were considered to be fit for surgical treatment with cure and had undergone anatomical lobectomy with mediastinal and/or hilar lymph-node assessment. Patients with clinical stages I–II disease who were considered appropriate candidates for lobectomy were eligible. Both male and female patients were included. The patients who underwent VATS lobectomy or conventional OT lobectomy during the study period were enrolled. Patients were excluded if they had locally advanced or metastatic lung cancer which could not be treated with curative lobectomy; if they had undergone pneumonectomy, wedge resection, or segmentectomy rather than a lobectomy; or if they had had a major thoracic surgery on the same side as the tumor, which affected the usual approach to the operation. These patients were excluded from the primary comparative analysis due to incomplete medical and/or operative records, emergency thoracic surgery, and surgery performed from VATS to open thoracotomy. Patients with synchronous malignancies or those who were removed to a different surgical procedure due to intraoperative findings were also excluded. Eligible patients were selected from the thoracic surgery unit and evaluated for the predetermined inclusion and exclusion criteria, after obtaining institutional ethical approval. Patients' informed consent was obtained in writing before enrollment. Data were collected using a standardized, predesigned data collection proforma that was used uniformly across all participating centers. Baseline variables included were age, sex, smoking status, body mass index, relevant comorbidities, pulmonary function variables, American Society of Anesthesiologists (ASA) physical status[16], tumor location, tumor size, clinical stage, and histopathological type. The operative variables used were surgical approach, type of lobectomy, duration of surgery, estimated blood loss, need for blood transfusion, need for conversion from VATS to thoracotomy, and extent of lymph-node dissection. The outcomes during the hospital stay were recorded following surgery. These included: postoperative pain, chest-tube duration, postoperative drainage duration, time to mobilization, postoperative complications, admission to intensive care, hospital stay, readmission, and in-hospital mortality. Postoperative complications included pneumonia, atelectasis, prolonged air leak, respiratory failure, requirement of prolonged ventilatory support, cardiovascular complications, wound infection, postoperative bleeding, arrhythmias, and other clinically significant adverse events. Pathological data, such as tumor size, histological subtype, pathological stage, lymph node involvement and margin status, were also recorded where applicable. Patients were followed until hospital discharge, and postoperative outcome was compared between both the VATS group and OT Groups. The data collected were entered and analysed in IBM SPSS Statistics version 26.0. Normality of continuous variables was determined by the Shapiro–Wilk test. Continuous variables were presented as mean ± standard deviation, while non-normally distributed variables were presented as medians (interquartile range). Frequencies and percentages were used to present categorical variables. An independent-samples t-test was applied when the continuous variables were normally distributed, and the Mann–Whitney U test was applied when the continuous variables were not normally distributed to compare the two groups (VATS and open thoracotomy). The chi-square test and Fisher's exact test were used for the comparisons of categorical variables. The main outcome was postoperative complications, with secondary outcomes being postoperative pain, chest-tube placement duration, operative duration, blood loss, hospital stay, readmission, and mortality. Multivariable logistic regression analysis was carried out for identification of independent factors associated with complications after adjustment for potential confounding factors such as age, sex, smoking status, comorbidities, ASA status, tumor size, and disease stage. Effect estimates were presented as odds ratios (ORs) with corresponding 95% confidence intervals (CIs). A two-sided p-value < 0.05 was deemed to be statistically significant.

A total of 280 patients from the participating centers who underwent lobectomy for early-stage lung cancer were analyzed, consisting of 140 patients who received VATS and 140 patients who received open thoracotomy. There were no significant differences between the two groups for demographic and baseline clinical variables such as age, sex, BMI, smoking status, comorbidities, ASA physical status, and preoperative pulmonary function. There were no significant differences for these baseline factors between the groups, supporting the comparability of the study groups at the time of surgery (Table 1).

Table 1. Baseline demographic and clinical characteristics of patients undergoing VATS and OT lobectomy (n=280)

The degree of tumor characteristics in the two surgical groups was also similar. There were no significant differences in tumor location, histopathological subtypes, clinical stage, or mean tumor size between VATS and open thoracotomy. The most common histopathological type was adenocarcinoma in both groups and stage I disease in most cases. These results suggested that the observed differences after surgery were not likely due to large differences in baseline tumor characteristics (Table 2).

Table 2. Tumor characteristics and disease stage among patients undergoing VATS and OT lobectomy

Operative characteristics were found to be significantly different between the two approaches. The operative time was significantly longer for VATS lobectomy, and the blood loss was significantly lower in the VATS group. Also, the need for transfusion of blood was significantly lower in patients with VATS. However, the number of nodes harvested and the percentage of complete R0 resections were similar in both groups despite the differences in operative parameters. There was only a small proportion (Table 3) of patients who underwent conversion from VATS to open thoracotomy.

Table 3. Operative characteristics of patients undergoing VATS versus OT lobectomy

The recovery period after VATS lobectomy was much better. Patients receiving VATS had significantly lower pain scores at 48 hours after surgery, shorter chest-tube drainage time, and an earlier time to mobilization than patients undergoing open thoracotomy. The VATS group also had a reduced requirement for postoperative intensive-care admission. Most importantly, VATS was associated with a significantly shorter overall hospital stay. There were no statistically significant differences in 30-day readmission or in-hospital mortality between the VATS and conventional groups (Table 4).

Table 4. Postoperative recovery outcomes in VATS and OT Groups

Postoperative morbidity was significantly different between the two surgical approaches. Postoperative complications were less frequent in patients who received VATS compared to those who received open thoracotomy. The frequencies of prolonged air leak, pneumonia, atelectasis, respiratory failure, postoperative bleeding, and arrhythmia were significantly lower in the VATS group, while wound infection and reoperation each exhibited a lower frequency in the VATS group, though these differences were not statistically significant. In summary, the key difference in postoperative morbidity was associated with the overall decrease in postoperative complications and the lesser incidence of prolonged air leak after the less invasive procedure (Table 5).

Table 5. Postoperative complications among patients undergoing VATS and open thoracotomy

Comparable oncological results were obtained at pathological examination of both groups. Tumor size, frequency of lymph-node involvement, number of examined lymph nodes and positive surgical margins were not found to be significantly different. In patients who underwent a minimally invasive approach, the proportion of patients that had an R0 resection was also high, indicating that the completeness of the oncological resection was not compromised (Table 6).

Table 6. Pathological outcomes following VATS and OT lobectomy

Several variables showed associations with postoperative complications in the univariable analysis on logistic regression analysis. Postoperative morbidity was significantly associated with COPD, ASA status grade III, and open thoracotomy. In addition to adjustment for age, sex, and smoking, postoperative complications were significantly predicted by open thoracotomy, while the effect of the other variables, such as COPD and ASA III status, was weakened and no longer reached conventional statistical significance after this adjustment (Table 7).

Table 7. Univariable and multivariable logistic regression analysis of predictors of postoperative complications

This study addressed the differences in perioperative, postoperative, and pathological results between VATS and thoracotomy in 280 patients with early-stage lung cancer undergoing lobectomy. The demographic, smoking, comorbidities, ASA status, pulmonary function, tumor characteristics, and clinical stage were well balanced between the two groups. This comparability reinforced the interpretation of observed differences in the postoperative outcomes and minimised the possibility that baseline differences were responsible for the findings. The present study showed a significantly longer operative time for VATS compared to OT, with mean times of 168.4 and 151.2 minutes, respectively. This result aligns with the results of the randomized VIOLET trial published by Lim et al. in 2021, in which VATS and open lobectomy in early-stage lung cancer patients were directly compared, and VATS provided important recovery benefits, despite some differences in operating characteristics.[17] Likewise, a systematic review and meta-analysis of the available randomized literature from 2022 by Alban et al. showed that the postoperative results of VATS were generally better than thoracotomy, despite the paucity of the randomized literature.[18] The operative time was marginally longer in VATS, but this was not due to a lack of technical proficiency of the surgeons, but to the technical challenge of the hilar dissection, division of the vessels, lymph-node evaluation, and retrieval of the specimen from limited access. One of the major findings of the present study was the significantly reduced intraoperative blood loss in the VATS group and less requirement for blood transfusion. The study of Hireche et al in 2022, which compared VATS lobectomy and open lobectomy following induction therapy, showed significantly less blood loss with VATS, and their pooled meta-analysis of nine studies showed less blood loss and fewer perioperative complications with VATS lobectomy compared to open lobectomy.[19] These findings support the concept that avoidance of extensive chest-wall disruption and rib spreading may contribute to reduced operative trauma and blood loss with minimally invasive lobectomy. This study also showed significantly improved postoperative recovery after VATS. Patients having VATS had significantly less pain at 24 hrs and 48 hrs, shorter chest-tube duration, earlier mobilization, and a significantly shorter hospital stay. This study is very similar to a randomized study by Lim et al. involving 503 patients, and they found that VATS had superior physical function 5 weeks after surgery compared to open lobectomy. The investigators found that the median physical-function score was 73 in the VATS group and 67 in the open surgery group, suggesting that the effect of reduced surgical trauma is not only in the immediate postoperative period.[20] The 2022 narrative review by Alban et al. of randomized comparative evidence also revealed reduced pain and hospital stay in some of the randomized studies comparing VATS with thoracotomy.[20] The shorter hospitalization found in our VATS group is in accordance with a study by Cai et al. 2024 found that VATS was significantly associated with shorter hospital stay and lower intraoperative blood loss, but longer operative time, compared to OT for lung sleeve resection. Importantly, they did not observe any significant differences with regard to the number of lymph nodes that were dissected or with respect to important oncological outcomes.[21] Sleeve lobectomy is a more technically challenging operation than a routine lobectomy and, therefore, it cannot be directly compared with the population of the present study. However, the similar characteristics of the perioperative findings indicate that the advantages of the less invasive approach may also be applied to technically challenging pulmonary resections. Another significant result of the present study was the postoperative morbidity. The overall complication rate was 20.0% for patients undergoing VATS and 35.7% for those with an open thoracotomy, which is a statistically significant difference. The frequency of prolonged air leak was also significantly lower following VATS, and pneumonia, atelectasis, respiratory failure, bleeding, arrhythmia, wound infection, and reoperation were also numerically less frequent, but were not individually statistically significant. These results align with the randomized evidence reported by Alban et al. A summary of several randomized trials reported fewer postoperative complications after VATS.[18] They are also in line with the meta-analysis, which showed significantly fewer perioperative complications in patients who underwent lobectomy after induction therapy.[19] The overall reduction in morbidity reported in our study is clinically significant, as postoperative complications after lung resection may delay mobilization, increase the duration of chest tube placement and hospital stay, and may interfere with the subsequent cancer treatment. Chest-wall trauma may contribute to the decreased postoperative morbidity seen with VATS. OT involves making a large incision and spreading the ribs apart, while VATS allows for the procedure to be completed through smaller access points. This may help to reduce the risk of postoperative pain and promote coughing, deep breathing, mobility, and pulmonary rehab. The same interpretation has been supported by the VIOLET trial, in which the benefit of VATS did not only manifest in terms of hospital outcome but in terms of postoperative physical function as well.[20] Therefore, the present data indicate that the advantages of VATS are multi-dimensional and are not only limited to a single postoperative parameter but extend to pain, respiratory recovery, mobility and hospital utilization as well. Even patients who have been treated with induction therapy offer reassurance about oncological adequacy. A retrospective study of patients after neoadjuvant chemoimmunotherapy (nCIT) for lobectomy was conducted in 2022, with an R0 resection rate of 95.4% and consideration of both VATS and open approaches.[22] Hireche et al. later showed that it was possible to conduct VATS safely even following induction treatment for stage III NSCLC, but these patients were a more advanced cohort than analyzed in our study.[19] Overall, these observations indicate that the minimally invasive approach does not necessarily provide a disadvantage with regard to the ability to obtain a complete oncological resection if properly selected and performed by a skilled thoracic surgeon. Our study found a conversion rate of 6.4% in patients who initially underwent VATS. This is similar to what has been reported in modern minimally invasive thoracic surgery series. A 2024 study done on 339 patients who had undergone uniportal and multiportal VATS lobectomy found an overall conversion rate of 5.01%, and that the conversion rates between the two VATS techniques were very similar.[8] Therefore, the word 'conversion' should not be considered a failure of minimally invasive surgery, but rather a judicious intra-operative choice in the presence of anatomical complexity, bleeding, adhesions or difficulties in achieving safe oncological margins. In the present study, a multivariable analysis further confirmed the relationship between approach and postoperative morbidity. OT was independently associated with postoperative complications after adjustment for the other factors listed above, with adjusted odds approximately 2.3-fold higher than with VATS. This result is consistent with the overall data supporting the benefit of minimally invasive lobectomy on reducing morbidity. In the 2022 randomized evidence synthesis, VATS showed better outcomes for length of stay, pain scores, and postoperative complications, and demonstrated similar oncological outcomes.[18] The significant morbidity difference between thoracotomy and non-thoracotomy, despite patient age, comorbidities, tumour size, and tumour/lymph node metastasis adjustments in our analysis, indicates that this was not merely the result of the differences in age, comorbidities, tumour size, or tumour/lymph node metastasis. Recent studies have further bolstered the argument for minimally invasive surgery. In their 2024 review of current VATS lobectomy for early-stage lung cancer, Rodriguez et al. highlighted that VATS was an established technique and highlighted its importance in the management of early-stage disease.[18] Likewise, in 2025, Steen et al. documented how VATS has become an increasingly popular alternative to OT for early-stage NSCLC and how VATS has become a common approach in modern thoracic surgery.[23] The present study findings are in line with these modern observations that VATS offers significant perioperative benefits without affecting the extent of cancer resection. Importantly, the latest evidence has started to answer the question of whether the perioperative benefits of VATS can be translated into long-term oncological benefit. In a study by Harris et al. 2026, the hazard ratio for overall survival for VATS was 0.79, suggesting a lower risk of death, and there was no significant difference between approaches in disease-free survival.[24] Importantly, in the current study, the comparable results on R0 resection and lymph node outcomes suggest that the short-term benefits of VATS were not compromised by surgical completeness. The present study was not aimed at assessing long-term survival, but the recent randomized evidence further supports the oncological suitability of VATS. The patients operated on using VATS had significantly fewer postoperative complications, less blood loss, less postoperative pain, shorter chest-tube duration, earlier mobilization, shorter hospital stay, and somewhat longer operative time, when compared with open thoracotomy. Meanwhile, the lymph-node assessment, margin status, and R0 resection were similar for both methods. The results indicate that VATS has a favorable balance of surgical safety, recovery, and oncologic adequacy in selected patients with early lung cancer. Therefore, the growing mastery of minimally invasive skills and perioperative pathways could further cement VATS as the preferred approach for lobectomy, wherever possible. Limitations Several limitations in this study need to be taken into consideration when interpreting the findings. Although the multicenter design enhanced the generalizability of the findings across different institutional settings, variations in surgical expertise, perioperative protocols, postoperative care pathways, and patient selection between participating centers may have introduced center-level heterogeneity. Secondly, the non-probability consecutive sampling technique might have led to selection bias. The two groups were similar in baseline characteristics, but there was no random allocation of patients to VATS or to open thoracotomy, which could result in residual confounding. Third, the study focused mainly on short-term postoperative results and on perioperative outcomes, and did not include long-term follow-up for overall survival, disease-free survival, recurrence, or quality of life. Fourth, the relatively low incidence of uncommon complications and deaths reduced the statistical power to see a difference in these outcomes. Lastly, it was not possible to evaluate the surgeon-specific experience or the learning curve of VATS, which could have an impact on operative duration, conversion rates, and postoperative results.

In patients with early-stage lung cancer, VATS lobectomy showed an interesting perioperative benefit over open thoracotomy. VATS had significantly less postoperative pain, fewer complications, earlier mobilization, shorter chest tube time, shorter hospital stay, and significantly less blood loss, but it took longer to operate. Importantly, these benefits of recovery did not come at the expense of lymph-node assessment, surgical margins or R0 resection rates. The risk of postoperative complications was still significantly increased following OT after controlling for other patient and tumour factors. Overall, these results provide evidence of the safety and efficacy of VATS in properly selected patients for lobectomy for early-stage lung cancer. If there is sufficient surgical skill and resources, VATS may provide the essential combination of reduced surgical trauma, rapid recovery and maintenance of oncological integrity.

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