Background: The advent and widespread adoption of competency-based education increased the need for objective and valid assessment tools (ATs) of operative skill. However, commonly used ATs are generic, limiting their ability to assess and provide feedback for proficiency in specialized procedures. Video-assisted thoracoscopic lobectomy (VATSL) is a complex procedure requiring knowledge and skills not captured by generic ATs. Therefore, the objective was to identify and evaluate VATSL ATs assessing surgical proficiency. Methods: A systematic literature search was performed using Embase, Google Scholar, Ovid Medline, PubMed and Web of Science (1990-2020). Conference abstracts, letters, commentaries, ATs assessing bronchoscopy, open surgery, pneumonectomy, wedge resections and ATs not evaluating technical skills were excluded. Results: Of 523 unique publications, 4 were included. One article described the development of an 8-item assessment tool (VATSAT) by iterative Delphi consensus with 31 experts but did not describe any validation. VATSAT was then modified by the same group to permit assessments of performance on a virtual reality simulator (mVATSAT). mVATSAT had high intraclass correlation coefficients for single (0.78, p < 0.001) and average (0.91, p < 0.001) measures and high reliability scores (G coefficient 0.79, Pearson coefficient 0.70, p < 0.001), but the proposed cut score had high false passing (29%) and failing (43%) rates compared with predicted performance by clinical experience. The third tool (TCAT-ARC) comprised 35 items scored on a 5-point Likert scale. TCAT-ARC was developed by iterative expert consensus and tested in simulated and clinical environments. TCAT-ARC had high discriminatory ability to differentiate novices from experts (Cronbach a 0.93, interobserver reliability 0.73, correlation with objective structured assessment of technical skills 0.68). However, a threshold score indicative of competence was not determined. The fourth used an error score to assess a porcine simulator but did not provide details regarding development or validation. Conclusion: This review identified 4 VATSL ATs evaluating technical skills: 1 has validity evidence from the clinical environment and none have a reliable competence threshold score. Further study is needed to refine VATSL ATs.