What are the indications for Video-Assisted Thoracic (VAT) surgery in patients with lung cancer or pulmonary nodules?

Indications for Video-Assisted Thoracic Surgery (VATS)

Primary Indications for VATS in Lung Cancer

VATS is the preferred surgical approach for clinical stage I non-small cell lung cancer (NSCLC) in experienced centers, offering equivalent oncologic outcomes with superior perioperative results compared to open thoracotomy. 1

Oncologic Indications

• Early-stage NSCLC (clinical stage I) with no lymph node metastasis represents the primary indication for VATS lobectomy. 2
• Clinical stage II disease (T1-2N1, T3N0) can be approached via VATS when surgeon expertise permits, as either open or VATS access yields similar oncologic outcomes. 1
• Pure ground-glass opacity lesions or adenocarcinoma in situ ≤2 cm are appropriate for VATS wedge resection, particularly in patients with compromised cardiopulmonary reserve. 3, 4
• Multifocal lung cancer with synchronous nodules in multiple lobes (ipsilateral or contralateral) without N2 disease can be managed with VATS when complete resection is achievable. 1

Diagnostic and Staging Indications

• VATS serves as a diagnostic tool for indeterminate pulmonary nodules when less invasive methods are inconclusive. 5
• Evaluation and treatment of suspected or known malignant pleural effusion. 5
• Complementary role to cervical mediastinoscopy for invasive staging of mediastinal lymph nodes. 5
• Pre-resection assessment to detect unsuspected causes of irresectability, thereby reducing open-and-close thoracotomy rates. 1

Functional and Patient-Specific Indications

Compromised Pulmonary Reserve

• Patients with FEV1 or DLCO <80% predicted who cannot tolerate standard lobectomy are candidates for VATS wedge resection. 3
• Elderly or high-risk patients with acceptable perioperative mortality risk benefit from the minimally invasive VATS approach. 3
• Patients with heterogeneous emphysema and concurrent lung cancer located in diseased lung tissue can achieve lung volume reduction effect through VATS resection. 1, 3

Demonstrated Perioperative Advantages

The evidence consistently shows VATS superiority in perioperative outcomes:

• Lower operative mortality, fewer complications (26% vs 35%), and shorter hospital length of stay (4 days vs 6 days median) compared to open thoracotomy. 1
• Reduced pulmonary complications (8% vs 12%), less atrial fibrillation (7% vs 12%), and fewer blood transfusions (2% vs 5%). 1
• Decreased postoperative pain with similar long-term survival to open resection. 1
• Earlier chest tube removal (median 3 days vs 4 days). 1

Absolute Contraindications to VATS

The following represent absolute contraindications where VATS should not be attempted:

• Inability to tolerate single-lung ventilation. 6
• Inability to achieve complete resection with lobectomy alone. 6
• T3 or T4 tumors (though select T3N0-1 and T4N0-1 cases may be considered in experienced centers). 6
• N2 or N3 disease. 6

Technical Requirements and Oncologic Principles

Mandatory Oncologic Standards

VATS lobectomy must adhere to the following non-negotiable oncologic principles:

• Individual division of vessels and bronchus of the target lobe. 2
• Systematic lymph node dissection is mandatory, with minimum 6 nodes/stations including at least 3 mediastinal nodes (including subcarinal station). 3, 2
• Minimize touching lymph nodes directly and avoid rupturing lymph node capsules. 2
• Achieve negative microscopic margins for complete resection. 1

Preoperative Assessment Algorithm

Before proceeding with VATS, the following systematic evaluation is required:

1. Meticulous clinical staging to rule out lymph node or distant metastasis using PET/CT, bronchoscopy, and endobronchial ultrasound or mediastinoscopy. 2, 6
2. Pulmonary function testing with FEV1 and DLCO measurements. 3
3. Cardiac risk stratification using recalibrated thoracic RCRI (Revised Cardiac Risk Index). 3
4. If FEV1 or DLCO <80%, proceed with exercise testing and split lung function assessment. 3
5. VO2max measurement with values >20 mL/kg/min indicating low risk for major resection. 3

Common Pitfalls and Conversion Considerations

Conversion to Open Thoracotomy

• Conversion rates of approximately 10% are expected, particularly early in the surgeon's learning curve. 6, 7
• Conversion should be regarded as a means of completing safe resection rather than surgical failure, as converted patients do not suffer increased morbidity or mortality. 6
• Causes of conversion include intraoperative complications, technical problems, anatomical difficulties, and oncological conditions. 6

Critical Warnings

• For solid tumors >2 cm, VATS wedge resection should not be used without compelling functional contraindications to lobectomy, as local recurrence rates are significantly higher (14-23% vs standard lobectomy). 1, 4
• Systematic nodal evaluation cannot be skipped regardless of resection type—accurate staging is mandatory. 3, 4
• VATS wedge resection results in 5-10% decreased long-term survival compared to lobectomy. 1, 8

Survival Outcomes

Long-term survival with VATS lobectomy for stage I NSCLC is equivalent to open thoracotomy:

• 3-year survival rate of 93% for clinical stage I disease and 97% for pathologic stage I disease. 7
• 3-year disease-free survival of 79% for clinical stage I and 89% for pathologic stage I. 7
• Meta-analyses demonstrate at least equivalent long-term survival when matched for stage. 1