Evolving techniques and comparative outcomes in video-assisted thoracic surgery and robotic-assisted thoracic surgery: a narrative review

Introduction

Background

Minimally invasive thoracic surgery has revolutionized the management of lung and mediastinal diseases by substantially reducing surgical trauma and associated morbidity compared to open thoracotomy (1). Video-assisted thoracic surgery (VATS) and robotic-assisted thoracic surgery (RATS) have become well-established approaches in this domain, offering oncologic outcomes comparable to those of open surgery (2-4). Meanwhile, patients undergoing VATS or RATS experience significantly less postoperative pain, faster recovery, shorter hospital stays, and fewer complications than patients undergoing open procedures (3,5,6). These benefits have solidified VATS and RATS as preferred surgical modalities for appropriate patients undergoing thoracic surgery.

Rationale and knowledge gap

Over the last decade, there has been a concerted effort to further minimize invasiveness in thoracic surgery by reducing the number of incisions required (7). This trend led to the development of uniportal VATS, in which major thoracic procedures are performed through a single small incision, and spurred the evolution of robotic systems from traditional multi-arm setups to innovative single port platforms (single robot “arm”) (8-10). The rationale behind these advances is to achieve equivalent or potentially superior surgical efficacy while further diminishing patient trauma, postoperative pain, and even improving cosmetic outcomes (7). However, it remains uncertain whether reducing the approach to a single incision truly translates into improved clinical outcomes or is primarily a cosmetic and comfort improvement (11,12). The current evidence comparing VATS and RATS techniques is still emerging, leaving a knowledge gap regarding their true advantages and any potential trade-offs. Additionally, adopting uniportal VATS or RATS involves a steep learning curve and unique technical challenges (13,14), factors which may influence their safety, early outcomes, and the rate at which surgeons embrace these new techniques.

Objective

The objective of this review is to critically examine and compare the latest minimally invasive thoracic surgical approaches that utilize reduced port strategies. We first outline the development and key features of uniportal VATS and the progression of RATS from multi-arm systems to new single port platforms. Next, we review the evidence comparing clinical outcomes between these approaches and conventional techniques in several key thoracic procedures. In particular, we focus on (I) mediastinal surgery such as thymectomy, (II) pulmonary resections including lobectomy and anatomical segmentectomy, and (III) complex lung resections like sleeve lobectomy. For each, we highlight comparative results in operative time, length of hospital stay, postoperative complication rates, and patient recovery. This structured analysis aims to clarify the relative merits of emerging uniportal approaches versus traditional multiport minimally invasive techniques, and to identify areas where further research or experience is needed. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-47/rc).

Methods

A narrative review of the literature was conducted using a search of PubMed, Embase, Web of Science, and Google Scholar using a combination of the terms: “robot-assisted thoracoscopic surgery”, “robot-assisted thoracic surgery”, “video-assisted thoracic surgery”, “minimally invasive thoracic surgery”, “uniportal”, “single port”, “single incision”, “multiport”, “multiple port”, “multiple incision”, “thymectomy”, “pulmonary lobectomy”, “anatomical segmentectomy”, “complex lung resections”, “sleeve lobectomies”, “survival”, and “outcomes” with Boolean operators AND/OR. A primary search was performed on 23 July 2025, and a final update was completed on 7 December 2025, covering all years from database inception up to this date. We included English articles reporting adult patients undergoing VATS or RATS for thymectomy, lobectomy, anatomical segmentectomy, or bronchial sleeve resections, and that described perioperative outcomes, oncologic outcomes, lymph node (LN) dissection, learning curves, or cost. We excluded animal or laboratory studies, non-thoracic procedures, editorials or letters without original data. The initial search identified approximately 2,719 records. After screening titles and abstracts, we reviewed the full text of about 328 articles and finally included around 104 key clinical studies, observational studies, systematic reviews, and meta-analyses that directly addressed the aims of this narrative review. See Table 1 for the search strategy summary.

Development of uniportal VATS

Uniportal VATS emerged as an extension of conventional multiport VATS, driven by the concept that a single incision may reduce intercostal trauma and postoperative pain. Early video-assisted thoracoscopic lung resections in the 1990s were typically performed using a multiport configuration with 3–4 ports (15,16). In 2010, Gonzalez-Rivas and colleagues introduced uniportal VATS for major pulmonary resection (17), and the initial clinical results were subsequently reported in 2012 (18). Notably, even before this, uniportal VATS had been explored for simpler procedures like wedge resection as early as 2004 (19). The successful 2010 uniportal lobectomy was a milestone that proved anatomic lung resection could be done through a single port, inspiring a rapid growth of uniportal VATS in the following years (20-22). Surgeons in Asia and Europe soon adopted the approach, noting that it aligned with minimally invasive surgical principles and potentially enhanced patient recovery (23,24).

By the mid-2010s, accumulating evidence showed that uniportal VATS was non-inferior to multiport VATS in perioperative outcomes. Several comparative studies and meta-analyses found no significant differences in operative time, blood loss, conversion to open thoracotomy, or mortality between single port and multiport VATS approaches (25,26). Importantly, some studies observed that uniportal VATS patients experienced less postoperative pain, shorter chest tube duration, reduced length of hospital stay, and overall lower morbidity compared to multi-incision VATS (12,27,28). For example, one randomized study noted better pain scores and shorter drainage and hospitalization with uniportal lobectomy, without compromising safety (26). This suggested that the single-incision technique could meet or exceed established standards for patient recovery while maintaining equivalent surgical and oncologic efficacy.

Encouraged by these outcomes, early adopters of uniportal VATS progressively extended the approach beyond initial lobectomies and segmentectomies for small peripheral tumors to include complex resections such as sleeve lobectomies, and even carinal resections (29). Reports emerged of surgeons successfully performing sleeve bronchial and vascular reconstructions using uniportal VATS, demonstrating the feasibility of resecting even centrally located tumors through a single incision in skilled hands (30-32). Furthermore, procedures previously regarded as relative contraindications, such as lung resections following neoadjuvant chemo-radiotherapy, have also been successfully performed with uniportal VATS by experienced surgeons (33,34). Moreover, uniportal VATS has been effectively combined with complementary innovations, such as non-intubated (spontaneously breathing) anesthesia, to further minimize perioperative impact and enhance recovery, highlighting its versatility (35,36).

A key factor facilitating the rise of uniportal VATS has been the parallel development of specialized instruments and optics. New thoracoscopes with ultra-thin profiles and high definition and three-dimensional (3D) cameras, along with narrow double hinged curved instruments designed for triangulation through a single incision, have improved the operative ergonomics (7,37,38). These allow surgeons to overcome the inline constraint of a single port and achieve effective exposure and dissection in the thoracic cavity. Moreover, it has been noted that uniportal VATS offers a more natural alignment of the surgeon’s eyes, hands, and target, potentially reducing physical strain. Unlike multiport VATS, which may require the operator to adopt awkward angles and significant shoulder abduction to avoid instrument clashing, the uniportal technique often lets the surgeon work with a more straightforward, caudal-cranial view and less fatigue (39,40). This ergonomic benefit is another reason many thoracic surgeons gravitated to the single-incision approach.

Mastering uniportal VATS does require dedicated training and experience. Experts suggest that approximately 50–60 uniportal cases are needed to become comfortable and consistently proficient, with perhaps 140 cases to truly master the technique (41). Early in a surgeon’s uniportal VATS experience, an accessory port may occasionally be added for safety, but with growing expertise, the need for extra incisions diminishes. Structured training programs, mentorship by experienced uniportal surgeons, and simulation including wet labs and video-based coaching have all been emphasized to safely disseminate this technique (42). Despite the steep initial learning curve, the consensus today is that uniportal VATS is here to stay as a mainstream minimally invasive approach (43). Its successful track record in thousands of cases worldwide, ranging from minor wedges to complex sleeve resections, has firmly established uniportal VATS alongside multiport VATS and RATS as a pillar of modern thoracic surgery.

Advances in RATS

RATS was introduced around the turn of the millennium, slightly earlier than uniportal VATS, and has itself undergone significant evolution. The first reported robot-assisted lung lobectomy was performed in the early 2000s (circa 2001–2002) by Melfi and colleagues in Italy (44). This pioneering effort used the da Vinci Surgical System, which had just been approved by the Food and Drug Administration (FDA) in 2000 for surgical use, to facilitate a thoracoscopic lobectomy with the surgeon controlling instruments from a console (45,46). In the ensuing years, multiple centres published small series demonstrating the feasibility and safety of robotic lung resections, mediastinal tumor excisions, and even esophagectomies (47,48). By the 2010s, RATS gained wider acceptance as technology improved and more surgeons became trained, making it a compelling alternative to VATS for major thoracic procedures.

Conventional multiport RATS

The standard robotic thoracic approach uses 3–4 separate ports for robotic arms (plus sometimes an additional assistant port). For example, a typical robotic lobectomy might use three 2-cm or 3-cm robotic incisions for camera and instruments plus a utility incision for specimen extraction (48,49). Compared to handheld VATS, the robotic system offers several technical advantages: high-definition 3D visualization, wristed instruments with 7 degrees of freedom, motion scaling, and tremor filtration (50). These features enable meticulous dissection in the confined thoracic anatomy and facilitate maneuvers (like suturing or fine LN dissection) that can be challenging with rigid VATS instruments (51). Indeed, some studies have found that RATS yields a higher count of resected LNs and nodal stations on average compared to VATS (52).

Early adopters also noted that the learning curve for basic robotic proficiency might be shorter than that for VATS, since the console interface is intuitive for those familiar with video gaming and the improved visualization flattens the hand-eye coordination challenge inherent to thoracoscopy (53). A systematic review of learning curves found that roughly 20 cases may be needed to overcome the initial learning phase of robotic lobectomy (with ~60 cases to achieve mastery), versus ~50 cases to overcome the learning curve for VATS lobectomy (53). This suggests a possible faster uptake for RATS, although in practice both techniques require significant skill and training to optimize. In any case, by the late 2010s, many high-volume centres had adopted multiport RATS for lung cancer surgery and thymectomies, reporting perioperative outcomes and survival equivalent to VATS and open approaches (54). As uniportal VATS demonstrated the benefits of a single incision, it was perhaps inevitable that robotic technology would also move toward a uniportal paradigm.

Transition to uniportal RATS

Uniportal RATS (multi-arm)

The first uniportal RATS lobectomy using a conventional multi-arm da Vinci Xi system was reported by a team at Shanghai Chest Hospital in 2021. They clustered three robotic arms through a single incision to perform a right upper lobectomy, providing proof-of-concept that a multi-arm platform could be adapted for uniportal access, albeit with significant ingenuity in port placement and instrument coordination (55).

Single port RATS (single robot “arm”)

To overcome the spatial constraints of multi-arm clustering, Intuitive Surgical introduced the da Vinci single-port (SP) system. This dedicated platform features a single cannula housing a flexible 3D endoscopic camera and three articulated instruments that fan out once inside the chest, effectively performing single port RATS (9). Building on the multi-arm proof-of-concept, the SP robot has now been tested in thoracic surgery with encouraging early results (56).

Early clinical experiences with the da Vinci SP in thoracic procedures have shown it to be feasible and safe. For example, a 2024 series reported on 115 patients who underwent various thoracic operations with the SP system, including 54 anatomic lung resections, 41 thymectomies, and others. No conversion to open surgery was required, although 1 case (0.9%) required conversion to VATS. The median post lobectomy hospital stay was approximately 3 days, with very low complication rates (10). In a pilot trial of 35 lung cancer patients receiving SP lobectomy or segmentectomy via a subcostal single incision, the conversion-to-open rate was 2.9%, there were no in-hospital mortalities, and both chest tube duration and postoperative stay remained brief (57). Although the da Vinci SP remains a relatively new platform which FDA-approved for thoracic use in some regions but not yet universally cleared for all indications, and instrumentation continues to evolve, ongoing trials and registries are now assessing long-term outcomes more rigorously (58,59).

Comparative outcomes in thymectomy (RATS vs. VATS)

Oncologic and survival outcomes

Both RATS and VATS thymectomy demonstrate excellent short-term outcomes, with negligible perioperative mortality and similar long-term survival, reinforcing that minimally invasive resection does not compromise oncologic efficacy. In modern series, in-hospital mortality and 30-day mortality are close to zero for both RATS and VATS, with no significant difference in short-term outcomes including readmission rates (60-62).

Longer-term outcomes appear equally favorable. A propensity-matched retrospective study found 5-year overall survival rates to be virtually identical between RATS and VATS (93% vs. 94%, P=0.571) (63). The two cohorts in that analysis had comparable follow-up durations (median ~54 vs. 57 months), indicating that survival comparisons were well balanced (64). Another systematic review confirmed that there was no significant difference in overall mortality between RATS and VATS approaches (65). Notably, one meta-analysis suggested that VATS might be associated with a higher 90-day postoperative mortality compared to RATS (albeit a very low absolute incidence in both cases) (5). This finding, however, comes from pooled data and should be interpreted with caution, as perioperative deaths in thymectomy are rare events in all modern series. Overall, the evidence to date indicates that when performed by experienced surgeons, both robotic and video-assisted thymectomy achieve excellent oncologic outcomes and long-term survival, with no clear superiority of one approach over the other in this regard.

Perioperative outcomes

Comparative studies and meta-analyses show that perioperative outcomes of robotic-assisted thymectomy and video-assisted thymectomy are broadly similar, with only modest differences in most parameters (5,60-62,64-71) (Table 2). The main signals relate to small variations in operative time, blood loss, chest drainage, length of stay (LOS), conversion rates, complications, and cost, which are often influenced by institutional practice, learning curve effects, and case selection rather than intrinsic differences between the two platforms.

Regarding operative time and blood loss, the evidence is heterogeneous. Several single-centre and propensity matched series report shorter operative times and slightly lower blood loss with robotic thymectomy, whereas others, including large multi-institutional cohorts and meta-analyses, show no clear advantage or even longer durations for robotic procedures (5,61,62,64-71) (Table 2). Across these studies, the absolute differences in time are typically within tens of minutes and blood loss is usually low for both approaches, suggesting that neither parameter should be the dominant factor when choosing between robotic and video-assisted techniques.

Postoperative chest drainage and LOS also show small and inconsistent differences. Some meta-analytic and single-centre data suggest that robotic thymectomy is associated with shorter chest tube duration, lower drainage volume, and a reduction in LOS of roughly 1 day or less (5,61,66,69,70) (Table 2). Other series, including large retrospective and matched cohorts, report no significant difference in drainage or LOS, and in some cases, the robotic group has similar drainage times but higher recorded fluid volumes (60,62,64,67,68,71) (Table 2). Overall, these findings indicate that both approaches enable rapid recovery, and observed variations are more likely related to local chest tube and discharge protocols than to the choice of platform.

Conversion to open thoracotomy remains infrequent for both techniques. Certain single-centre and database studies have reported lower conversion rates with robotic thymectomy, including series in which no conversions occurred in the robotic group compared with measurable conversion rates in the video-assisted group (64,67) (Table 2). However, other multi-institutional and single-centre analyses describe similarly low conversion rates for both approaches (61,62,68) (Table 2). In contemporary practice, conversion is rare in experienced hands regardless of platform, and any advantage of robotic surgery in this respect appears to be context dependent.

Complication profiles are likewise comparable. Most retrospective series and meta-analyses do not demonstrate a significant difference in overall intraoperative or postoperative complications between robotic- and video-assisted thymectomy, including respiratory events, phrenic nerve or vascular injury, and prolonged air leak (61,62,64-66,68,70,71) (Table 2). More detailed analyses have suggested that robotic thymectomy may be associated with fewer specific events such as cardiac complications or intraoperative haemorrhage in some cohorts, potentially reflecting improved visualization and instrument control (60). These signals, however, are based on relatively small numbers, and both techniques can be considered safe when performed by experienced teams.

In contrast, cost differences are consistent across studies. Robotic thymectomy incurs higher operative and total hospital costs than video-assisted thymectomy due to the capital expense of the robotic system, maintenance, disposable instruments, and often longer operating room occupancy (60,64) (Table 2). For example, direct comparisons show substantially higher median hospital charges for robotic cases than for video-assisted cases, both in Asian centres and in United States datasets (60,64). At present, the small and inconsistent differences observed in perioperative outcomes, such as a possible reduction of less than 1 day in LOS or subtle variation in specific complications, do not clearly offset the higher procedural cost of the robotic platform. Robust, procedure specific cost effectiveness analyses are still limited, and video-assisted thymectomy therefore remains the more economical option in most health care systems, while the choice of robotic surgery is often driven by surgeon preference, institutional resources, and broader programmatic considerations (72).

Comparative outcomes in lung resections (RATS vs. VATS)

Lobectomy and anatomical segmentectomy

Oncologic and survival outcomes

Lobectomy for lung cancer is the prototypical thoracic operation where minimally invasive approaches (VATS and RATS) have been extensively studied. Numerous retrospective comparisons, meta-analyses, and a few prospective trials have compared VATS versus RATS lobectomy and anatomical lung resection (50,54,73-77). Overall, both approaches are safe and effective. They show no difference in 30-day mortality or long-term survival for early-stage lung cancer, and both far outpace open lobectomy in terms of patient recovery. Some evidence even suggests RATS may have oncologic advantages: one meta-analysis found RATS lobectomy/segmentectomy had a lower recurrence rate than VATS [odds ratio (OR) =0.51, P<0.001] (78), and another meta-analysis reported better 5-year disease-free survival with RATS lobectomy/segmentectomy (P=0.01) (79). Overall, these data support oncologic equivalence between RATS and VATS for early-stage disease, with any potential survival advantage of RATS remaining exploratory. Aside from these oncologic outcomes, there are several nuanced differences in perioperative results to consider.

LN dissection

Perioperative outcomes of RATS versus VATS for lobectomy and anatomical segmentectomy have been explored in randomised trials, retrospective series, propensity matched cohorts, multicentre studies and meta-analyses. Detailed quantitative data for each study (50,52,54,73-85), including LN yield, operative time, blood loss, pleural drainage, hospital stay, conversion rates, complications, pain related outcomes and costs, are summarised in Table 3.

Many centres report that RATS facilitates more extensive lymphadenectomies in lobectomy. Series from Shanghai Chest Hospital and Xiangya Hospital, and a single-centre randomised trial showed higher LN yields or more nodal stations sampled with RATS lobectomy than with VATS lobectomy (54,77,80) (Table 3). A multicentre study and one propensity matched study including both lobectomy and segmentectomy and several meta-analyses similarly found that robotic anatomical resection was associated with modestly higher numbers of stations and nodes examined (78-81) (Table 3).

In segmentectomy, investigators from Xiangya Hospital and another group reported higher nodal station counts or node numbers with RATS segmentectomy compared with VATS segmentectomy (80,84) (Table 3). A focused review of robotic mediastinal lymphadenectomy found better station clearance with RATS in most comparative studies (86).

Conflicting data also exist. Retrospective cohorts and meta-analyses have described no meaningful difference in nodal yield for lobectomy, segmentectomy or wedge resection (52,74,75,82,83), and one propensity matched study even reported fewer stations sampled with RATS lobectomy (76) (Table 3). Overall, these findings indicate that both RATS and VATS are capable of achieving guideline-based systematic mediastinal lymphadenectomy. The modestly higher LN yields reported in many robotic series likely reflect technical ease and institutional practice rather than a clearly established oncologic advantage. From an oncologic perspective, it remains uncertain whether the small increases in LN and station counts observed with robotic lobectomy or segmentectomy translate into clinically meaningful improvements in survival or primarily represent more thorough dissection enabled by enhanced instrumentation and visualisation.

Large population-based studies outside the robotic literature have demonstrated that examination of a sufficient number of LNs across multiple mediastinal stations is associated with more accurate pathologic staging and improved recurrence-free or overall survival. Several analyses based on large population data suggest that retrieval of approximately eight to ten LNs is adequate for optimal staging, beyond which the prognostic benefit appears to plateau (87-89). Although these studies do not specifically compare surgical platforms, they underscore the importance of systematic mediastinal lymphadenectomy, including clearance of prognostically critical stations such as the subcarinal station 7. In contrast, most comparative series of robotic-assisted and video-assisted lobectomy or segmentectomy report only modest differences in nodal yield, typically one to two additional stations or a small number of nodes, and frequently do not demonstrate corresponding increases in nodal upstaging or long-term survival (54,77). Taken together, these data suggest that the primary oncologic objective is reliable, guideline-based clearance of key mediastinal stations irrespective of platform, and that the higher nodal yields reported with robotic surgery should currently be interpreted as a marker of technical facility and staging thoroughness rather than definitive evidence of superior oncologic efficacy.

Operative time

For elective lobectomy, most evidence indicates similar operative durations between RATS and VATS. A single-centre randomised trial, several meta-analyses and multiple single-centre and multicentre comparative studies all reported no clinically relevant difference in operative time for lobectomy, or for combined lobectomy plus segmentectomy cohorts (52,54,73,74,77-81) (Table 3). Retrospective series and propensity matched analyses showed comparable operative times for RATS and VATS segmentectomy and for wedge resection plus segmentectomy cohort (75,84) (Table 3).

During early adoption of robotics, some groups observed longer procedures for RATS lobectomy compared with VATS lobectomy, with this gap narrowing and disappearing once the learning curve was overcome (82). Subgroup analyses have produced heterogeneous results in segmentectomy and combined cohorts, with some studies reporting shorter segmentectomy times with VATS (50), and others demonstrating shorter segmentectomy times with RATS (83), and another showing shorter lobectomy or segmentectomy time with VATS (76) (Table 3). Taken together, these data suggest that in experienced programmes operative time is largely comparable between RATS and VATS, and that observed differences mainly reflect case complexity and team experience.

Blood loss

Several randomised, retrospective and meta-analytic comparisons indicate that RATS lobectomy or segmentectomy may be associated with slightly lower intraoperative blood loss than VATS (52,76-80) (Table 3). Cohorts from Shanghai Chest Hospital reported less blood loss with RATS in wedge resection or segmentectomy (75). Other retrospective series focusing on segmentectomy have also favoured RATS in this respect (83).

On the other hand, some retrospective analyses and at least one meta-analysis have found no significant difference in blood loss when lobectomy and segmentectomy are considered together, in segmentectomy alone, or when examining the proportion of lobectomy patients with low estimated blood loss (54,73,82,84) (Table 3). In contemporary minimally invasive practice, absolute blood loss is usually low with both approaches, so any advantage of RATS is modest and unlikely to be a decisive factor in platform selection.

Pleural drainage and postoperative stay

Evidence on chest tube drainage and LOS is mixed. Meta-analyses suggest that RATS anatomical resection may shorten LOS compared with VATS lobectomy and segmentectomy, although the reported differences are small on average (78,79) (Table 3). A large single-centre segmentectomy cohort has also described shorter drainage times or lower drainage volumes with RATS, as well as shorter LOS in some subgroups (83).

Conversely, a randomised trial found greater postoperative drainage with RATS lobectomy despite similar drainage duration and LOS (77), and some retrospective series from Shanghai Chest Hospital and other centres have reported no significant difference in drainage duration, drainage volume or LOS between RATS and VATS for lobectomy, segmentectomy, or wedge plus lobectomy cohorts (50,73,74,76,81,82,84). In at least one cohort, RATS was even associated with a slightly longer hospital stay despite shorter drainage time (80). Variability in enhanced recovery protocols, fluid management and discharge criteria likely contributes to these inconsistent findings. Overall, both platforms provide short chest tube durations and brief hospitalisations, and any advantage for RATS appears small and context dependent.

Conversion to open thoracotomy

Conversion to open thoracotomy is uncommon for both RATS and VATS anatomical lung resection. A meta-analysis and propensity matched studies have reported lower conversion rates for RATS in lobectomy (82) and combined lobectomy plus segmentectomy cohorts (78-80) (Table 3). For wedge resection and segmentectomy, conversion rates are low and generally similar between platforms in high volume centres (75).

However, several randomised trials, retrospective series and meta-analyses did not identify significant differences in conversion rates between RATS and VATS lobectomy or segmentectomy (50,52,54,74,76,77,81) (Table 3). In experienced minimally invasive programmes, conversion usually remains rare, and differences between platforms may be difficult to interpret because surgeon skill, anatomy and case selection are major determinants.

Complications

Overall postoperative morbidity, including pulmonary and cardiac complications and prolonged air leak, is broadly comparable between RATS and VATS lobectomy and segmentectomy. Studies from single-centre, randomized multicentric study, propensity matched analyses and meta-analyses have consistently shown similar overall complication rates between the two platforms for lobectomy or segmentectomy (52,54,73,74,76,77,79-81,83,84) (Table 3). A large Shanghai Chest Hospital cohort found equivalent complication rates for RATS and VATS wedge resection and segmentectomy (75).

Some data suggest potential differences in specific complications. A propensity matched lobectomy series reported fewer prolonged air leaks after RATS compared with VATS (82), and meta-analyses suggested a small overall reduction in complications with RATS lobectomy or segmentectomy (78) (Table 3). These findings, however, have not been consistently replicated (85). At present, both RATS and VATS can be considered safe for anatomical lung resection, and differences in aggregate complication rates are unlikely to drive platform choice.

Pain and cost

With respect to pain and functional recovery, a case-control study reported shorter postoperative narcotic use and faster return to usual activities with RATS lobectomy and segmentectomy compared with VATS (73) (Table 3). Another single-centre retrospective found shorter postoperative analgesic use with RATS segmentectomy compared with VATS (83). These findings align with clinical impressions that the improved dexterity and visualisation of the robot may reduce tissue trauma in some settings, although robust patient reported outcome data remain limited.

In contrast, all available cost analyses clearly favour VATS. Meta-analytic estimates and single-centre cost studies from both Western and Chinese centres consistently show substantially higher hospital and operative costs for RATS lobectomy, segmentectomy and combined lobectomy plus segmentectomy compared with VATS (52,77,78,80,83,85) (Table 3). The higher expenditure is largely driven by the capital and maintenance costs of robotic systems and the greater price of disposable instruments, with only small offsets in nonoperative costs. In the absence of a proven survival advantage and with only modest perioperative benefits, RATS currently remains the more expensive option for anatomical lung resection (90). The magnitude and direction of the cost gap, however, vary across healthcare systems and institutional volumes (91). High volume robotic centres with shorter operative times, standardised perioperative pathways, and low complication rates have reported that total hospital costs for RATS can approach those of VATS once the learning curve is overcome, whereas low volume centres often experience a more pronounced cost premium (92). Economic evaluations generally suggest that, under current pricing structures, RATS lobectomy is less cost effective than VATS lobectomy from a payer perspective because higher operative and supply costs outweigh small perioperative advantages. By contrast, RATS can be cost effective compared with open lobectomy in some settings where it reduces complications, conversion rates, and LOS (93). Overall, these findings highlight that the economic value of RATS is context dependent and is likely to be greatest when used in high volume centres and for patients or procedures in which its technical advantages translate into clinically meaningful benefits.

Complex lung resections

Bronchial sleeve lobectomy, once the exclusive domain of open thoracotomy has been successfully performed via VATS and RATS in expert centres. Although case numbers remain limited, available data demonstrate that minimally invasive sleeve lobectomy is feasible and yields comparable oncologic and safety outcomes when executed by experienced teams. However, most of the current series come from a small number of high-volume centres, predominantly in China, so the generalisability of these findings to lower volume institutions and other healthcare systems is uncertain (34,94,95) (Table 4).

Outcomes

The available data on oncologic and peri-operative survival after minimally invasive sleeve lobectomy demonstrate equivalent outcomes for RATS and VATS. In a retrospective study from Shanghai Pulmonary Hospital, 30-day mortality was comparable between RATS and VATS sleeve lobectomy, and no differences were observed in overall survival or progression-free survival between the two groups (34). Similarly, a 2023 single-centre analysis from Gansu Provincial Hospital reported no significant difference in 30-day or 90-day mortality for RATS versus VATS sleeve lobectomy, nor in 3-year overall survival rates (95). These consistent findings across independent centres suggest that, when performed by experienced thoracic teams, sleeve lobectomy by either robotic or video-assisted platforms yields equivalent short- and mid-term oncologic outcomes.

LN dissection

A 2025 retrospective report from Shanghai Pulmonary Hospital showed that RATS sleeve lobectomy retrieved slightly more LNs on average than VATS, with a similar number of nodal stations examined (34). Supporting this, a 2023 single-centre series likewise observed a comparable pattern, with a modestly higher node count but fewer stations sampled for robotic sleeve lobectomy compared with video-assisted procedures (95). A similar consideration applies to LN dissection in minimally invasive sleeve lobectomy. Available retrospective series report that robotic sleeve lobectomy retrieves, on average, one to two more LNs than video-assisted approaches, while the total number of examined mediastinal stations does not differ significantly between techniques in the cohorts reported and sample sizes remain limited (34,95). These studies do not provide detailed station-specific counts, including for the subcarinal station 7. Importantly, the modest differences in overall nodal yield have not been accompanied by consistent increases in nodal upstaging or demonstrable improvements in survival outcomes. In this context, the slightly higher LN counts reported with the robotic approach are most plausibly interpreted as reflecting technical facilitation of lymphadenectomy in anatomically complex settings, such as a scarred hilum or superior mediastinum, rather than evidence of a proven oncologic advantage. Larger, multi-institutional datasets with comprehensive station-specific reporting will be required to determine whether robotic assistance confers any independent prognostic benefit, particularly with respect to reliable clearance of critical mediastinal stations.

Operative time and blood loss

Regarding operative duration, a retrospective study from Shanghai Pulmonary Hospital in 2025 found no significant difference in operative time between RATS and VATS sleeve lobectomy (34). In contrast, both a Bayesian network meta-analysis (94) and a 2023 single-centre study from Gansu Provincial Hospital (95) suggested shorter times with RATS bronchial sleeve lobectomy (Table 4). These conflicting findings likely reflect differences in surgeon experience with robotic docking and reconstruction techniques, as well as heterogeneity in how “operative time” is defined such as inclusion of setup or anastomosis time.

As for blood loss, two retrospective studies and a Bayesian network meta-analysis showed no significant difference between RATS and VATS sleeve lobectomy (34,94,95) (Table 4). The consistency of these results across methodologies suggests that both platforms afford comparable hemostatic control in complex airway reconstructions.

Pleural drainage, hospital stay, and cost

When chest-tube outcomes were assessed, Shanghai Pulmonary Hospital’s 2025 retrospective study reported no difference in chest-tube duration or total drainage volume between RATS and VATS sleeve lobectomy (34), a finding echoed by the Bayesian network meta-analysis (94) (Table 4). Conversely, a 2023 single-centre study from Gansu Provincial Hospital reported that RATS, compared to VATS, was associated with a shorter drainage duration, lower 24-hour output, and reduced total drainage volume (Table 4) (95). Such discrepancies may stem from institutional variations in chest-tube management protocols and differing criteria for tube removal.

Neither the Shanghai Pulmonary Hospital’s 2025 retrospective analysis nor the 2024 Bayesian meta-analysis found a significant difference in postoperative LOS between RATS and VATS sleeve lobectomy (34) (Table 4). However, a 2023 single-centre study from Gansu Provincial Hospital indicated a shorter LOS with RATS alongside a higher cost compared with VATS (95) (Table 4). These mixed results likely reflect differing discharge criteria and healthcare system practices, while the consistent cost premium for RATS underscores the financial impact of robotic instrumentation and disposables.

Conversion to open thoracotomy and complications

Shanghai Pulmonary Hospital’s 2025 retrospective cohort revealed a significantly lower conversion rate for RATS sleeve lobectomy compared to VATS (34), indicating that the enhanced dexterity and three-dimensional visualisation may help maintain a minimally invasive approach in technically challenging hilar and bronchial reconstructions. However, two retrospective studies reported equivalent rates of postoperative complications including prolonged air leak, hydrothorax, empyema, pneumonia, and bronchopleural fistula between RATS and VATS sleeve lobectomy (34,95) (Table 4). Taken together, these data indicate that both minimally invasive platforms can achieve low conversion and complication rates for sleeve lobectomy in experienced centres, and that any advantage of the robotic approach is likely to be incremental and heavily influenced by surgeon expertise and case selection.

Limitation

This narrative review has several limitations. First, most comparative studies of VATS and RATS do not specify whether the procedures were performed via uniportal or multiport access, precluding a focused analysis of uniportal VATS versus uniportal RATS outcomes. Moreover, even within uniportal VATS, there is heterogeneity between intercostal, subxiphoid, and subcostal approaches, which may influence perioperative outcomes, but comparative studies rarely differentiate surgical access. Second, the available evidence is dominated by retrospective, single-centre series and meta-analyses that incorporate heterogeneous surgical techniques, patient selection, and follow-up durations, which introduces variability and potential selection bias. Data on complex resections such as sleeve lobectomy remain sparse and largely derived from expert centres, lacking the power and generalizability of large, prospective randomized trials.

Finally, our review has primarily focused on surgeon-reported perioperative metrics, including operative time, blood loss, LN dissection, chest tube duration, and LOS. Patient-reported outcomes, such as postoperative pain, health-related quality of life, and return to usual activities or work, have been assessed in relatively few studies using heterogeneous instruments and follow-up schedules and were therefore not systematically extracted. Available comparative data on patient-reported outcomes are limited and heterogeneous, but existing studies suggest that medium-term postoperative quality-of-life scores do not differ markedly between RATS and VATS, while some observational studies have reported lower early postoperative pain scores and modest functional advantages with RATS that are not consistently observed across all cohorts (96-98). Patient reported outcomes therefore remain a key evidence gap in the current literature, limiting definitive conclusions regarding patient centred benefits of reduced port and robotic approaches.

Future directions

Several technological and educational trends are likely to shape the next decade of minimally invasive thoracic surgery. Artificial intelligence assisted systems may support preoperative planning, intraoperative anatomy recognition, and performance standardisation through analysis of operative video and large registries (99,100). Image guidance and navigation technologies, including electromagnetic navigation bronchoscopy, cone beam computed tomography, and hybrid operating rooms, are increasingly integrated into workflows for localisation and combined diagnostic therapeutic strategies (101,102). Training for uniportal and robotic surgery is also evolving through virtual reality simulation, three dimensional models, and structured curricula that may shorten learning curves while improving safety (103,104). Finally, dedicated single port robotic platforms and alternative access routes have shown encouraging early results, but further refinements in instrumentation, broader regulatory clearance, and robust comparative studies will be essential to define their long-term role.

Conclusions

Minimally invasive thoracic surgery has evolved with the adoption of uniportal VATS and newer robotic platforms, extending reduced port strategies across procedures ranging from thymectomy to anatomical lung resection and selected complex reconstructions. Across the current evidence base, RATS and VATS provide comparable safety and oncologic outcomes, and for lung resection in particular the literature consistently supports similar short-term mortality, long-term survival, and overall perioperative morbidity between platforms. Differences between approaches are generally incremental and context dependent. In thymectomy, some series suggest modest perioperative advantages with RATS in selected metrics, whereas in pulmonary lobectomy and anatomical segmentectomy, the main distinctions relate to lymphadenectomy patterns, conversion risk in some cohorts, and learning curve considerations. For complex resections such as bronchial sleeve lobectomy, both approaches appear feasible with acceptable outcomes in expert centres, and robotic assistance may help maintain a minimally invasive approach in technically demanding cases. The higher costs associated with robotic platforms remain an important consideration, and the net value of RATS is most likely to be greatest in high volume centres and in selected complex procedures where technical advantages translate into clinically meaningful benefits. Overall, the current evidence supports a tailored approach based on case complexity, team expertise, and institutional resources rather than a universal preference for any single technique.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-47/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-47/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-25-47/coif). C.S.H.N. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from August 2025 to July 2027. C.S.H.N. was a consultant to Johnson and Johnson, Medtronic, Olympus and Siemens Healthineer. R.W.H.L. was a consultant to Medtronic and Siemens Healthineer. The other authors have no 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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