Robotic-assisted tracheal, carinal, and bronchial sleeve resections without lung resection: a narrative review of techniques, airway management, and early outcomes

Introduction

Airway resections with lung preservation are challenging procedures for both thoracic surgeons and anesthesiologists. They require careful patient selection and planning. Throughout history, different techniques and approaches have been described, ranging from open surgery with sacrifice of lung parenchyma in the form of lobectomy or pneumonectomy to modern minimally invasive approaches with all efforts made at lung preservation (1).

Open surgery provides optimal exposure of airway structures, allowing good visualization for the surgeon; however, this is accompanied by increased tissue trauma, larger incisions and higher potential postoperative morbidity, and slower functional recovery (2). Video-assisted thoracic surgery (VATS) marked an important step toward minimally invasive approaches in this field, but its application to complex airway resections remains limited by restricted instrument articulation and suturing capabilities, particularly during airway reconstruction (3).

Robotic-assisted surgery is the latest surgical technological advance that has deeply permeated the field of thoracic surgery. Improvements in visualization, precision, and range of motion of instruments have expanded the possibilities of what is feasible using a minimally invasive approach allowing surgeons to push the boundaries and perform complex operations using robotic-assisted surgery platforms. Resections of the central airways, that is trachea, carina, and mainstem bronchi, are not the exception.

Despite the increasing interest in the use of robotic-assisted approaches in tracheobronchial surgery, the published experience remains limited and heterogeneous, consisting predominantly of case reports and small series from highly specialized centers. Moreover, there are no reviews specifically focused on compiling and describing cases performed with complete lung preservation, including essential aspects such as anesthetic management, surgical technique and early outcomes. Therefore, the purpose of this narrative review is to summarize the principles of tracheobronchial surgery and how they have been applied to robotic-assisted resections with lung preservation, while appraising the published preliminary experience with particular attention to anesthetic strategies, surgical techniques, and early reported outcomes, to understand what has been possible today and what the future might hold in this field. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-50/rc).

Methods

A bibliographic search was performed from July 7 to July 20, 2025 using the PubMed and Google Scholar databases (Table 1). Six different keyword combinations were applied in both databases, resulting in a total of 12 individual searches. The following terms were combined using Boolean operators and limited to title and abstract fields: “carina resection”, “tracheal resection”, “airway resection”, “bronchial resection”, “bronchial sleeve resection”, “robotic surgery”, “robotic assisted surgery”, “robot-assisted”, and “robotic-assisted thoracic surgery”. Filters were set to include only articles published between January 2015 and July 2025 focusing on adult patients. Eligible publications included original research, case reports, and review articles related to robotic-assisted thoracic surgery (RATS) to perform resection and reconstruction of the trachea, carina, or bronchi with complete lung preservation. In addition, articles that described airway management techniques during airway surgery, particularly when using a minimally invasive approach, were included. Articles were excluded if they reported operations that also involved lung resections such as sleeve lobectomy or carinal pneumonectomy, if they were published in languages other than English or Spanish, or if they related to studies in which VATS or open thoracotomy was used as the main surgical approach. Duplicates were manually removed, and titles and abstracts were screened based on the previously mentioned criteria and appropriateness. As a narrative review, this work did not follow a formal systematic methodology, which might limit the generalizability of the findings.

Historical perspective

Airway resection surgery has undergone multiple changes throughout history. In the late nineteenth century, Gluck and collaborators demonstrated in animal models that tracheal end-to-end anastomosis could heal adequately, laying the foundation for airway reconstruction (1). Shortly thereafter, Küster reported the first successful tracheal resection with anastomosis in humans, followed by early descriptions of tracheal resections for malignant disease (1). Subsequent experiences, including bronchial repairs reported during the first half of the twentieth century, further expanded the scope of airway surgery (4).

A deeper understanding of tracheal anatomy and vascular supply in the mid-twentieth century allowed surgeons to define safe limits of resection and recognize anastomotic tension as a key determinant of postoperative complications (5). These concepts were systematically developed and standardized by Grillo at Massachusetts General Hospital, whose contributions established adequate mobilization and preservation of blood supply as central tenets of tracheobronchial surgery (2).

The evolution to minimally invasive thoracic surgery represented an important shift, offering potential reductions in postoperative morbidity and faster functional recovery while adhering to the principles of airway surgery. In 2005, Nakanishi reported the first successful circumferential tracheal resection with primary end-to-end anastomosis performed via VATS for adenoid cystic carcinoma of the intrathoracic trachea (3).

Although technically demanding and limited to highly specialized centers, this experience demonstrated that minimally invasive techniques could be applied to complex airway resections. RATS subsequently introduced additional technical capabilities that expanded the application of minimally invasive approaches to selected complex airway procedures requiring precise dissection and reconstruction, including isolated tracheal and bronchial resections with lung preservation. From a technical and ergonomic standpoint, this platform may facilitate the execution of these demanding procedures for surgeons, with the potential to influence perioperative performance and early outcomes; however, the extent of this potential benefit remains to be clearly defined. To be successful, minimally invasive surgical approaches to perform tracheobronchial surgery, like RATS, need to adhere to well-established principles of airway surgery.

Principles of tracheobronchial surgery to be considered for robotic-assisted operations

Patient selection and preoperative evaluation

Tracheobronchial surgery follows the same fundamental principles as pulmonary surgery regarding patient selection. It requires a comprehensive preoperative evaluation, including detailed imaging and functional studies to determine physiologic reserve and surgical candidacy (6). A CT scan of the chest is imperative to assess the anatomy of the tracheobronchial tree and surrounding structures. In cases of primary airway tumors, PET-CT can help assess regional or distant metastases. Bronchoscopy is essential for direct inspection of the airway anatomy and for obtaining measurements of the length of the airway involvement, as this impacts resectability. Airway resections exceeding 4 cm in length are associated with a higher risk of complications secondary to excessive tension at the anastomosis after reconstruction (7). Bronchoscopy also allows for evaluation of mucosal inflammation or signs of infection that might need to be treated before proceeding with surgery. Pulmonary function tests are mandatory and their results can impact the anesthetic strategy. If appropriate, a transthoracic echocardiogram or a stress test is ordered to rule out cardiac comorbidities.

Airway management

Intraoperatively, tracheobronchial surgery requires careful attention to both anesthetic and surgical considerations. Airway management before, during, and after the operation is critical. Techniques to maintain ventilation and oxygenation during airway operations must be selected after discussion with the anesthesiologist to ensure adequate oxygenation and ventilation while facilitating the conduct of the operation from a technical perspective.

The surgeon and the anesthesiologist need to discuss the anesthetic plan prior to surgery, with the objective of understanding the surgical procedure to be performed and the sequence of events. The tumor location and the laterality of the surgical approach will be the key factors in deciding the anesthetic plan (Table 2), mainly the management of the airway and ventilation. Lesions or tumors located within the bronchial tree are usually approached from the ipsilateral hemithorax, therefore, orotracheal intubation with selective ventilation using a double-lumen endotracheal tube (DL-ETT) can be used in a standard fashion. Depending on the location of the tumor, a right-sided or left-sided DL-ETT is selected to avoid interference of the DL-ETT with the surgical field. On the other hand, if the tumor is located centrally in the distal trachea, carina, right mainstem bronchus, or in the proximal left mainstem bronchus, they are commonly approached via the right chest. The need to ventilate the left lung while isolating the right lung requires careful consideration of alternative ventilation management strategies. Several options are available and were described in the literature including cross-field ventilation, jet ventilation, or extracorporeal membrane oxygenation (ECMO). Resection of the central airways has also been described under spontaneous ventilation; however, this experience remains limited and is controversial for widespread use.

Standard selective endotracheal intubation with single lung ventilation

In cases not involving the trachea or carina and only involving the bronchial tree, single lung ventilation is possible with selective endotracheal intubation using a single-lumen ETT (SL-ETT) or DL-ETT if approached surgically from the ipsilateral hemithorax. This greatly facilitates anesthetic management as ventilation and oxygenation are carried out in a standard fashion throughout the operation.

Cross-field ventilation

This is the most common anesthetic technique in airway resection surgeries (19). It is preceded by conventional anesthesia with an SL-ETT or DL-ETT during the dissection phase. After incising the airway during resection, the surgeon inserts a SL-ETT directly into the distal trachea or the mainstem bronchus. In cases of minimally invasive approaches such as RATS, the cross-field ventilation ETT is brought out of the chest through a thoracic port site and connected directly to the anesthesia machine using sterile connectors. Intermittent episodes of apnea might be needed to complete the airway resection and reconstruction, as the tube used during cross-field ventilation impedes uninterrupted work constructing the anastomosis. After resection and anastomosis are completed, conventional ventilation is resumed via the orotracheal ETT.

Jet ventilation

This technique uses fine catheters to provide ventilation that allows greater tracheal mobility. Given the smaller size of the catheters, they can be useful in cases of tight airway stenosis or near-obstructing tumors, as they can be navigated distally to provide ventilation. Jet ventilation catheters can be placed through an ETT or through a laryngeal mask airway (LMA). Compared with cross-field ventilation, its main potential advantage is that it can eliminate the need for intermittent ventilation with apnea episodes, as the small size of the jet ventilation catheter allows the surgeon to work around it (19).

Veno-venous extracorporeal membrane oxygenation (VV-ECMO)

VV-ECMO can replace and maintain the respiratory function of the lungs while the operation is carried out. Depending on the characteristics and locations of the airway lesion, VV-ECMO can be established after standard induction of anesthesia and intubation or with the patient awake breathing spontaneously. A percutaneous cannula is inserted into the right femoral vein for drainage, and the internal jugular vein is used for return (17). VV-ECMO is initiated before resection begins, which obviates the need for lung ventilation during the operation. Typical cannulation includes a 23–25 F multistage femoral drainage cannula and a 17–19 F jugular return cannula. Anticoagulation is usually achieved with a bolus of 2,000–5,000 IU of unfractionated heparin, targeting an activated partial thromboplastin time (aPTT) of 50–60 seconds or activated clotting time (ACT) of 180–220 s (20,21). However, in selected high-bleeding-risk cases, the procedure may be performed without systemic anticoagulation (20). After the airway resection and reconstruction are completed, conventional orotracheal ventilation can resume. VV-ECMO is then weaned off and cannulae are removed.

Spontaneous ventilation with LMA or non-intubated approach

Minimally invasive tracheobronchial surgery under spontaneous ventilation remains controversial and limited to a few centers worldwide. It involves anesthetic induction without muscle relaxation, allowing the patient to breathe spontaneously. This is a challenging approach as it requires proper patient selection, strict monitoring, and readiness for intubation with the patient in the lateral decubitus position or rapid establishment of alternative methods such as cross-field ventilation or ECMO (19). This type of anesthesia has been previously used in thoracic surgery, but it has only been described recently in combination with RATS. Some authors consider it innovative, while others see it as an additional risk on top of the inherent risks of the surgery itself (22-24). Among its potential benefits is that it can provide the surgeon with the necessary space to work around the airway without an ETT interfering with the procedure, as well as avoiding the potential risks of orotracheal intubation, such as tracheal injury or vocal cord injury among others, while seemingly reducing anesthesia recovery times (19,25). On the other hand, hypercapnia represents one of the most important risks and, at present, there are not enough studies to properly evaluate its repercussions. This would also prevent the use of CO₂ insufflation in the chest during RATS if needed to improve exposure. Additionally, the absence of muscle relaxation may trigger the cough reflex, leading to unintended patient movements that may cause potential injury (26,27). The generalizability of this technique is questionable and in the literature, it has been clustered in centers in Asia.

Preoperative preparations in robotic-assisted airway surgery

RATS central airway resections should only be undertaken by surgeons and multidisciplinary teams with substantial prior RATS experience. The surgical team must be specifically trained in robot handling, including its configuration, port placement, docking, and safe undocking and conversion to open in case of emergencies. Proper patient positioning is crucial not only for anesthetic safety but also to ensure optimal port alignment. Surgical planning should define the optimal number and location of ports. For RATS procedures, typically four robotic arms are used with the frequent addition of an assistant port (28,29).

Surgical principles

The procedure should start with on-table bronchoscopy to reassess the exact location of the tumor, take final measurements, and assess for concomitant signs of airway inflammation or infection that could prompt delaying the operation. Several surgical factors must be considered, including the safe extent of resection, the true resectability in cases of malignant tumors of the airway, the preservation of segmental blood supply by avoiding excessive dissection of the proximal and distal airways, the creation of a tension-free anastomosis which might require the application of release maneuvers, and a meticulous anastomotic technique. In addition, the use of vascularized flaps to reinforce and protect the anastomosis can be considered individually (30).

Why a robotic-assisted approach in airway surgery?

RATS offers certain advantages over open or VATS techniques, but it also demands careful technical execution and well-structured preparation. The use of RATS in central airway resections with complete lung preservation is emerging with a current small number of cases reported. Nevertheless, this technology provides a unique technical platform to address the inherent complexity of these operations. The improved visualization, precision, and range of motion provided by robotic surgical platforms allow the surgeon to follow the principles of tracheobronchial surgery without compromises when performing these operations using a minimally invasive approach. Most of the technical complexity of airway resection with primary reconstruction is centered in the construction of the anastomosis. Many surgeons have strongly hesitated to perform these operations using VATS approaches as suturing movements and angles are more limited. However, RATS involves the use of wristed instrumentation that allows for precise and complex intra-corporeal suturing. Effectively overcoming this barrier might allow more patients with central airway pathology to benefit from the advantages provided by minimally invasive surgery such as lower pain and faster functional recovery.

Early published experience with robotic-assisted tracheobronchial surgery

Patient characteristics in reported robotic airway resections

The implementation of RATS in cases of tracheobronchial surgery with complete lung preservation is relatively recent. The evidence base is limited with only 11 original articles identified for this review consisting of small case series or case reports published in the last 10 years, reporting a total of 18 cases of this type of surgery worldwide. Primary airway tumors were the main indication described for RATS central airway resection (Table 2). The most frequent tumor locations treated with RATS airway resections were the distal trachea (6/18) and the left mainstem bronchus (4/18). The distribution of tumor locations across the reviewed studies is illustrated in Figure 1. Patients’ representation by age varies widely with peak frequency observed in the fifth decade of life, but with patient presentation ranging from their 30s to their 70s. Female patients represented the majority of patients who underwent RATS central airway resections.

Figure 1 Summary of tumor locations in cases of robotic-assisted isolated airway resection (8-18). Each number represents the respective reference. *, more than one case from the same article. Original illustration created by Luisa Tolosa Jaimes.

Anesthesia management

RATS central airway resections have been described using different anesthetic airway management techniques. Standard selective intubation was used in 8 of 18 (44%) cases included in this review, including 7 cases of bronchial sleeve resections and 1 case of non-circumferential tracheal resection. Cross-field ventilation has been described during RATS airway resection by passing an SL-ETT through an additional thoracoscopy port. For example, Qiu et al. placed a port in the third intercostal space at the mid-axillary line in a case of a tracheal lesion nearly obstructing airflow to the left main bronchus, while Mughal et al. reported a case of a tumor in the carina, where the port was inserted in the fourth right intercostal space at the paraspinal line (8,14). Overall, cross-field ventilation was used in 3 of 18 (17%) cases included in this review. No cases using jet ventilation during RATS airway resections were identified. VV-ECMO was used to support ventilation and oxygenation during RATS airway operations in 1 of 18 cases (6%). Finally, RATS airway resections under spontaneous breathing were identified in 6 of 18 (33%) cases included in this review, although 5 of these cases originated from a single center with prior experience using this technique during VATS.

Surgical technique and procedure-specific considerations

Among the cases in which the surgical approach was specified, a right chest approach was reported in 7 patients and a left chest approach in 1 patient. A right chest approach was preferred in cases of tracheal, carinal and mainstem bronchus tumors, while the left chest was preferred for distal left mainstem tumors. The literature described mostly the use of the da Vinci robotic surgical system (Intuitive Inc, Sunnyvale, California, United States). Most commonly, placement of five ports was described: four for the robotic arms and one assistant port (Table 3). Once selective lung ventilation is achieved, if compatible with the ventilation strategy, CO₂ insufflation to an intrathoracic pressure of 8–10 mmHg can be established to facilitate collapse of the ipsilateral lung and to optimize visualization of the surgical field (10,16).

After the dissection of the posterior mediastinal pleura and pulmonary ligament, the pulmonary hilum is identified, the esophagus is mobilized, and both the distal trachea and the mainstem bronchi are exposed (17). Lymph node sampling is typically performed at this stage. After identification of the lesion, resection is performed, and negative margins must be confirmed with frozen section pathology examination in cases of airway neoplasms. The airway is then reconstructed by performing the corresponding anastomosis, followed by an underwater air leak test; if bubbles appear, the suture line must be reinforced. Anastomotic techniques are described below when describing each type of airway resection and in Table 3.

Carinal resection

Carinal resections are among the most challenging procedures. There were 3 cases of RATS carinal resection in the literature (13,14,18). Indications included an inflammatory myofibroblastic tumor and two cases of squamous cell carcinoma, one of which was treated with neoadjuvant chemo-immunotherapy with carboplatin, paclitaxel and sintilimab. The ventilation strategy requires careful selection. Two cases reported the use of cross field ventilation introducing a single lumen ETT into the left mainstem bronchus through a separate incision. The remaining case reported the use of spontaneous ventilation with assistance of an LMA. Division of the azygos vein is frequently required to achieve adequate exposure of the carina. The esophagus is mobilized widely away from the airway to get unobstructed access to the carina. After resection, primary reconstruction was performed in all cases. The type of anastomosis varied depending on tumor location and extension (13,14,18). Cases of RATS carinal resection and reconstruction described an anastomotic technique using absorbable barbed suture, non-absorbable monofilament suture, or absorbable monofilament suture (Table 3).

Tracheal resection

Robotic approaches to tracheal resection have only been described for resection of the intrathoracic trachea, as lesions in the cervical trachea are approached through a neck incision. We identified 6 cases of RATS tracheal resections in the literature (8,13,15-17). Indications included adenoid cystic carcinoma, neuroendocrine tumors, leiomyoma, and leiomyosarcoma of the trachea. The ventilation strategy in these cases included the use of a DL-ETT (n=1), cross-field ventilation (n=1), VV-ECMO (n=1), and spontaneous ventilation with assistance of an LMA (n=3). Exposure is achieved with mobilization of the esophagus along the length of the trachea. If needed, the azygos vein is divided. Anastomotic technique in these cases described the use of non-absorbable monofilament suture (n=5), and barbed absorbable suture (n=2); one case used both types of sutures. In addition, in several cases the anastomosis was reinforced with vascularized tissue such as pericardial fat or thymus flaps (8,13,15-17).

Bronchial sleeve resection

We found a total of 9 cases of RATS isolated bronchial sleeve resection in the literature (9-13). Right-sided bronchial sleeve resections were described in 4 cases, including the right mainstem bronchus (n=1) and the bronchus intermedius (n=3). On the other hand, left-sided bronchial sleeve resections were described in 5 cases, including the left mainstem bronchus (n=4) and the LC2 minor carina (n=1). Indications for surgery included mucoepidermoid carcinoma, neuroendocrine tumors, hamartoma, and schwannoma. In bronchial sleeve resections, anesthesia may be performed with conventional selective intubation of the contralateral lung, either with an SL-ETT or a DL-ETT. Two cases of left-sided bronchial sleeve resections described the use of spontaneous ventilation with assistance of an LMA (13). During dissection, encircling the main bronchi, for example, with umbilical tape, can help with handling. Also, placement of stay sutures on the bronchi can help with manipulation and alignment for anastomosis. The most frequently used suture material for anastomosis was absorbable barbed suture (n=7), although a layered anastomosis with non-absorbable and absorbable monofilament sutures was also described (n=2) (9-13).

Outcomes of robotic tracheobronchial surgery

The early reported outcomes following robotic tracheobronchial resections were generally favorable within the limitations of the available evidence. Across the included reports, no conversions to open surgery were described and all resections achieved negative margins. Length of hospital stay ranged from 3 to 14 days. No major postoperative complications were reported, and anastomotic healing was described as uneventful, with no evidence of stenosis in the short-term follow-up reported. After a median follow-up of approximately one month, no cases of local tumor recurrence were described.

However, interpretation of these outcomes is limited by the small number of reported cases, the predominance of case reports and small single-institution series, and the short and heterogeneous follow-up. Given the small sample size, the published cases are likely highly selected which raises concerns about selection and publication bias. In addition, the absence of comparative studies with established approaches such as thoracotomy or VATS precludes meaningful conclusions regarding relative safety or oncologic efficacy. Longer-term data are required to better assess durability of anastomotic results and oncologic outcomes.

Discussion

In the current narrative review, we have appraised the principles of tracheobronchial surgery, mentioned the potential benefits of robotic surgical approaches during these operations and summarized the early published experience with robotic-assisted approaches for isolated airway surgery, including six cases of tracheal resections, three cases of carinal resections, and nine cases of bronchial sleeve resections with complete lung preservation. Although the existing literature is limited to case reports and small single-institution series, the early available data suggest that RATS is technically feasible and a safe alternative to thoracotomy or VATS in carefully selected patients. However, it must be emphasized that the reported outcomes reflect the experience of highly specialized centers with established expertise in both airway surgery and robotic thoracic surgery, which limits generalizability. RATS tracheobronchial surgery should be implemented clinically as part of a comprehensive robotic thoracic surgery program due to the complexity of these procedures. Close collaboration between anesthesiologists and surgeons is critical in centers interested in exploring the use of RATS for these complex airway operations.

As previously emphasized, the availability of a surgical and anesthetic team trained in rapid conversion to an open approach is fundamental when undertaking robotic-assisted airway surgery. The most frequently reported indications for conversion in RATS mirror those described in minimally invasive thoracic surgery in general, including uncontrolled vascular injury, severe anatomical challenges such as dense adhesions or distorted anatomy, large or locally invasive tumors precluding safe dissection, unexpected technical complications, and inadequate exposure that compromises procedural safety. In the setting of tracheobronchial resections, where airway management poses an additional level of complexity, it is particularly important to anticipate and clearly delineate alternative intraoperative ventilation and oxygenation strategies. In this context, ECMO backup capabilities would be ideal, but not mandatory.

Future research should focus on larger cohorts with longer follow-up to better characterize outcomes. In particular, further exploration of different airway management strategies, such as spontaneous ventilation or ECMO in conjunction with RATS, is warranted. As mentioned, long-term follow-up is needed to better understand anastomotic and oncologic outcomes. Given the technical complexity of these procedures, future studies should also address learning curves and training requirements associated with robotic airway surgery. Multicenter collaborations will be essential to accumulate sufficient data to support the development of standardized indications, techniques, and follow-up protocols.

Conclusions

Robotic-assisted approaches for tracheal, carinal, and bronchial sleeve resections without concomitant resection of lung parenchyma are emerging with limited early reports suggesting their safety and technical feasibility in highly selected patients when performed at expert centers. While early reported outcomes are encouraging, continued investigation, longer follow-up, and collaborative multicenter efforts are required to more clearly define the role of robotic technology in complex airway surgery.

Acknowledgments

The authors acknowledge the limited use of ChatGPT (OpenAI, version GPT-5) exclusively for grammar correction. The content, scientific interpretation, and writing style are entirely the authors’ own.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-50/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-50/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-50/coif). L.F.T. serves as an unpaid editorial board member of Video-Assisted Thoracic Surgery from November 2024 to December 2026. The other author has 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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