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VATS vs open lung surgery | CION Cancer Clinics
VATS is keyhole surgery for the chest: two or three small cuts, a camera, and no spreading of the ribs. Open surgery, a thoracotomy, uses one longer cut between the ribs. The lobe and the glands removed are the same either way. Keyhole usually means less pain and a shorter stay, but a large, central or stuck-down tumour can make open the safer choice. This page explains what changes and what does not. CION Cancer Clinics’ surgical oncologists in Hyderabad can talk this through with you.
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Medically reviewed by Dr. Muralidhar MuddusettyConsultant Surgical Oncologist · MBBS (AIIMS), MS (Surgery, AIIMS), DNB (Surgical Oncology), MRCS (Edinburgh) · last reviewed September 2026, next review due September 2027
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The short answer
What is the difference between VATS and open lung surgery?
VATS is keyhole surgery for the chest. The surgeon works through two or three small cuts, watching a camera on a screen, and the ribs are not spread apart. Open surgery, called a thoracotomy, uses one longer cut between the ribs, which are gently parted so the surgeon can see and work directly. The operation inside, a lobectomy or a smaller resection, is the same either way.
What changes, and what does not
What changes is the chest wall. Spreading the ribs is what causes most of the pain after open surgery, so keyhole usually means less pain, fewer days in hospital and a quicker return to normal breathing. What does not change is what is removed: the same lobe, the same glands, the same care over the cut edge.
Who VATS does not suit
Keyhole is not the safer route for everyone. A large tumour, one wrapped around the main vessels or airway, dense scarring from old TB or a previous operation, or a tumour that has grown into the chest wall all make open surgery the wiser choice. The surgeon's own experience with keyhole matters too, and it is fair to ask about it.
This page cannot tell you which approach is right for you. That depends on your scans and your surgeon's judgement.Side by side
VATS and open surgery, compared
VATS (keyhole)
Open (thoracotomy)
Two or three small cuts and a camera; ribs not spread
One longer cut between the ribs; ribs gently parted
Usually less pain, and less need for strong painkillers
More pain in the first weeks; a nerve block or epidural is common
Usually a shorter hospital stay and faster return to activity
Usually a longer stay and a slower return
Suits small and medium tumours away from the centre
Suits large, central or stuck-down tumours, and sleeve resections
Same lobe, same glands, same chest drain
Same lobe, same glands, same chest drain
When open is chosen
Why would a surgeon choose an open cut?
An open operation is a judgement about safety, not a sign that the surgeon is behind the times or that your cancer is worse.
A large or central tumour
When the tumour sits close to the main artery, vein or airway at the root of the lung, the surgeon needs direct hands-on control of those vessels. A sleeve resection, where a piece of airway is removed and rejoined, is often done open for the same reason.
Scarring from old infection or surgery
Old TB, pleurisy or a previous chest operation can glue the lung to the chest wall and the glands to the vessels. Freeing them through a camera can be slow and risky, and open surgery is safer.
The chest wall is involved
If the tumour has grown into a rib or the lining of the chest, part of the wall may need to come out with it. That is an open operation.
Converting during a VATS
Sometimes a keyhole operation starts and the surgeon finds bleeding, dense scarring or a tumour that is larger than the scan suggested. Switching to an open cut is a planned safety step, and you will have been told beforehand that it might happen.
Ask your surgeon how often they convert, and what would make them do it in your case.Not sure whether this applies to you?
Ask an oncologistOn the day
What happens during a VATS lobectomy?
Going to sleep
The anaesthetist places a breathing tube that rests the lung on the operating side while the other keeps you going. You lie on your side with the arm raised out of the way.
The ports
Two or three small cuts are made between the ribs. One takes the camera, the others the instruments. Some surgeons work through a single slightly longer cut, called uniportal VATS.
The operation
Watching the screen, the surgeon seals the lobe's artery, vein and airway with staples, divides the lung, and lifts the lobe out in a bag through one of the cuts. Glands from the root of the lung and the middle of the chest are removed for the pathologist.
Drain and recovery
A chest drain goes in through one of the cuts. You wake in recovery and usually spend the first night somewhere you can be watched closely. Most people are walking the next morning.
Commonly believed
Four things families tell us, and what is actually true
"Keyhole is less thorough. They cannot see properly."
The camera gives a magnified, well-lit view, often clearer than the eye through an open cut. The same lobe and glands are removed. Where keyhole is unsuitable, it is usually because of access or safety, not because the surgeon would see less.
"They opened him up, so it must have been worse than they thought."
Sometimes, but often not. Open surgery is chosen for scarring, tumour position, or the surgeon's judgement about safety. The stage comes from the pathology report, not from the size of the cut.
"After keyhole surgery there is no pain."
There is less pain, not none. The cuts sit between ribs, the chest drain is uncomfortable, and coughing hurts for a while. Good pain control is planned for keyhole surgery just as it is for open.
"If my surgeon offers open, I should find one who does keyhole."
Ask why open is recommended first. If the reason is the tumour or scarring, a second surgeon will likely say the same. If it is the centre's experience with keyhole, a second opinion is reasonable and no good surgeon will be offended.
Being straight with you
What this page cannot tell you
It cannot tell you whether keyhole or open is right for your operation, and it carries no prognosis, which means the likely course of the illness, for either. The approach changes the recovery. It does not, on its own, change what the cancer does afterwards, because what is removed is the same.
Questions worth asking your surgeon
Ask which approach is planned and why. Ask how many keyhole lung operations the surgeon does in a year, and how often they convert to open. Ask what would make them convert in your case, and whether the cost or insurance cover differs between the two. Ask how pain will be managed in the first days, whichever approach is used.
Robotic surgery
Robot-assisted surgery is a form of keyhole in which the surgeon controls the instruments from a console. It is not available at every centre and usually costs more. If it is offered to you, ask what it adds in your case over standard VATS. There is a separate page on it.
If you have a report you do not understand, call the helpline and someone will read it with you.Questions we are asked
Common questions about VATS and open lung surgery
Is VATS as safe as open surgery for cancer?
For tumours that suit it, yes. The same lobe and the same glands are removed, and large studies have found the cancer outcomes similar, with less pain and a shorter stay after keyhole. For tumours that do not suit keyhole, open surgery is the safer choice, and a good surgeon will say so plainly.
How big are the cuts?
Keyhole cuts are small, a few centimetres for the one the lobe comes out through and smaller for the others. An open cut runs along the side of the chest under the shoulder blade and is much longer. Both fade over the following year. The difference that matters more is whether the ribs were spread.
Will I still need a chest drain after keyhole surgery?
Yes. The drain is about the lung, not the cut. It lets air and fluid out while the remaining lung expands, and it comes out once the air leak has stopped. Some centres remove it a little sooner after keyhole surgery, but it is not skipped.
What does it mean if the surgeon "converted" to open?
The operation began by keyhole and was completed through an open cut. Common reasons are bleeding, dense scarring or a tumour that was harder to reach than the scan suggested. It is a safety decision. The lobe and glands still come out, and the pathology report is what tells you about the cancer.
Is the hospital stay really shorter after VATS?
Usually, by a day or two, though the drain and any air leak decide it more than the cuts do. The bigger differences are in the weeks after: less pain, easier deep breathing, and an earlier return to walking, work and driving.
Does open surgery leave long-term pain?
It can. Some people have lasting discomfort along the cut where the nerve between the ribs was stretched, and it is less common after keyhole. Most settle over months. If pain is still limiting you well after surgery, tell your team, because it can be treated. There is a separate page on this.
Does VATS cost more than open surgery?
The staplers and instruments used in keyhole surgery add to the bill, though a shorter stay offsets part of it. Whether your scheme or insurer covers the keyhole charges varies. Ask the centre for an estimate for both approaches before you decide, and call the helpline if you want that checked against your cover.
Is VATS covered by Aarogyasri or my insurance?
Lung cancer surgery is usually covered when it is part of an approved treatment plan. Aarogyasri, CGHS, ECHS and EHS are accepted at CION, and most cashless insurers are empanelled. Whether the keyhole instrument charges are included varies between schemes, so call the helpline with your card details and we will check.
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Sources
- Cancer Research UK — Surgery for lung cancer
- American Cancer Society — Surgery for Non-Small Cell Lung Cancer
- NHS — Lung cancer: treatment
- NICE — Lung cancer: diagnosis and management (NG122)
This page is general information, not a prescription. Do not change or stop any treatment based on what you read here. If anything is worrying you, contact your own treating team — or call our helpline and we will help you reach the right specialist.
Keep reading
Related pages
Robotic Lung Surgery in IndiaThe robot-assisted form of keyhole, and what it costsLobectomy: What the Operation InvolvesThe operation that happens inside, whichever approach is usedPain After Thoracic SurgeryHow pain is controlled after each approachPost-Thoracotomy Pain SyndromeThe lasting pain that can follow an open cutChoosing a Surgeon and a CentreHow to ask about experience without offending anyone
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Been offered open surgery and wondering about keyhole?
Send us your CT report, or call the helpline. A surgical oncologist will explain what is planned and why. One helpline serves every CION centre.