Robotic thoracic surgery—current evidence and perspectives: a narrative review

Introduction

The evolution of technology in recent times has facilitated the emergence of more minimally invasive techniques for surgical approaches across all surgical specialities. This is driven by the goals of greater technical precision and enhanced recovery following surgery. The aspiration to reduce surgical trauma and improve perioperative outcomes has led to a profound transformation within the field of thoracic surgery, with a series of paradigm shifts from open thoracotomy to video-assisted thoracoscopic surgery (VATS) and robotic-assisted thoracic surgery (RATS).

The first VATS pulmonary lobectomy was reported by Roviaro and colleagues in Italy in 1992 (1). The practice of VATS has subsequently been established at thoracic units in multiple centres, with programs that recognised an initial learning curve for training and modifications to the theatre environment (2). The benefits of VATS in comparison with open lobectomy have been assessed in the VIOLET study (3). This was a prospective randomised trial with its primary end outcome showing improvement in physical recovery 5 weeks following surgery for VATS, compared to thoracotomy.

Robotic thoracic surgery was introduced using the da Vinci^® model, which was first approved by the Food and Drug Administration (FDA) in 2000. Robot-assisted lobectomy was first described in Europe by Melfi et al. in 2002 (4). This surgical system has continued to evolve and become the leading robotic platform worldwide, with the FDA approving the fourth-generation da Vinci robot in 2014 (Xi) (Intuitive Surgical Inc., Sunnyvale, CA, USA). This system is currently the leader in robotic platforms worldwide. A major competitor in the field of robotic systems includes the Versius Surgical System (CMR Surgical Ltd., Cambridge, UK), as well as various emerging robotic platforms across Asia, including the Toumai^® Surgical Robot (MicroPort Toumai Robotics, Shanghai), and ShuRui (Beijing ShuRui Technology Co., Ltd., Beijing) originating from China.

Since the introduction of RATS, a variety of thoracic procedures for both malignant and benign disease have been reported. Despite widespread adoption of RATS, there remains debate regarding the true added benefits, cost-effectiveness and comparative efficacy to VATS. Early studies comparing robotic to open thoracotomy (5,6) have suggested potential benefits such as improved lymph node dissection, reduced post-operative pain, reduced hospital stays and shorter recovery.

However, there is a paucity in large-scale randomised controlled trials comparing robotic thoracic surgical approach to VATS. The heterogeneity of existing data regarding robotic approaches to anatomical lung resection and mediastinal surgery also creates a challenge for drawing distinct conclusions. In this narrative review, we aim to provide a comprehensive synthesis of the current published literature on robotic thoracic surgery outcomes. We focus particularly on the evidence regarding robotic pulmonary lobectomy, robotic segmentectomy, and robotic thymectomy. We chose to focus on these particular procedures due to the larger body of published data available for review. We also discuss anaesthetic considerations in robotic thoracic surgery and robotic technical advancements, as well as the cost-effectiveness. We present this article in accordance with the Narrative Review reporting checklist (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-41/rc).

Methods

We performed a literature search using PubMed with the following search terms: ((Robotic surgical procedures OR robotics OR robotic surgery OR robotic assisted surgery) AND (thoracic surgery OR thorax OR mediastinum OR thymectomy OR thoracic surgical procedures OR lung surgery OR thoracic OR lung resection OR lobectomy OR segmentectomy)). Studies were collated that were published from 1st January 2015 to 1st August 2025. Titles and abstracts were screened to identify studies directly relating to robotic thoracic surgery that were published in this timeframe. This period was chosen because of the prominence of published evidence over the last 10-year period. All authors independently assessed the full-text manuscripts, and any disagreement was resolved with consensus and discussion. The inclusion criteria were restricted to studies published in the English language, retrospective studies including >10 patients, randomised control studies, narrative reviews, systematic reviews, or meta-analyses that included adult patients undergoing relevant thoracic procedures. The exclusion criteria were studies not published in English, undertaken in a paediatric cohort, or reporting fewer than 10 patient cases. We conducted a qualitative synthesis of the data extracted. Database search is summarised in Table 1.

Robotic pulmonary lobectomy

Pulmonary lobectomy is the most studied thoracic surgical procedure and remains the gold standard procedure for managing early-stage non-small cell lung cancer (NSCLC) >2 cm size in patients fit to undergo surgery. To date, there have been few randomised controlled trials to analyse the benefits of the robotic approach compared to VATS lobectomy.

The Robotic-assisted vs. Video-Assisted Lobectomy (RAVAL) trial (7), initiated across four centres in 2016, published its early results in 2023, including 81 patients in the robotic arm and 83 patients in the VATS group. In addition to the clinical and economic outcomes, they evaluated health-related quality of life at 12 weeks using the EuroQol 5 Dimension 5 Level (EQ-5D-5L) questionnaire. Notably, the robotic arm demonstrated significantly less blood loss compared to VATS {50 [30–150] vs. 150 [50–200] mL; P=0.002} and a higher number of lymph nodes sampled {10 [8–13] vs. 8 [5–10]; P=0.003}.

In September 2021, the ROMAN study reported on data from 4 centres comparing RATS vs. VATS major lung resections in patients affected by early lung cancer (8). This randomised patients with stage T1–T3, N0–N1 early lung cancer to either 1–4 port VATS lobectomy, anatomical segmentectomy or robotic lobectomy using da Vinci Xi. In this study, the robotic approach was superior in mediastinal and hilar lymph nodal harvesting without significant differences in the primary endpoint of post-operative adverse events or conversion. A notable limitation of this trial was the premature termination due to a lack of significant difference between the two arms, therefore limiting the sample size to 35 in the robotic cohort and 37 in the VATS group.

The Robotic-assisted Versus Video-assisted Thoracoscopic Lobectomy Short-term Results of a Randomised Clinical Trial (RVlob Trial) was published in 2022 (9). This single-centre trial studied primary endpoints including 3-year survival and the extent of lymph nodal dissection. Significant findings included high chest tube drainage in the RATS cohort and greater hospitalisation costs, while presenting similar outcomes in post-operative complications to video-assisted lobectomy. Data on lymph nodal stations were consistent with other published studies, reporting a higher number of lymph node stations harvested in the RATS group. Operative technique compared a 5-port robotic approach to single VATS port incision, which could be viewed as a limitation of the study. Longer-term survival data were published in August 2024. This showed that robotic lobectomy resulted in similar outcomes in overall survival and disease-free survival at 3 and 5 years in patients with resectable NSCLC, as compared with VATS (10). This is currently the only multicentre randomised study to report long-term follow-up of patients for robotic outcomes of recurrence and survival to date at 3 and 5 years. Even though 5-year data has been reported, the primary end point of 3-year overall survival and median follow up of 58 months is still less than the recommended surveillance period of at least 5 years as stated by international guidelines such as the European Society for Medical Oncology.

Catelli et al. published a smaller single-centre randomised control trial in 2023 (11). This study compared 3-port VATS to 4-port robotic lobectomy for NSCLC. There was no statistically significant difference observed in terms of hospital stay [RATS 6.6±2.2 days vs. VATS 7±3.6 days (P=0.68)]. Furthermore, the overall survival and quality of life did not differ between the two samples. Nonetheless, pain assessment on post-operative day 1 did show a significant reduction in pain for the robotic group, although the average duration of surgery was significantly higher in the robotic group, 180 vs. 160 min (P=0.036). Notably, there was a higher rate of cardiac complications for the VATS group, including postoperative atrial fibrillation. This was suggested to be due to a higher pleural effusion rate in the VATS cohort and the lack of carbon dioxide (CO₂) insufflation used in the robotic surgery cohort. The study had a limited number of patients with 25 robotic cases and 50 VATS, reducing its statistical power.

The Brazilian randomised study: Robotic-Assisted vs. Video-assisted lung lobectomy Outcomes (BRAVO trial) (12), published in 2022, was a single-centre randomised study with an aim to examine 90-day morbidity in patients undergoing lobectomy for either primary lung cancer or lung metastasis. This reported a significantly higher 90-day readmission rate with VATS compared to RATS. Other reported outcomes, including operative time, complication rate and chest tube duration, were not statistically different between the groups.

Collectively, these randomised studies have given some evidence of the benefits of robotic compared to VATS lobectomy; however, they have been limited by small sample size, lack of long-term overall and disease-free survival. Most studies have shown the advantages of higher lymph nodal dissection, possibly due to enhanced ergonomics and enhanced vision.

A narrative review by Mattioni et al., published in 2023 (13), included 72 studies on robotic lobectomy for lung cancer resection, reporting surgical approaches and outcomes. This review concluded that robotic lobectomy is a comparable approach to VATS, with similar overall surgical and oncological outcomes. A meta-analysis reported by Aiolfi et al. published in 2021 (14), which compared robotic, VATS and open lobectomy, found that among the 15 studies that reported lymph nodal stations sampled, robotic lobectomy yielded a higher number compared to VATS. The analysis also demonstrated a shorter length of stay (LOS) for the robotic lobectomy cohort, although operative times were longer, with a mean difference in operative time of 56 minutes when compared to VATS. Importantly, 5-year overall survival and oncological resection margin were similar across all approaches. Another meta-analysis by Mao et al. (15) included 18 publications and 8,726 robotic cases and reported equivalence in peri-operative outcomes between VATS and RATS but noted that the incidence of postoperative complications was lower in patients who underwent RATS after 2015 (P=0.01), suggesting improved techniques, surgical expertise, and peri-operative management over time.

The PORTAL study (16), a large retrospective analysis comparing RATS, VATS, and open lobectomy, reported contrasting results. Unlike most prior studies, operative time was shorter for RATS when compared to open and VATS approaches (P<0.001). Variability in operative time across studies is likely explained by heterogeneity in surgeon experience, with some analyses reflecting outcomes from high-volume robotic centres and others including cases performed by surgeons earlier in their learning curve. The PORTAL study also reported no significant difference in 30-day mortality among approaches. However, compared with VATS, robotic lobectomy was associated with a lower conversion rate (P<0.001) and a lower postoperative transfusion rate (P=0.01). A summary analysis of randomised control trials comparing RATS with conventional techniques for lobectomy is presented in Table 2 (7-12).

Several studies assessing the adoption of RATS lobectomy have reported comparable learning curves to VATS, with most surgeons achieving proficiency after approximately 23–25 cases (17,18). In parallel, the use of simulation tools has supported the implementation of robotic programs. One example is the Da Vinci SimNow platform, which provides a structured curriculum that ranges from basic psychomotor exercises to full procedural simulations, including lobectomies. The system offers guided modules as well as free-mode training, along with objective performance metrics that may facilitate continuous skill acquisition and evaluation for thoracic surgeons in training (19).

Robotic segmentectomy

While lobectomy has long been considered the gold standard for stage 1 NSCLC, accumulating evidence suggests that anatomic segmentectomy in <2 cm tumours provides non-inferior overall survival at 5 years, while offering the advantage of preserving lung parenchyma (20-22). Segmentectomies are generally classified as either simple (SS) or complex (CS) according to the number of intersegmental planes that must be dissected. SS requires dissection of a single intersegmental plane, whereas CS involves the division of two or more intersegmental planes (23).

Historically, open thoracotomy and VATS have represented the standard approaches for pulmonary segmentectomy. More recently, RATS has emerged as a feasible technique, demonstrating outcomes comparable to those achieved with open and VATS approaches (24). This was particularly exemplified in the work by Cerfolio et al., where they conducted 100 RATS segmentectomies, demonstrating favourable operative outcomes (25). Although this has been further exemplified in the literature, results vary between studies.

Regarding intraoperative outcomes, several studies have shown benefits for RATS in terms of reduced operative times, less intraoperative bleeding, and improved lymph node dissection, as well as a decreased rate of conversion when compared to VATS and open thoracotomy (24,26-30). Nevertheless, these findings are not universal. Some studies have reported prolonged operative times for RATS relative to VATS and open approaches, highlighting variability in reported outcomes (28,31). Importantly, most of the observed advantages of RATS appear more pronounced when compared to open thoracotomy than when compared directly with VATS.

The postoperative course appears to follow a similar trend, with complication rates largely comparable between RATS and VATS, and differences emerging primarily when compared with open thoracotomy, including in 30- and 90-day morbidity and mortality (27-29,31-33). With respect to postoperative pain, RATS has consistently demonstrated improved recovery and reduced pain compared with open thoracotomy, whilst yielding outcomes similar to VATS (34). Although a recent study has highlighted improved postoperative pain outcomes and quality of life at 6 weeks with RATS, when comparing it to VATS segmentectomies (26). Nonetheless, it’s important to note that when comparing postoperative pain in RATS segmentectomies against uniportal VATS (u-VATS), patients have demonstrated improved outcomes with the latter, in particular with a decreased reported pain over the first postoperative week, and lower frequency of analgesic use at 2 months postoperatively (35). Perhaps with the evolving integration of uniportal RATS (u-RATS) into segmentectomies, benefits such as the aforementioned will be added to the already beneficial outcomes of RATS.

Beyond the domains of complications and pain, outcomes related to LOS appears to partially favour RATS over other approaches (27,31). However, this reduction may not be solely attributable to improved clinical outcomes. A recent meta-analysis by Francis et al. (34) reported that although RATS may be associated with shorter LOS compared with VATS and open surgery, this benefit was offset by a higher rate of hospital readmission in their study.

The variability in reported outcomes may reflect intrinsic differences in patient populations and methodological heterogeneity rather than inherent advantages or disadvantages of the robotic platform. Recent evidence evaluating specific subgroups has demonstrated potential advantages of RATS over VATS. As exemplified in a study evaluating obese patients [body mass index (BMI) >30 kg/m²] undergoing anatomic segmentectomy, Seder et al. found that VATS was associated with a fivefold higher conversion rate and a longer LOS compared with RATS (36). Similarly, Pan et al. conducted a study in octogenarians undergoing segmentectomies and reported that RATS was associated with less intraoperative blood loss and a shorter LOS compared with VATS (37). Importantly, both studies employed propensity score matching to mitigate bias inherent to retrospective designs, thereby strengthening the validity of their findings.

Equally important as clinical outcomes, surgeon training has become essential in the expanding role of RATS segmentectomy. Several authors have evaluated the learning curve, most describing three phases with technical competency achieved after approximately 40–50 cases. Compared with VATS, surgeons appear to reach proficiency more rapidly with the robotic approach (38-41).

Despite the intrinsic advantages of RATS for segmentectomy, such as three-dimensional vision, seven degrees of freedom in instrument movement, and a favourable learning curve, limitations remain. These include challenges in accurately identifying intersegmental planes and confirming adequate margins without palpation. In such situations, adjunctive techniques, such as intravenous indocyanine green (ICG) injection with fluorescence imaging or the inflation-deflation method, have been shown to facilitate reliable identification of the intersegmental plane. This highlights the importance of integrating adjuvant techniques in robotic segmentectomy and structured training to enable the successful adoption of RATS into routine clinical practice (42-44). A summary of the existing literature comparing RATS with VATS and open segmentectomies is presented in Table 3 (26,31,33,34,37).

Robotic thymectomy

Robotic-assisted thymectomy has emerged as a minimally invasive approach offering surgeons and patients several compelling advantages over traditional VATS. Although randomised controlled trials directly comparing robotic thymectomy and VATS thymectomy are lacking, a growing body of retrospective comparative studies, systematic reviews, and meta-analyses offers valuable insights into their respective strengths.

Thymectomy has been widely accepted as an effective surgical option for thymic tumours and myasthenia gravis (MG). Robotic thymectomy has been advocated as a safe and feasible approach. This procedure can be performed using either the lateral or subxiphoid approach. Benefits of the subxiphoid robotic approach have been reported, including an enhanced view of the bilateral upper poles of the thymus and bilateral phrenic nerves, improved pain from not spreading the intercostal space, and excellent cosmesis (45,46).

A systematic review and meta-analysis by O’sullivan et al. (47) reported the advantages of the robotic approach over the open approach, but no clinical advantage in comparison to VATS thymectomy. This included analysis of 7 studies directly comparing VATS and robotic thymectomy, including 994 patients. This showed no significant difference in blood loss, hospital LOS or operative time between the two approaches.

A landmark pooled meta-analysis of five comparative studies reported key perioperative outcomes, including conversion rates, operative time, and length of hospitalisation (48). This did not significantly differ between robotic thymectomy and VATS thymectomy. However, several subsequent reports have shown meaningful advantages favouring the robotic approach.

Multiple meta-analyses found that robotic thymectomy significantly reduces intraoperative blood loss, postoperative drainage volume and duration, length of hospital stay, and postoperative complication rates relative to VATS (49,50). One single-institution analysis (51), although focused across various surgical comparisons, reported that robotic thymectomy yielded shorter operative times (once the docking process is excluded), less intraoperative bleeding, shorter chest drainage duration, reduced LOS, lower complication rates, and enhanced postoperative quality of life, including less pain and better cosmetic outcomes when compared to both VATS and open approaches. These variations in reported outcomes across studies are likely influenced by differences in surgical technique or, more importantly, by the underlying indication for thymectomy. A recent study demonstrated that the learning curve for thymectomy in patients with MG is slightly longer than in non-MG patients, which may further contribute to discrepancies in operative results (52).

With regards to robotic thymectomy technique, a recent meta-analysis by Shen et al. (50) undertook a subgroup analysis of studies reporting the robotic subxiphoid approach and those reporting unilateral robotic approach compared to VATS. The pooled analysis of studies showed the unilateral robotic approach had lower blood loss, shorter LOS, and fewer complications when compared to VATS. In contrast, studies evaluating the robotic subxiphoid approach showed no significant differences in blood loss, LOS, or complication rates relative to VATS. However, this approach was associated with a shorter duration of chest drainage and lower postoperative drainage volume, although it was also associated with longer operative times when compared with the VATS group.

Long-term outcomes appear comparable between these minimally invasive approaches. This has been substantiated by Zhu et al. (53,54) in a propensity-matched analysis, reported in 2024, of 180 patients with thymic epithelial tumours. This reported robotic thymectomy had favourable perioperative outcomes in comparison to VATS, with shorter operative time and less blood loss, with similarly low complication rates, mortality and 5-year progression-free survival results equivalent to VATS.

In the constrained anatomy of the anterior mediastinum, high-definition visualisation with magnification, fine articulation with seven degrees of freedom, tremor filtering, and elimination of the fulcrum effect of VATS could allow more precise dissection. This enables safer handling of critical vascular and neural structures and potentially enhances oncologic accuracy. However, not all studies uniformly favour robotic thymectomy. Some analyses have found no statistically significant differences in outcomes between robotic thymectomy and VATS (48). The lack of randomised trials and heterogeneity in study design, surgeon experience, patient selection, and primary endpoints remain limitations of the current evidence base.

While no direct comparative analyses exist between RATS and VATS or open thymectomy learning curves, studies by Kamel et al. and Meacci et al. indicate that the learning curve for RATS thymectomy plateaus after roughly 15–20 cases, suggesting a shorter path to proficiency than that described for VATS (52,55,56). Practical considerations of robotic thymectomy compared to VATS and open technique need to be balanced with the known increased cost comparison and observed length of operative time. Pertinent studies on robotic thymectomy are summarised in Table 4 (47,48,50,54,57-59).

Anaesthetic considerations in robotic thoracic surgery

Logistical factors such as the operating room size need to be considered for a safe robotic surgical procedure. Accommodation of the robot, ancillary equipment, space for bedside assistant, surgical nurse, support staff, and for essential anaesthetic equipment such as anaesthetic machine, monitoring, medication fridge, etc. Safety must be maintained to allow passage of the robot with a clear pathway to allow movement of the robot in an emergency (60).

Intraoperative use of CO₂ insufflation may lead to increased gastrointestinal (GI) risks such as postoperative ileus and bowel obstruction. A retrospective study compared the use of intraoperative nasogastric tube placement and found a significantly lower rate of GI complications without increasing respiratory risks (61). Other consequences of CO₂ insufflation are the cardiovascular effects with compression of mediastinal vessels, causing hypotension and bradycardia at high pressures. This is an important factor to consider, which is not apparent in VATS surgery.

Technical advancements

A narrative review by Cusumano et al. (62) discussed the use of robotics in complex thoracic cases and the technical innovations. This review addressed the use of robotic surgery in more advanced clinical-stage lung cancer, with the first studies published in 2021 (62,63). Shahin et al. described a series of robotic resections in 95 patients with stages IIB–IVA NSCLC, with 10.5% patients receiving neoadjuvant chemoradiotherapy, reporting its safe and feasible use in this setting (64). It is recognised that robotic surgery in more locally advanced tumours and post-neoadjuvant therapy is feasible; however, it can be more challenging with the need for a more experienced robotic operating surgeon. Open thoracotomy is still the most utilised approach. Cusumano et al. (62) also described the role of advanced 3D planning software for robotic procedures to increase the level of precision. Technologies allow mapping and tracking of surgical instruments during resection surgery to guide the operator.

Another advanced robotic technique includes pulmonary sleeve lobectomy, described by Cerfolio in 2016 (65). Qiu et al. (66) published data comparing robotic, VATS and open sleeve lobectomy. In this study, a higher mortality was observed among the VATS cases, while the robotic group registered lower blood loss, earlier chest drain removal, and a shorter surgical time. The manoeuvrability of the robotic needle holder in creating the bronchial anastomosis was reported to offer advantages.

The introduction of the single-port robot has been another advancement in the field of robotic surgery. This again aimed to minimise surgical trauma by working through one incision. Gonzalez-Rivas et al. (67) described the surgical considerations of single-port robotic surgery using the da Vinci^® Xi model, and further developed this technique through the utilisation of the ShuRui (Beijing ShuRui Technology Co., Ltd.) (68). These authors highlighted advantages such as easier undocking in the event of intraoperative bleeding, which may facilitate safer conversion. Although the adoption of u-RATS is relatively new, a growing number of comparative studies have reported on outcomes. Chen et al. conducted a propensity-matched analysis comparing multiportal RATS (m-RATS) with u-RATS, including 153 patients in each cohort (69). Their study demonstrated lower intraoperative blood loss and fewer postoperative complications in the u-RATS group, although chest tube duration and LOS were slightly longer. Conversely, Manolache et al. reported comparable operative outcomes between uniportal and m-RATS, with u-RATS showing shorter chest drainage duration and reduced LOS in a multicentre cohort of 202 patients (70). However, it is important to consider that the u-RATS group included a higher proportion of segmentectomies, whereas most m-RATS procedures were lobectomies, which may in part account for the more favourable postoperative outcomes reported.

Similarly, in a recent propensity-matched analysis comparing u-VATS and u-RATS, Paradela et al. reported comparable operative outcomes between the two techniques, with u-RATS demonstrating more extensive lymph node dissection, fewer postoperative complications, and a shorter chest drain duration (71). With the expansion of u-RATS expertise worldwide, a greater volume of methodologically robust studies will likely emerge, contributing essential data to guide clinical practice and future adoption.

Technical advancements in robotic surgery continue to evolve, particularly with the integration of artificial intelligence (AI) and augmented reality (AR) into training and intraoperative guidance. These technologies are expected to play a central role in shaping the next decade of robotic thoracic surgery. AI algorithms may support surgeons intraoperatively by recognising anatomical structures, predicting optimal dissection planes, and reducing unintended instrument motion. AI has also shown promise in enhancing the detection of pulmonary nodules, facilitating the diagnosis of early-stage lung cancers (72). In parallel, machine learning–based performance analytics offer real-time feedback that could accelerate the surgical learning curve (73).

AR complements these developments by enabling three-dimensional visualisation of anatomical landmarks and tumour margins, thereby improving precision and safety during complex resections. Emerging image-guided robotic platforms aim to integrate preoperative computed tomography (CT) data directly into the operative field, supporting more accurate lymphadenectomy and vessel preservation (74).

Cost effectiveness

Cost-effectiveness remains an area of ongoing debate in robotic thoracic surgery. While acquisition and maintenance costs of robotic platforms are substantial, studies such as the RAVAL trial (7) have demonstrated that reduced conversion rates, shorter LOS, and faster recovery may offset initial expenditures, particularly in high-volume centres. However, Deen et al. reported that when comparing procedure-specific costs for lobectomy and segmentectomy, VATS remained less costly than RATS (75). More recently, a cost-effectiveness analysis comparing open, VATS, and robotic resections for NSCLC found that although overall costs for RATS were higher, robotic lobectomy was cost-effective relative to open surgery when evaluated over a 5-year horizon of quality-adjusted life-years within the Chinese healthcare system (76). Overall, RATS appears to be associated with higher direct costs compared with open or VATS resections, with expenses influenced by institutional case volume, the impact of the learning curve, and local cost structures. As robotic platforms and instruments become more widely available, it is possible that overall costs will decrease, potentially narrowing the cost gap with VATS and open surgery.

Strengths and limitations

This narrative review offers a comprehensive and contemporary synthesis of the evidence of robotic thoracic surgery across a variety of thoracic procedures. We aimed to provide an overview of published randomised control trials comparing robotic and VATS approaches, meta-analysis, systematic reviews and retrospective reports on robotic thoracic surgery operative and clinical outcomes. The methodology of a narrative review does not include a formal meta-analytic approach and may be subject to selection bias despite the structured search strategy. Given the heterogeneity of study designs, the application of a single standardised study quality-assessment tool would not yield easily comparable results therefore a risk-of-bias assessment tool has not been reported, however, we have critically appraised the current literature. We analysed post operative complication rate as an overall outcome measure, it is possible that further insights could have been gained by comparing specific sub-categories of complications such as cardiopulmonary, vascular, neurological, and infectious and evaluating these according to a standardised complication grading system such as Clavien-Dindo. The current lack of long-term oncological reported data comparing VATS with RATS also has limited the ability to meaningfully synthesise recurrence and survival outcomes. Future work should focus on increasing the length of longitudinal follow up to analyse this further.

We recognise the current data has limitations such as heterogeneity among reported studies and variability in the reported operative metrics, highlighting the need for larger, randomised multicentre trials with standardised protocols. Another recognised limitation is the over-representation of studies from Asia, Europe and North America. This is due to the nature of robotic technology access and institutional experience in robotic surgery being more prevalent in these areas. Nevertheless, this review provides a valuable summary and critical analysis of notable studies in the rapidly advancing field of robotic thoracic surgery.

Conclusions

Robotic thoracic surgery has evolved significantly over recent times and is increasingly recognised as a viable and often advantageous alternative to traditional open and VATS techniques for a range of thoracic procedures. In the context of anatomical lung resections, multiple studies have demonstrated non-inferiority of RATS compared with VATS, with potential advantages including more thorough lymph node dissection, reduced intraoperative blood loss, improved surgeon ergonomics, and better postoperative pain outcomes. Robotic thymectomy has shown its benefit in retrospective and meta-analytic data, particularly in reduced blood loss, hospital stay, and complication rates.

Technical innovations continue to expand the clinical indications and refine the precision of robotic thoracic surgery. Despite high costs and a recognised learning curve, the robotic platform is poised to play an increasingly central role in thoracic surgery. The current data is highly heterogenous and high-quality evidence evaluating VATS vs. RATS remains limited due to variability in centre volume, robotic system accessibility and operator experience. In order to answer meaningful research questions regarding clinical, oncological and health-economic outcomes for RATS, further randomised multicentre trials with standardised protocols and larger cohorts need to be undertaken in the field.

Acknowledgments

None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Current Challenges in Thoracic Surgery for the series “Progress in Robotic Thoracic Surgery”. The article has undergone external peer review.

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-41/rc

Peer Review File: Available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-41/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ccts.amegroups.com/article/view/10.21037/ccts-25-41/coif). The series “Progress in Robotic Thoracic Surgery” was commissioned by the editorial office without any funding or sponsorship. M.G. served as the unpaid Guest Editor of the series. The authors have no other conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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