Abstract
BACKGROUND: Currently, the predominant method for surgical intervention in lung cancer is minimally invasive thoracoscopic lobectomy (MITL). This study, however, seeks to evaluate and compare various operative techniques to determine which approach offers superior efficacy for lymph node (LN) dissection during pulmonary resection. METHODS: We conducted a comprehensive systematic search across several electronic databases, including Embase, the Cochrane Library, PubMed, Medline, and Web of Science, to identify studies that compared MITL (either robotic-assisted or video-assisted) with conventional thoracotomy in the context of lung cancer resection. For the meta-analysis, pooled standard mean differences (SMDs) and relative risks were computed, along with their corresponding 95% confidence intervals (CIs). The protocol for this systematic review was prospectively registered on PROSPERO under the registration number CRD420251147327. RESULTS: The analysis incorporated data from 42 studies, involving a total of 8947 participants. When compared to MITL, the thoracotomy group exhibited a significantly higher total lymph node number (LNN) (SMD -0.22; 95% CI -0.28 to -0.16; I² = 81.6%, P = .000). This trend remained consistent in the video-assisted thoracoscopic lobectomy (VATL) subgroup, where thoracotomy was associated with increased total LNN (SMD -0.27; 95% CI -0.33 to -0.21; I² = 80.5%, P = .000). In contrast, no significant difference in total LNN was observed between thoracotomy and robotic-assisted thoracoscopic lobectomy (RATL) (SMD 0.12; 95% CI -0.04 to 0.27; I² = 16.1%, P = .133). Similarly, thoracotomy yielded a greater number of total lymph node stations (LNS) relative to MITL (SMD -0.16; 95% CI -0.21 to -0.11; I² = 88.9%, P = .000). The VATL subgroup analysis also showed advantage for thoracotomy in total LNS (SMD -0.18; 95% CI -0.23 to -0.12; I² = 88.8%, P = .000), whereas no notable difference was found within the RATL subgroup (SMD 0.21; 95% CI -0.04 to 0.47; I² = 90.0%, P = .098). Furthermore, patients receiving thoracotomy demonstrated higher N1 LNN (SMD -0.22; 95% CI -0.32 to -0.12; I² = 35.3%, P = .000) and more N1 LNS (SMD -0.24; 95% CI -0.41 to -0.07; I² = 43.8%, P = .005) compared to the MITL group. An increase in N2 LNN was also observed with thoracotomy (SMD -0.12; 95% CI -0.20 to -0.03; I² = 50.4%, P = .006). This significance persisted in the VATL subgroup for N2 LNN (SMD -0.18; 95% CI -0.28 to -0.08; I² = 43.1%, P = .000), but not in the RATL subgroup, where no statistical difference was detected (SMD 0.07; 95% CI -0.09 to 0.24; I² = 0%, P = .395). CONCLUSION: Thoracotomy demonstrates a significant advantage over MITL in LN dissection for lung cancer. Subgroup analyses further indicate the superiority of thoracotomy compared to VATL. In contrast, no statistically significant differences were observed between thoracotomy and RATL in terms of total LNN, total LNS, or N2 LNN. Future studies should incorporate additional high-quality literature to enhance the robustness of these findings.