BackgroundSegmentectomy is increasingly performed for non-small cell lung cancer (NSCLC). However, comparative outcomes data between open, robotic-assisted (RATS) and video-assisted thoracoscopic (VATS) approaches are limited. MethodsA retrospective cohort study of NSCLC segmentectomy cases (2013-2021) from the Society of Thoracic Surgeons General Thoracic Surgery Database was performed. Baseline characteristics were balanced using inverse probability of treatment weighting and compared by operative approach. Volume trends, outcomes, and nodal upstaging were assessed. ResultsOf 9,927 segmentectomy patients, 84.8% underwent minimally invasive surgery (MIS), with RATS becoming the most common approach in 2019. Open segmentectomy is more likely performed at low-volume centers (p<0.0001), whereas RATS more likely high-volume centers (p<0.0001). VATS had higher open conversion rate than RATS (OR 11.8, CI [7.01-21.6], p<0.001). MIS had less 30-day morbidity compared to open segmentectomy (VATS OR 0.71 95% CI [0.55-0.94], p=0.013; RATS OR 0.59, CI [0.43-0.81], p=0.001). Number of nodes and stations harvested were highest for RATS, however N1 upstaging was more likely in open compared to RATS (OR 0.63, CI 0.45-0.89, p< 0.007) and VATS (OR 0.61, CI 0.46-0.83, p=0.001). ConclusionsSegmentectomy volume has increased considerably with RATS becoming the most common approach. MIS has less major morbidity compared to open segmentectomy with no difference between VATS and RATS. However, risk of open conversion is higher with VATS. RATS had increased nodal harvest whereas hilar nodal upstaging was highest with thoracotomy. This study reveals significant differences in outcomes exist between segmentectomy operative approach; the impact of approach on survival merits further investigation.