Thoracic Surgical Approaches: VATS and Thoracotomy

Why the approach matters

Two patients on the same ward may have had the same lobectomy for the same tumour, and present entirely differently. One walked to the bathroom on the evening of surgery; the other cannot lift the arm on the operated side, is splinting against a chest drain and has not taken a deep breath since waking. The difference is usually the incision.

The approach determines how much muscle was divided, whether the ribs were spread, how much intercostal nerve trauma occurred, how many drains are in place and how long they stay. Each of those has a direct physiotherapy consequence.

The approaches

Posterolateral thoracotomy

The traditional access to the chest and still the standard for complex or extensive resections. A curved incision from below the scapula, dividing latissimus dorsi and usually part of serratus anterior, followed by entry through an intercostal space with mechanical rib spreading.

Physiotherapy consequences follow directly from that anatomy. Division of latissimus and serratus produces measurable shoulder girdle dysfunction and scapular winging. Rib spreading causes intercostal nerve injury — the principal driver of chronic post-thoracotomy pain. Chest wall mechanics on the operated side are impaired for weeks.

Muscle-sparing and anterolateral thoracotomy

Variants that mobilise rather than divide latissimus dorsi, and enter through an anterior or lateral intercostal space with less or no rib spreading. Shoulder function recovers faster; the intercostal nerve is still at risk wherever a rib retractor is used.

Video-assisted thoracoscopic surgery (VATS)

Two to four small port incisions, or a single port in uniportal VATS, with the resection performed under camera vision and the specimen removed through a small utility incision. No rib spreading and no major muscle division. Increasingly the default for early-stage lung cancer.

Robotic-assisted thoracic surgery (RATS)

Mechanically similar to VATS from the patient's perspective — port incisions, no rib spreading — with better instrument articulation for the surgeon. Post-operative recovery broadly resembles VATS; the physiotherapy approach is the same.

Sternotomy and clamshell

Median sternotomy is the cardiac surgical access and is occasionally used for bilateral lung disease; the clamshell (bilateral anterolateral thoracotomy with transverse sternal division) is used for bilateral lung transplantation and some large tumours. Both bring sternal considerations rather than thoracotomy ones — see Sternal Precautions.

How they compare

The evidence

VIOLET is the definitive randomised comparison: 503 patients with known or suspected early-stage lung cancer randomised to VATS or open lobectomy across nine UK centres.⁵ VATS produced less in-hospital pain, fewer complications, shorter stay and better physical function at five weeks, with no difference in oncological outcomes at one year. The earlier Danish randomised trial had already shown lower pain scores and better quality of life over the first year after VATS.¹

The Enhanced Recovery After Surgery (ERAS) Society and ESTS guidelines for lung surgery recommend a minimally invasive approach where technically feasible, alongside avoidance of routine urinary catheters, early drain removal, and mobilisation within 24 hours.⁶

For analgesia, paravertebral block is comparable to thoracic epidural for pain control after thoracotomy, with a better side-effect profile — less hypotension, urinary retention and nausea, all of which matter for early mobilisation.⁷ Where a patient is failing to mobilise because of an epidural-related motor block or hypotension, that is reasonable for physiotherapy to raise.

What this means for treatment

After thoracotomy

• Shoulder and scapular exercise from day one. A structured post-operative shoulder programme improves function and reduces pain after open thoracotomy in randomised comparison — this is one of the few thoracic physiotherapy interventions with direct trial support.⁴
• Posture and thoracic mobility. Patients adopt a protective side-flexed, internally rotated posture that becomes habitual within days.
• Analgesia before treatment, every time. A thoracotomy patient with inadequate analgesia cannot take a deep breath or cough, and no technique substitutes for that.
• Watch for chronic pain developing. Neuropathic features — burning, allodynia along the scar or dermatome — in the early weeks warrant referral rather than reassurance.

After VATS

• Do not assume nothing is needed. Reduced surgical trauma does not remove the general anaesthetic, the single-lung ventilation, the drain or the underlying lung disease. Patients with chronic obstructive pulmonary disease (COPD), poor exercise capacity or a smoking history remain at risk.
• Mobilise early and expect more. The realistic day-one target is walking, not sitting out.
• The drain is usually the rate-limiting factor, not pain or breathlessness. See Chest Drains.

Role of the physiotherapist

Establish the approach and the extent of the resection first. After open approaches, the priorities are analgesia, shoulder girdle function and posture alongside the respiratory work. After minimally invasive approaches, the priority is early and progressive mobilisation, with respiratory intervention reserved for those who develop a problem rather than applied routinely. In both, pre-operative contact remains the highest-value intervention — see Post-operative Pulmonary Complications.

References & evidence base

1. Bendixen M, Jørgensen OD, Kronborg C, Andersen C, Licht PB. Postoperative pain and quality of life after lobectomy via video-assisted thoracoscopic surgery or anterolateral thoracotomy for early stage lung cancer: a randomised controlled trial. Lancet Oncol 2016;17(6):836–844.
2. Wildgaard K, Ravn J, Kehlet H. Chronic post-thoracotomy pain: a critical review of pathogenic mechanisms and strategies for prevention. Eur J Cardiothorac Surg 2009;36(1):170–180.
3. Bayman EO, Brennan TJ. Incidence and severity of chronic pain at 3 and 6 months after thoracotomy: meta-analysis. J Pain 2014;15(9):887–897.
4. Reeve J, Stiller K, Nicol K, et al. A postoperative shoulder exercise program improves function and decreases pain following open thoracotomy: a randomised trial. J Physiother 2010;56(4):245–252.
5. Lim E, Batchelor TJP, Dunning J, et al. Video-assisted thoracoscopic or open lobectomy in early-stage lung cancer (VIOLET): a randomised controlled trial. NEJM Evid 2022;1(3):EVIDoa2100016.
6. Batchelor TJP, Rasburn NJ, Abdelnour-Berchtold E, et al. Guidelines for enhanced recovery after lung surgery: recommendations of the ERAS Society and the European Society of Thoracic Surgeons. Eur J Cardiothorac Surg 2019;55(1):91–115.
7. Yeung JHY, Gates S, Naidu BV, Wilson MJA, Gao Smith F. Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev 2016;(2):CD009121.
8. Agostini P, Cieslik H, Rathinam S, et al. Postoperative pulmonary complications following thoracic surgery: are there any modifiable risk factors? Thorax 2010;65(9):815–818.

References are numbered in citation order (Vancouver/BMJ style) and were current at the time of writing. Guidelines are living documents — verify against the latest version before clinical use.