Non-small cell lung cancer (NSCLC) accounts for approximately 85% of lung cancers, and surgical resection is the gold-standard treatment for resectable disease. Minimally invasive surgery (MIS), which includes video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracoscopic surgery (RATS), has emerged as an alternative option to thoracotomy, with the aim of minimizing perioperative morbidity without compromising oncological efficacy. This narrative review evaluates long-term oncological outcomes (overall survival (OS), disease-free survival (DFS) and recurrence-free survival (RFS)) in patients with NSCLC at different stages who underwent MIS. Retrospective and prospective studies, as well as meta-analyses, are included. VATS has shown comparable and, in many cases, superior oncological outcomes compared to open surgery, with more evident benefits in the early stages of the disease. Although mainly in retrospective studies, RATS has demonstrated efficacy in terms of oncological outcomes comparable to open surgery, even in advanced stages or complex resections. With regard to the direct comparison between VATS and RATS, the two MIS techniques have shown similar OS rates, albeit some prospective data and meta-analyses suggest a potential DFS advantage for RATS. MIS is a safe and effective surgical approach in terms of oncological outcomes for resectable NSCLC; nevertheless, it will be necessary to await the results of further randomized studies currently ongoing to better define the long-term benefits of each technique.

Thoracic surgery has progressively moved from open thoracotomy to video-assisted and robot-assisted approaches, reducing access-related trauma while changing the technical environment in which pulmonary resections are performed and taught. This narrative review examines the clinical evolution of open, video-assisted thoracic surgery (VATS), and robot-assisted thoracic surgery (RATS), with particular attention to the evidence supporting their perioperative and oncological outcomes, the learning curves associated with minimally invasive surgery, and the role of simulation-based training. Randomized trials now provide robust evidence that VATS improve postoperative recovery compared with thoracotomy in appropriately selected patients with predominantly early-stage non-small cell lung cancer, without compromising long-term oncological outcomes. Randomized comparisons between RATS and VATS support RATS as an oncologically acceptable minimally invasive alternative and suggest advantages in selected technical endpoints, particularly blood loss and lymph node retrieval, but do not demonstrate consistent superiority in major clinical or survival outcomes. Learning curves vary according to previous experience, case complexity, supervision, institutional volume, and the endpoint used to define competence, making fixed case-number thresholds an incomplete measure of proficiency. Simulation can improve selected technical skills and provide objective performance assessment, although evidence becomes progressively less robust when moving from simulator performance to operating room transfer and patient-level outcomes. Surgical approach, therefore, should be interpreted within a broader framework that includes patient and tumour characteristics, oncological quality, surgical expertise, institutional resources, and structured training.