Approaching lobectomy in a VIOLET tinted world: video-assisted thoracoscopic surgery (VATS) vs. open thoracotomy for lobectomy

The publication of the VIdeo assisted thoracoscopic lobectomy versus conventional Open LobEcTomy (VIOLET) trial answered decade long calls for a trial investigating surgical approach for lobectomy. Now with 30 years of work on this topic and a large, multicenter, randomized trial, we must parse out whether video-assisted thoracoscopic surgery (VATS) is truly the optimal approach for lobectomy. However, with an in-depth review of both VIOLET and the existing literature, it becomes clear that the age-old question of VATS vs. thoracotomy is inherently flawed. Existing studies aiming to answer this question are littered with surgeon selection bias, and rightfully so: open thoracotomy and/or VATS should not be offered to patients when it is not in the patients' best interest. If a patient can undergo both VATS or thoracotomy, VATS is a viable option. This is what is done in practice and why minimally invasive surgery (MIS) approaches have revolutionized thoracic surgery. However, what is not clearly evident is the surgical decision making necessary to decide what approaches a patient can undergo for lobectomy. We review VIOLET in the context of the existing literature, discuss indications and contraindications of VATS, emphasize the importance of converting from VATS to open thoracotomy when necessary, and highlight the need for training towards open thoracotomy in a world where MIS has become the standard of care. There may never be a simple answer to VATS vs. open thoracotomy for lobectomy, but it should always be clear that surgical decision making must prioritize patient safety and survival.