We read with interest the article by White et al1 in a recent issue of CHEST (March 2011), which proposed that based on cytokine gene expression, algorithms can be developed that may help identify patients who are at increased risk of hospital-acquired pneumonia following major lung resection. The authors acknowledged that the extent of tissue trauma can affect the inflammatory and immune response to surgery. It is noteworthy that the choice of surgical approach for the cancer resection has a significant impact on the extent of access trauma and the subsequent modulation of the immune response. Vittimberga and colleagues2 reviewed the literature on laparoscopy vs laparotomy and concluded that surgical trauma can cause a systemic inflammatory cytokine response, resulting in increased circulating levels of IL-1, IL-6, and tumor necrosis factor-α; however, the body’s response to laparoscopy is one of lesser immune activation as opposed to immunosuppression. Traditionally, lung cancer resection has been performed using open thoracotomy, but recently there has been increased use of video-assisted thoracic surgery (VATS).3 In patients with stage I non-small cell lung cancer who underwent lung resection either using VATS or open thoracotomy, we showed3 that the plasma levels of IL-6, IL-8, and IL-10 were elevated in both groups. However, the IL-6 and IL-8 levels were significantly lower in the VATS group at the end of surgery than in the open group. Moreover, reduced release of IL-10 was also observed in the VATS group.4 Craig et al5 also showed that compared with open thoracotomy, VATS was associated with lower C-reactive protein and IL-6 levels. In the study by White et al,4 the entire cohort underwent open thoracotomy.