Prehabilitation in the era of minimally invasive thoracic surgery: a narrative review of evidence, implementation, and future directions

Introduction

Prehabilitation, broadly defined as the enhancement of a patient’s functional capacity before surgery, has gained increasing recognition as a key adjunct to perioperative care. Typically encompassing structured exercise, nutritional optimization, respiratory training, psychological support, and smoking cessation, prehabilitation aims to improve physiological reserve and mitigate the stress of surgery. Across multiple surgical disciplines, including colorectal, surgical oncology, and thoracic surgery, systematic reviews and meta-analyses have demonstrated associations between prehabilitation and improved outcomes, such as reductions in postoperative complications, shorter hospital length of stay (LOS), and enhanced functional recovery, although the certainty of evidence remains limited due to heterogeneity in study design and interventions (1-4). Multimodal programs integrating exercise, nutrition, and psychological support appear to confer the greatest benefit (1,5).

In thoracic surgery, where postoperative pulmonary complications remain a major cause of morbidity and mortality, prehabilitation has gained particular importance (6,7). Exercise-based interventions such as aerobic conditioning and inspiratory muscle training, alongside multimodal approaches that integrate nutrition and psychological support, have been shown to improve ventilatory capacity, reduce pulmonary complications, and shorten hospital LOS (6-8). High-intensity interval training (HIIT) conducted in the preoperative period can improve aerobic fitness, though feasibility in frail or older patients remains under investigation (7,9). Accordingly, prehabilitation is increasingly incorporated into enhanced recovery after surgery (ERAS) pathways for thoracic procedures as a complementary element of standardized perioperative care (6,10,11).

Minimally invasive techniques, including video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracoscopic surgery, have transformed the surgical management of lung cancer, offering reduced pain, LOS, and morbidity compared to open surgery. However, even in the minimally invasive era, pulmonary complications remain a significant challenge, particularly among patients with impaired baseline pulmonary function, malnutrition, or frailty (6,8). This highlights the need to clarify whether the benefits of prehabilitation can extend meaningfully to patients undergoing minimally invasive lung resections and to determine how best to tailor interventions to this population.

Prior reviews have systematically examined prehabilitation in thoracic surgery or surgical oncology more broadly, as well as within specific procedural contexts such as esophageal resection and lung cancer surgery (12-14). However, these reviews have not specifically synthesized or provided commentary on the evidence as it pertains to patients undergoing minimally invasive lung resections. The present review addresses this gap by focusing on prehabilitation in the era of a rapidly increasing minimally invasive thoracic surgery paradigm. We examine the efficacy of various prehabilitation modalities, their impact on perioperative outcomes, and key considerations for implementation across diverse patient populations. By integrating findings from recent trials and systematic reviews, we seek to define the role of prehabilitation within modern thoracic surgical practice and identify opportunities for future research. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-53/rc).

Methods

A comprehensive literature review was performed using the PubMed and Cochrane databases in October 2025 to identify studies and trials relevant to prehabilitation in thoracic surgery. The following search items were applied in various combinations: “thoracic surgery”, “lung cancer”, “minimally invasive”, and “prehabilitation”. Titles and abstracts were screened for relevance to prehabilitation, with emphasis on studies involving lung resection or thoracic procedures. Articles addressing prehabilitation in other major surgical domains were also reviewed when they contributed conceptual or methodological insights applicable to thoracic surgery.

Exclusion criteria included studies not relevant to the topic of prehabilitation and non-English publications without an available translation. No date restrictions were applied, and studies of all designs, including randomized controlled trials, cohort studies, and systematic reviews, were eligible for inclusion. A summary of the search methodology is presented in Table 1.

Overview of prehab modalities

Contemporary prehabilitation programs for lung cancer surgery adopt a multimodal approach. Nutritional optimization is a central component, with evidence supporting targeted protein intake of 1.5 g/kg/day, typically achieved through dietary counseling and protein supplementation taken after exercise to maximize muscle recovery (15). In higher-risk patients, specialized “immunonutrition” enriched with arginine, omega-3 fatty acids, and nucleotides has been associated with reduced postoperative complications and enhanced immune competence (16). Addressing malnutrition and sarcopenia before surgery remains essential as both are strongly correlated with adverse postoperative outcomes (17,18).

Behavioral and psychological supports complement the physical and nutritional components of prehabilitation. Guided relaxation, visualization, and calming music have been utilized to reduce preoperative anxiety and improve patient engagement (15). Broader behavioral strategies such as cognitive-behavioral therapy, structured patient education, and motivational interviewing reinforce adherence and resilience, enhancing compliance with exercise and nutrition regimens (19). A recent meta-analysis demonstrated that psychological prehabilitation reduces LOS, pain, anxiety, and depression following surgery (20). Smoking cessation, with its long-established benefits on pulmonary morbidity and mortality outcomes, is universally endorsed in thoracic surgery as a standard preoperative practice rather than an adjunctive prehabilitation intervention. By mitigating distress and improving coping mechanisms, these interventions contribute meaningfully to recovery quality.

Expectedly, exercise and respiratory training remain cornerstone components of thoracic surgery prehabilitation. Typical programs combine aerobic exercise, such as walking, cycling, or jogging, three or more times per week with resistance exercises for major muscle groups performed twice weekly, often using elastic bands or free weights. Recent trials support the efficacy of HIIT, though its feasibility in frail or elderly patients remains under scrutiny (21,22). Respiratory interventions are particularly emphasized, including inspiratory muscle training, structured breathing and coughing exercises, incentive spirometry, and balloon-blowing techniques, all of which improve ventilatory capacity and, in several studies, reduce pulmonary complications (15,21).

Impact on surgical outcomes

A growing body of literature has evaluated the potential benefits of prehabilitation before thoracic and abdominal surgery (Table 2). Substantial evidence supports the role of prehabilitation in enhancing perioperative recovery among thoracic surgery patients. Physical exercise is the most extensively studied modality, with interventions targeting aerobic capacity, strength, and functional mobility. A study by Lau et al. evaluated eleven randomized controlled trials including 929 patients who underwent gastrointestinal cancer surgery. The study demonstrated that exercise-focused prehabilitation significantly improved 6-minute walk distance both preoperatively and 4–8 weeks postoperatively (12). The methodological quality of the included trials was assessed using the Jadad scale to support robust evaluation of prehabilitation interventions and their effects on surgical outcomes. The most pronounced benefit observed in thoracic surgery is the reduction in postoperative pulmonary complications, particularly pneumonia and respiratory failure (13). A meta-analysis of 16 studies encompassing more than 2,000 non-small cell lung cancer patients found that exercise prehabilitation reduced postoperative pulmonary complications [odds ratio (OR) =0.45], postoperative severe complications (OR =0.51), and hospital LOS by an average of 2.46 days (14). Even brief prehabilitation interventions can meaningfully improve physical capacity and facilitate smoother recovery following minimally invasive lung resections.

Malnutrition is closely associated with increased postoperative complications and prolonged recovery among lung cancer patients (28). Optimizing nutritional status is therefore a critical determinant of thoracic surgical outcomes. Both ERAS protocols and the European Society of Thoracic Surgeons have recommended systematic nutritional screening and support as core elements of multimodal prehabilitation (29). Even within short preoperative timeframes, targeted nutritional interventions can improve functional mobility and mitigate the catabolic response to surgery (23). A systematic review of 15 randomized controlled studies demonstrated that nutritional support reduced the risk of infection [risk ratio (RR) =0.58], non-infectious complications (RR =0.74), and shorter hospital LOS (−5.1 to −0.2 days) (24). Combining nutritional counseling with physical exercise may produce synergistic benefits, further enhancing physiological reserve before minimally invasive thoracic procedures.

Psychological well-being plays an important yet frequently underrecognized role in postoperative recovery after thoracic surgery. The emotional burden of a lung cancer diagnosis and the anticipation of surgery can heighten anxiety and depression (13). Prehabilitation programs emphasizing patient education, stress management, and counseling have been shown to reduce preoperative anxiety and enhance psychological resilience. Improved mental health not only supports recovery but also strengthens adherence to physical and nutritional interventions (30). A virtual mind-body prehabilitation program implemented by Mao et al. demonstrated significant anxiety reduction in 94% of participants and high patient satisfaction, underscoring the feasibility of remote psychological interventions (25).

While hospital-based, supervised programs generally yield superior outcomes, emerging data suggest that structured virtual models can achieve comparable benefits when adequately supported (26,31). Overall, such findings emphasize the importance of program structure, proper supervision, and patient engagement in the effectiveness of prehabilitation interventions.

Special populations

The impact of prehabilitation varies across patient subgroups, influenced by baseline fitness, comorbidities, and physiological reserve. Licker et al. demonstrated that prehabilitation outcomes differ by patient risk profile: low-risk patients achieved faster functional recovery after thoracic surgery, whereas high-risk patients experienced improved clinical outcomes and shorter hospital stays (6).

Frailty, a clinical state of decreased physiological reserve and increased vulnerability to stressors, is a well-established predictor of postoperative complications and adverse outcomes (32). While there is not currently a consensus definition, the frailty phenotype encompasses the diminished physiologic reserve consequent of advanced age, deconditioning from chronic illness or hospitalization, malignancy, or malnutrition. Frailty is associated with a 2–6-fold higher risk of major adverse cardiac events and prolonged intensive care unit (ICU) and hospital stays (25). It also impairs immune response and wound healing, further increasing surgical vulnerability. In 2021, the American Association for Thoracic Surgery identified frailty as a critical factor in assessing candidacy for lung cancer resection (33). Importantly, studies examining prehabilitation in frail populations have shown a reduction in severe postoperative complications (34), suggesting that targeted prehabilitation can meaningfully improve surgical outcomes and potentially expand operability among this high-risk group.

Elderly patients specifically constitute a population in themselves that benefits from tailored prehabilitation interventions. In addition to a higher prevalence of frailty, these individuals often experience cognitive vulnerability, predisposing them to postoperative delirium, a well-recognized complication following thoracic surgery (35). Delirium is associated with prolonged hospitalization, functional decline, and increased mortality (35). Prehabilitation strategies emphasizing both physical conditioning and cognitive resilience have been shown to mitigate the incidence of postoperative delirium (36).

Transplant candidates and immunocompromised patients represent particularly high-risk cohorts for whom prehabilitation may be especially valuable. Frailty, sarcopenia, and malnutrition are common in this population yet often underrepresented in conventional assessment tools such as the Model for End-Stage Liver Disease score for liver transplantation. Discontinuation of prehabilitation prior to transplantation has been associated with declines in peak maximal oxygen uptake (VO₂), underscoring the importance of maintaining interventions up to the time of surgery (26). Among lung transplant candidates, functional capacity as measured by the 6-minute walk test correlates strongly with both waitlist mortality and post-transplant survival (37). Recent guidelines increasingly recognize frailty as a modifiable risk factor, reinforcing the need to integrate prehabilitation into pre-transplant care.

Collectively, these vulnerable populations face disproportionate surgical risk. Implementing tailored, multimodal prehabilitation may not only reduce postoperative morbidity and improve recovery but also expand surgical eligibility for marginal candidates who might otherwise be deemed inoperable.

Implementation

The implementation of prehabilitation programs in thoracic surgery requires coordination, institutional support, and patient engagement to achieve benefit within the perioperative window, which is often narrow. Multiple studies have demonstrated that prehabilitation can reduce postoperative complications and shorten hospital stay, but translating these findings into routine clinical practice remains challenging due to organizational complexity, resource limitations, and logistical barriers. Successful programs are typically grounded in multidisciplinary collaboration and integrated within ERAS pathways, which standardize perioperative care and facilitate adoption (6,7).

A recurring theme in the literature is the importance of assembling a motivated multidisciplinary team by leveraging existing staff. Anesthesiologists, surgeons, oncologists, pulmonologists, physiotherapists, dietitians, psychologists, and nurses must work together to assemble and deliver a coordinated prehabilitation program (6,31). However, coordinating a multimodal team introduces several challenges, including the need for clear and consistent communication across disciplines, limited provider capacity, and uncertainty regarding financial support (32). Strong institutional backing is therefore critical for both resource allocation and the reduction in the administrative burden of providers. The Promoting Action on Research Implementation in Health Services (PARiHS) framework emphasizes that an organization’s readiness to provide prehabilitation is reflected in its leadership support and the flexibility of existing surgical practice culture (38). Many programs also designate a coordinating nurse or case manager who serves as the primary point of contact, organizing consultations and testing, reinforcing patient adherence, and monitoring progress throughout the intervention (6). Even small operational adjustments, such as locating the prehabilitation unit within the hospital’s outpatient clinic, may be helpful in reducing the burden on the healthcare team (31).

Patient selection and risk stratification play an essential role in implementation. Pilot programs typically prioritize those at greatest risk of poor postoperative outcomes. Selection criteria include age greater than 70 years, American Society of Anesthesiologists class III–IV, significant comorbidities such as chronic obstructive pulmonary disease (COPD), heart failure, or chronic kidney disease, and impaired baseline functional capacity (31). Risk stratification tools such as pulmonary function tests (PFTs) as well as cardiopulmonary exercise testing (CPET) are commonly used to identify patients most likely to benefit. High-risk cut-offs are often set at postoperative predictive (PPO) values of forced expiratory volume in the first second (FEV1) or diffusion capacity for carbon monoxide (DLCO) of 30%, or VO₂ max <10 mL/kg/min (7).

The length of the preoperative window is another important consideration. Participation in prehabilitation programs has most frequently been studied when a minimum of 3 to 4 weeks is available before surgery, allowing time for physiological improvement (31). However, in clinical practice, the interval between diagnosis and surgery is often shorter to prioritize oncological outcomes and reduce patient anxiety. In these settings, abbreviated and home-based prehabilitation programs may represent a pragmatic alternative. A randomized control trial by Liu et al. implemented a 2-week, home-based prehabilitation program before VATS lobectomy and found higher perioperative functional capacity as assessed by 6-minute walk distance in the prehabilitation group compared with the control group (15). Complementing these findings, the PREPACHIR study demonstrated that a teleguided, high-intensity, home-based prehabilitation program was feasible in lung cancer patients and significantly improved VO₂ max before surgery (27). Together, these studies indicate that prehabilitation delivered through shorter, home-based models can yield early functional and physiologic improvements prior to surgery, supporting the feasibility of prehabilitation even within constrained preoperative timelines. A structured shared decision-making process involving the patient, their relatives, and the interdisciplinary care team then helps determine the appropriate program intensity, modality, and setting, whether inpatient, outpatient, or home-based, to create a program that the patient is likely to adhere to and succeed in (7,32).

Most modern prehabilitation programs are multimodal and patient-centered, combining medical and nutritional support, education, lifestyle modification, structured exercise, and psychological interventions (6,34,38). Medical and nutritional components focus on controlling chronic diseases, treating active infections, reviewing medications, correcting anemia, malnutrition, and poor glycemic control, and micronutrient supplementation, including iron, folate, vitamin B12, and protein as needed (6). Educational and behavioral interventions empower patients to participate actively in their recovery, emphasizing smoking cessation at least 3 weeks before surgery, alcohol abstinence for 4 to 8 weeks, and oral hygiene measures, antiseptic showers, and microbiological decolonization to lower the risk of developing a surgical site infection (6). Exercise training is consistently reported as the cornerstone of prehabilitation, with programs incorporating aerobic and resistance training, flexibility, and respiratory muscle conditioning. HIIT has emerged as particularly effective for achieving rapid improvement in VO₂ max within the short preoperative window, with physiotherapists adjusting intensity based on patient tolerance and comorbidity profile (6,7). When safety is a concern, such as in cardiac or frail patients, supervised exercise with electrocardiogram (ECG) monitoring has been shown to be feasible and safe (39).

Patient adherence remains one of the strongest determinants of program success. In one study, 66% of patients failed to finish their prehabilitation program due to scheduling changes or lack of compliance (31). A recent systematic review of adherence in prehabilitation confirmed that while pooled adherence rates across trials average around 79–80%, definitions of adherence are highly variable, and logistical barriers, limited social support, and medical comorbidities often interfere with completion (40). Alternatively, supervision by specialists and tailoring programs to individual needs consistently emerged as facilitators that improve adherence.

Emerging strategies

As prehabilitation programs continue to gain traction, new strategies are focusing on optimizing delivery models, creating advanced risk prediction tools, and providing health economic frameworks to improve scalability, personalization, and sustainability of programs. One such development is the use of virtual and hybrid prehabilitation, which leverages telehealth, remote monitoring, and wearable technology to address barriers to access. In a proof-of-concept study, virtual prehabilitation showed no statistically significant improvement in most measured outcomes, with the exception of the five-times sit-to-stand (5STS) component (37). Because the 5STS was directly targeted through one-on-one lower limb strengthening sessions, this improvement was expected and suggests that virtual prehabilitation may serve as a feasible alternative to in-hospital sessions when individualized supervision is preserved. This study was designed as a single-center proof-of-concept evaluation in a limited population, and while not powered to detect broad functional changes, it provides important preliminary insight into feasibility, safety, and targeted functional gains with virtual delivery models. In addition to its clinical feasibility, virtual delivery may be economically advantageous. Home-based telerehabilitation is associated with similar or lower costs compared with in-person programs, and it reduces the need for patients to travel or relocate closer to rehabilitation centers, potentially decreasing financial and social burden (41).

Efforts are being made to refine risk prediction tools for patients undergoing lung cancer surgery, which could also provide insight into determining which patients would most likely benefit from prehabilitation. Beyond traditional VO₂ max cut-offs, ventilatory efficiency (VE/VCO₂ slope) has emerged as a robust prognostic marker. A proposed three-tier model (<30, 30–41, >41) improves discrimination compared with a single threshold by distinguishing low, intermediate, and high-risk groups, giving clinicians clearer insight into surgical candidacy and potentially guiding the need for prehabilitation (42).

To translate these risk stratification concepts into a clinically actionable framework, Figure 1 proposes a practical approach for integrating physiologic, functional, and patient-centered factors when selecting a prehabilitation format. The framework provides an algorithm for how a provider can weigh CPET metrics, including VO₂ max and VE/VCO₂ slope, alongside PFTs and frailty assessment, while also accounting for contextual considerations such as time to surgery, patient preferences, and accessibility.

Figure 1 Proposed risk stratification framework to guide prehabilitation format selection. DLCO, diffusion capacity for carbon monoxide; FEV₁, forced expiratory volume in first second; VE/VCO₂ slope, ventilatory efficiency; VO₂, maximal oxygen uptake.

Risk stratification metrics for assessing patient fitness continue to evolve, with growing interest in multidimensional models that extend beyond traditional physiologic thresholds. For example, combining CPET metrics with biomarkers may enhance predictive accuracy. Lin et al. demonstrated that the combination of VO₂/kilogram and red blood cell distribution width achieved the highest diagnostic value for predicting cardiovascular complications, suggesting that multidimensional models could guide prehabilitation intensity and perioperative surveillance (43).

Implementation of science and health economic frameworks is increasingly being applied to support the sustainable adoption of prehabilitation. The PARiHS framework highlights the importance of evaluating contextual readiness, including leadership commitment, availability of resources, and the flexibility of existing surgical practice culture, as prerequisites for success (38). Economic evaluations, though still limited, demonstrate that prehabilitation is either cost-neutral or cost-saving. Reported savings are largely driven by reductions in hospital LOS, but also by shorter ICU admissions, the setting in which prehabilitation is delivered (hospital vs. home-based), and patient adherence to prescribed programs (44).

Artificial intelligence (AI) has been incorporated into rehabilitation, where it has been used to supervise exercise, recognize posture and gestures, deliver tailored feedback through messaging systems, and collect data via wearable sensors (45). Applications of AI in rehabilitation have demonstrated benefits such as improvements in physical activity and functional outcomes, although differences in study populations, interventions, and outcome measures make the evidence difficult to generalize (45,46). Building on these applications, AI has naturally become a topic in prehabilitation, where it has been described as a tool to support programs when integrated with telemedicine and wearable devices for remote monitoring and preoperative functional optimization (47). It is important to consider, however, that adherence to AI-assisted and virtual prehabilitation may be limited by digital literacy barriers, particularly among elderly patients. Difficulties navigating unfamiliar or complex digital interfaces can impede sustained engagement even when access to technology is available. Practical mitigation strategies include leveraging familiar, low-burden platforms such as telephone calls, short message service (SMS)-based communication, or widely used instant messaging and video call applications, as well as incorporating brief onboarding or hybrid support to enhance usability. Future research will be needed to determine how these technologies can be validated, scaled, and effectively implemented within routine prehabilitation practice.

As prehabilitation moves towards broad implementation, it is critical to proactively understand and address disparities that may be encountered. Socioeconomic status has been shown to influence both access to and participation in prehabilitation. In one analysis of pooled multimodal prehabilitation studies, fewer patients from lower socioeconomic status enrolled and remained in programs compared with those from higher socioeconomic status, despite similar improvements in preoperative functional capacity across all groups (48). Reported barriers include limited health literacy, financial costs, geographical distance to hospitals delivering prehabilitation, transportation challenges, and competing personal or professional responsibilities, all of which may disproportionately contribute to lower adherence among patients of lower socioeconomic status (49). Current initiatives, including the Prehabilitation for Cancer Surgery: Quality and Inequality project, are examining how prehabilitation services are developed, funded, and delivered, with particular attention to how these processes may mitigate or exacerbate health inequalities (50).

Limitations and future directions

A key limitation of this review is the limited availability of data specific to minimally invasive thoracic surgery, as much of the literature includes open thoracic procedures or minimally invasive operations in other surgical specialties. Consequently, conclusions regarding minimally invasive thoracic surgery are, in part, extrapolated from these related populations, highlighting the need for procedure-specific, prospective studies. Future studies should continue to examine outcomes regarding the various prehabilitation modalities across multiple centers in order to refine protocols and improve patient care. With AI becoming increasingly integrated into medicine and rehabilitation, large language models will likely be used to further augment prehabilitation algorithms as they pertain to personalizing prehabilitation and risk stratification.

Conclusions

Prehabilitation has emerged as a pivotal strategy for optimizing outcomes in patients undergoing management of various surgical diseases, and this remains true for patients undergoing minimally invasive thoracic surgery. Across the literature, the benefits of a prehabilitation program include improved pulmonary function, which helps mitigate post-operative complications such as respiratory failure. It may also allow patients previously assessed as “non-operative” to undergo surgery as their pulmonary function improves. Additional advantages include shortened hospital stays, enhanced physical fitness, and improved quality of life.

The evidence strongly supports the use of tailored, multimodal prehabilitation programs that incorporate exercise training regimens, nutritional support and augmentation, psychological support, and smoking cessation. These approaches appear particularly beneficial to high-risk populations such as the elderly and those with COPD or interstitial lung disease. The integration of predictive tools such as the CPET and formalized frailty assessments can help personalize prehabilitation approaches and stratify surgical risk. In short, the current literature supports the incorporation of prehabilitation into all patients undergoing pulmonary resections in conjunction with standardized ERAS protocols.

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-2025-1-53/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-53/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-2025-1-53/coif). The 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.

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