Short-term postoperative complications of robot-assisted thoracoscopic resections for lung cancer

Introduction

Lung cancer remains the leading cause of cancer-related deaths worldwide (1). Surgical resection continues to be the standard of care for treating early-stage disease. Over the past decade, robot-assisted thoracoscopic surgery (RATS) has emerged as a minimally invasive alternative to conventional video-assisted thoracoscopic surgery (VATS) and open approaches, offering enhanced visualization, dexterity, and potentially improved perioperative outcomes (2-4). Prior studies comparing robotic lobectomy to conventional VATS or thoracotomy have demonstrated reductions in mortality and shorter hospital stays (4,5).

Lobectomies are the gold standard for early-stage lung cancer, but sublobar resections such as segmentectomies and wedge resections have gained validity as parenchymal-sparing alternatives, particularly for patients with limited pulmonary reserve or significant comorbidities. In 1973, Jensik et al. were the first to propose a segmentectomy in the treatment of early-stage tumors for improved postoperative lung function (6). Sublobar resections remain a viable option for selected high-risk patients without compromising oncological outcome (7).

Despite the growing body of evidence supporting robotic surgery, limited data directly compare postoperative outcomes across different robot-assisted pulmonary resections. Most prior studies contrast robotic with VATS or open approaches, leaving uncertainty about variation within robotic procedures themselves. This study uniquely examines early postoperative complications and outcomes using the Clavien-Dindo grading system among patients undergoing robotic lobectomy, segmentectomy, or wedge resection, providing a more comprehensive evaluation of differential risk posed by extent of resection. We present this article in accordance with the STROBE reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-25-43/rc).

Methods

Study design and patient cohort

We conducted a retrospective chart review on patients who underwent an elective robot-assisted lung resection performed by a single thoracic surgeon (P.C.L.) within a multicenter health system in the United States. Patients were included if they underwent a lobectomy, segmentectomy, or wedge resection for treatment of selected stages I–III lung nodules between September 2015 and December 2024. All other procedure types were excluded. A total of 1,438 patients were included in this analysis. This study was approved by the Institutional Review Board of Northwell Health (No. 24-0797) and was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. Individual consent for this retrospective study was waived.

Surgical approach & method

Individual baseline characteristics and clinical factors were evaluated on a case-by-case basis to determine resection type along National Comprehensive Cancer Network (NCCN) guidelines. Procedures were performed robotically using the DaVinci XI system. Patients were placed in the lateral decubitus position with the bed flexed. For wedge resections, typically 3 mm robotic ports were placed with a camera port at the 5^th intercostal space posterior axillary line. Other working ports were 4 fingerbreadths apart, 1 medially and 2 laterally, avoiding the scapula. A 6^th port was placed in the 7^th intercostal space. We also placed a 12 mm port for wedges, or a 15 mm port for larger resections. The robotic arm, tip-up, went into the posterior robotic port. The right-hand port was typically long bipolar, while the left-hand side was fenestrated bipolar. For lower lobes, the procedure typically started by taking the inferior pulmonary ligament. Then the inferior pulmonary vein was isolated before dissecting and opening the oblique fissure, thereby isolating the basilar arteries. We typically resected lungs starting with the pulmonary vein, then artery, then bronchus. At times, this order may be altered for ease, depending on individual anatomy. For upper lobes, we typically started with the posterior-to-anterior approach, and the sequence of division was from vein, then artery, then bronchus when possible.

Definitions and data collection

The data in this study were collected from the Society of Thoracic Surgeons’ Database, which is managed by Northwell Health’s Department of Cardiothoracic Surgery’s Quality Improvement Team, and from Northwell’s electronic health records. From this database, we analyzed patient demographics such as age, gender, sex, racial/ethnic background, smoking status, comorbidities, American Society of Anesthesiologists (ASA) score, clinical stage, procedure type and duration from incision to closure, and primary tumor characteristics. Postoperative outcomes regarding complications, their severity, length of stay, readmissions, and mortality within the first 30 days following the date of surgery were evaluated. Comorbidities included hypertension (HTN), congestive heart failure (CHF), coronary artery disease (CAD), peripheral vascular disease (PVD), diabetes, and chronic obstructive pulmonary disease (COPD). All procedures were performed robotically, and patients were categorized by procedure type: lobectomy, segmentectomy, or wedge resection.

Postoperative complications included prolonged air leak for over 5 days, atelectasis, pleural effusion, acute respiratory distress syndrome (ARDS), respiratory failure, pneumothorax, pneumonia, ventilatory support for over 48 hours, bronchopleural fistula, myocardial infarction (MI), atrial fibrillation (A-fib), stroke, postoperative bleeding, reoperation, discharge with a chest tube in place, and patient death. Events were recorded for analysis if they occurred within the first postoperative month. “Any complication” was considered if a patient experienced at least one of these events.

Assessment of complication severity was modeled after the Clavien-Dindo scale, which quantifies the impact of a complication on a patient’s health from 1 to 5 (8). “Minor” complications were self-limiting or were resolved by oral pharmacologic intervention and were respectively graded 1 and 2. Grade 1 complications included being discharged with a chest tube or a mini-atrium. Grade 2 complications were scored if any oral treatment was indicated. Grades 3–5 complications constituted “major” complications. Grade 3 required surgical, endoscopic, or radiologic intervention performed with or without anesthesia. This included chest tube reinsertions, thoracentesis, pleurodeses, and bronchoscopies. Grade 4 complications were life-threatening, emergent complications that required urgent, intensive care attributed to single or multiorgan dysfunction. These included reoperations, (re)intubations, and ventilatory support. Grade 5 complications were deaths that occurred during the same hospital admission.

Statistical analysis

Data were summarized using frequencies and percentages for categorical variables, and medians with interquartile ranges (IQRs) for continuous variables. Outcomes were compared between groups using Chi-squared, Fisher’s exact, or Kruskal-Wallis test as appropriate based on the type and distribution of the variables. Univariate and multiple logistic regression models were used to identify factors associated with the major complication. Demographic, clinical, and procedural characteristics were considered for the multivariable model, with a significance level of 0.25 for variable entry and 0.025 for variable retention in the final adjusted analysis. Tumor size and procedure time were restricted entry into the adjusted model due to strong collinearity with procedures. Forced expiratory volume in 1 second (FEV1) % predicted (%pred) and clinical T3 stage were included in the multivariable model, but removed during the backward variable selection process to arrive at the best predictive model. The final model used a backwards selection method, which ultimately selected the same predictive variables as the stepwise regression model. Ten-fold cross-validation was performed to validate the final model’s predictive performance and ensure reproducibility. Model discrimination was assessed using the area under the receiver operating characteristic curve (AUROC), and model fit was assessed using the Hosmer-Lemeshow goodness-of-fit test (Figure S1). Firth’s penalized regression was used to analyze variables with small cell counts (Table S1). SAS 9.4 (SAS Institute Inc., Cary, NC, USA) and R 4.3.3 (R Core Team, 2024) were used for data preprocessing and statistical analysis. Omnibus tests without pairwise comparisons were employed, and a two-sided P value of <0.05 was considered statistically significant.

Results

Demographics and clinical factors

Patient demographics, preoperative characteristics, comorbidities, and clinical staging are compared between lobectomy, segmentectomy, and wedge resection patients and reported in Table 1. Among the 1,438 patients we identified, 861 patients (60%) received a lobectomy, 179 patients (12%) underwent a segmentectomy, and 398 (27%) underwent a wedge resection. Nearly three-quarters of the total study sample was of Asian descent. Wedge resection patients were slightly older with median age of 70 years, compared to lobectomy and segmentectomy patients (each 69 years; P=0.07). Patients in the segmentectomy group tended to have the most comorbidities, although rates were comparable to those of wedge resections. COPD was more likely to be present in both sublobar groups, with 17.9% of segmentectomy and 16.3% of wedge resection patients having COPD, compared to the 9.2% of lobar patients (P<0.001). Additionally, slightly more patients in the segmentectomy group tended to have CAD (17.9%) and diabetes (31.8%), compared to lobectomy patients (11.4% and 23.9%) and wedge resection patients (12.6% and 27.9%), though differences were minimal and nonsignificant (P=0.058 and P=0.054). Nearly half of the patients included in this study were never/non-smokers, with 49.9% of lobar, 42.5% of segmentectomy patients, and 45.0% of wedge resections having never smoked (P=0.08).

Clinical assessment of both pulmonary function and cancer stage were additionally associated with procedures, with sublobar patients tending to have reduced lung function and lower staged tumors. Among lobectomies, median preoperative values of diffusing capacity of the lung for carbon monoxide (DLCO) %pred and FEV1 %pred tended to be higher among lobectomies (83% and 93%, respectively), compared to the segmentectomy (DLCO 79% and FEV1 87%) and wedge resection groups (DLCO 77% and FEV1 87%; P<0.001). Clinical tumor size and stage also differed across procedures. Median tumor size of lobectomy patients (2.0 cm; IQR: 1.6 cm) was larger compared to those in segmentectomy (1.3 cm; IQR: 0.8 cm) and wedge resection groups (1.2 cm; IQR: 0.8 cm) (P<0.001). The majority of segmentectomy (93.9%) and wedge resection patients (94.7%) had clinical T1 tumors, while a comparatively greater portion of lobectomies were clinical T2 or higher (25.9%) (Table 1).

Procedure and pathology

The bivariate analyses of procedural factors and pathologic characteristics across procedures are reported in Table 2. Adenocarcinoma was the most common histology in this study, constituting 86% of lobectomies, 84% of segmentectomies, and 87% of wedge resections (P=0.63). All procedures commenced with an initial robotic approach, and less than 2% of all procedures were intraoperatively converted to open thoracotomy. There was minimal difference in conversion rates between procedures, with 1.9% of lobectomies, 1.7% of segmentectomies, and 2.0% of wedge resection cases converting to an open approach (P=0.96). Lobectomies and segmentectomies had comparable median operative times and appeared to take longer than wedge resections did. The lobectomy and segmentectomy groups both had median operative times between 130 and 140 minutes, whereas wedge resections had a median operative time of 85 minutes (P<0.001).

Postoperative course and outcomes

Frequencies of postoperative outcomes regarding complications, mortality, length of stay, and readmissions that occurred in the first postoperative month are reported in Table 3. Excluding reoperation and mortality, specific complications that had five or less instances are reported in Table S2. The most frequent complication across procedures was a prolonged air leak, occurring in 12.2% of the lobectomy group, 5.3% of wedge resection, and 3.9% of segmentectomies (P<0.001). Similarly, more lobectomy patients (4.3%) were discharged with a chest tube, compared to 1.7% of segmentectomies and 1.5% of wedge resections (P=0.02). There were additionally more cases of A-fib among lobectomies (2.1%), compared to wedge resection patients (0.5%), while none were observed among segmentectomies (P=0.02).

Following air leaks and A-fib rates, the cumulative evaluation of postoperative complications using the Clavien-Dindo scale displayed a similar pattern, with highest rates of “any”, “minor”, and “major” complications consistently observed among lobectomies. Segmentectomies simultaneously had the lowest rates of complications that were more comparable to wedge resections. Approximately 9.1% of lobectomies were associated with major complications, compared with 3.8% of wedge resections and 1.7% of segmentectomies (P<0.001). Similarly, complications that required direct intervention (i.e., chest tube reinsertions, thoracentesis, pleurodeses, or bronchoscopies), and categorized as grade 3, were seen in 8.6% of lobectomies, 3.5% of wedge resections, and 0.6% of segmentectomies (P<0.001). Grade 4 complications affected more wedge resection patients (1.8%), than segmentectomies (0.6%) and lobectomies (0%), although this was not significant.

Several postoperative complications were experienced by less than 1% of each procedure type. ARDS, bronchopleural fistula, pleural effusion requiring drainage, MI, chylothorax, bleeding, and/or reoperations within the same hospital admission each transpired in under a total of 10 cases (Table S2). There were no patients who had a stroke, nor any who required ventilatory support for over 48 hours. There were five cases of postoperative respiratory failure overall. One was from the lobectomy group (0.1%), another was from the segmentectomy group (0.6%), and three were from wedge resections (0.8%), though this was nonsignificant (P=0.09). Overall, three patients experienced mortality during the first postoperative month, one from each procedure group with two of them being in-hospital mortalities, but this was also not significantly different between groups (P=0.22) (Table 3).

Procedures were associated with length of stay and readmissions, with lobectomy patients tending to have longer hospital admissions and higher rates of 30-day readmissions. The lobectomy group had longer median length of stay of 3 days, than patients who underwent segmentectomies (2 days) and wedge resections (2 days) (P<0.001). Additionally, more lobectomy patients (2%) were readmitted within 30 days of their operation compared to none among segmentectomy patients (0%) and only one among wedge resections (0.3%) (P=0.01).

Adjusted analysis and independent predictors for major complications

Univariate analysis and multivariable models for major complication risk are presented in Table 4. After considering all demographic, clinical, and procedural variables for the unadjusted analysis, the final adjusted model identified four independent predictors of “major” complications. The type of procedure, specifically lobectomies, was seen to increase risk of complications, independent of clinical or demographic factors. Compared to wedge resections, lobectomies demonstrated over two-fold increase in risk of “major” complications in adjusted analysis [odds ratio (OR) =2.76; 95% confidence interval (CI): 1.52–5.03; P<0.001]. On the other hand, segmentectomies displayed a downwards trend in risk compared to wedge resections, though this did not reach significance (OR =0.28; 95% CI: 0.06–1.26; P=0.10). Gender was an additional independent predictor, as female patients were 41% less at risk of a “major” complication, compared to their male counterparts (OR =0.59; 95% CI: 0.37–0.93; P=0.02). Preoperative DLCO %pred was the third factor, with lowered odds of “major” complications as DLCO increased (OR =0.98; 95% CI: 0.97–0.99; P<0.001). Another procedural trait, unanticipated conversions to open, was shown to independently predict risk. Conversion-to-open saw a near three-fold increase in risk of “major” complication, compared to procedures without conversions (OR =2.9; 95% CI: 1.01–8.30; P=0.048).

Discussion

Despite a significant increase in major complication risk, we did not observe any significant differences in 30-day mortality between procedures. We observed one mortality case in each group, resulting in 0.1% of lobectomies, 0.6% of segmentectomies, and 0.3% of wedge resections. Mortality rate of segmentectomies appeared highest, but likely due to its smaller sample. Procedure association with mortality was ultimately not significant, conflicting with Stokes et al. who reported progressively higher hazard ratios for mortality with increasing extent of resection at 30 days from sublobar to lobectomies (9). They reported 2% 30-day mortality among lobectomy patients compared to 1.8% of sublobar resections, but acknowledged baseline pulmonary function and surgical approach were unable to be determined for analysis. In our study, 0.1% of lobectomy mortality was consistent with others’ 30-day figures for robot-assisted resections, and lower than VATS lobectomies. Significantly higher rates of mortality following VATS compared to robotic procedures are widely discussed overall (4,5,10-13). Perioperative outcomes between conventional VATS and the robotic method are comparable, but reduced mortality following robotic procedures presents an additional advantage over VATS (10-15). Several studies and reviews report mortality for robotic lobectomies ranging from 0.2–0.7%, compared to 1.1–2.9% of VATS lobectomies (4,11,12). A multicenter review by O’Sullivan et al. examined six centers and reported an estimated two-fold reduction in mortality in robotic resections compared to VATS resections (13).

Our data showed higher rates of “major” postoperative complications in lobectomies compared with segmentectomies and wedge resections. Lobectomies exhibited higher rates of grade 3 complications, which greatly factored into major complication assessment. This appears to be driven primarily by higher rates of prolonged air leaks that were managed through interventions categorized grade 3 on the Clavien-Dindo scale. A prolonged air leak was the most common complication across all groups, particularly in lobectomies (12%), which also had higher rates of chest tube retention at discharge compared to segmentectomies and wedge resections. This was consistent with prior reports of prolonged air leaks ranging from 10–26% following pulmonary resection (16-18). Although air leaks are common and typically resolve on their own within 48 hours, persistent air leaks lasting over 5 days posed risk of extending hospital stay, delaying recovery, or predisposing patients to additional interventions. Air leaks were confirmed by persistent bubbling in chest tube drainage, and chemical pleurodesis or mini-atrial chest tubes were employed to mitigate these effects (19).

At our centers, management commonly involved increased suction or chemical pleurodesis performed bedside. Doxycycline pleurodesis was done frequently for prolonged air leaks. Consequently, despite “major” complication risk associated with lobectomies, these were managed safely without posing risk to patients. Grade 4 complications that are life-threatening and require reintubation, reoperation, or ventilatory support were not significantly more likely to occur from lobectomies than in sublobar resections. Our findings support that although lobectomies increase the risk of complications, these can be managed with routine interventions without posing a significant threat to mortality.

In our study, two clinicodemographic factors emerged as independent predictors for complications. Gender, specifically the female sex, was significantly associated with a 41% reduction in odds of “major” complications compared to their male counterparts. This observation aligns with prior retrospective studies attributing similar gender disparities in complication rates to various psychosocial and possibly immunologic factors, including longer smoking histories, reduced pulmonary function, and diminished immune responsiveness among men (20-22). The second predictor pertained to preoperative DLCO %pred, with increasing DLCO corresponding with reduced odds of complications. VATS studies report similar findings that strongly support a predictive role for preoperative diffusing capacity in estimating postoperative morbidity (23,24). Ferguson et al. additionally proved that complication risk was associated with diffusing capacity among patients with and without COPD, and found around 27% reduced odds for each 10-point increase in DLCO (24).

Given the various clinical and preoperative characteristics that factor into determining resection type, groups clinically differed at baseline. Better pulmonary function and larger tumors were expectedly observed among the lobectomy group. Sublobar patients tended to have higher rates of COPD, reduced FEV1 and DLCO, as well as smaller tumor sizes. Wedge resections have long been viewed as a safe, minimally invasive surgical option to resect lower stage cancers in the elderly (25). Alongside segmentectomies, wedge resections are often performed for patients whose limited pulmonary reserve or comorbidities preclude lobectomies (26-29).

Ongoing debate persists over the factors driving complication rates across the lobar and sublobar, and anatomic and non-anatomic dichotomies. On one hand, appropriately-selected patients undergoing sublobar resection represent a population with increased baseline risk of postoperative morbidity (27,28). The Suzuki et al. [2019] meta-analysis found a two-fold increase in odds of postoperative complications associated with segmentectomies when compared to lobectomies (OR =2.07; 95% CI: 1.11–3.88; P=0.023) (30). Another study even found that comorbidities increased mortality among wedge resection patients (31).

Conversely, higher complication rates among patients receiving anatomic resections are consistently compared to lower rates among non-anatomic wedge resections. In our study, lobectomies were significantly associated with increased risk complications after adjustment, independent of demographic or clinical factors. Within the VATS discourse, lobectomy is consistently portrayed as a significant risk factor for the development of any complication compared to sublobar resections (9,32-35). Despite better preoperative pulmonary status, higher complication rates among lobectomy patients are primarily attributed to longer operative times and greater anatomic manipulation (26-29). We observed longer operative times and increased complication risk among lobectomy patients compared to those who received wedge resections. This aligns with prior associations of longer procedures and significantly higher complication rates, though these studies solely compared VATS and thoracotomies (17,36,37).

Unanticipated conversion to open thoracotomy was independently associated with postoperative complication risk after adjustment. Most conversions were attributed to anatomic difficulty encountered intraoperatively and adhesions that indicated converting to an open approach at surgeon discretion. Anatomic resections are inherently more involved, requiring precise lysis of pleural adhesions and manipulation of surrounding anatomy, resulting in longer operative times and increased chances of developing complications. More lobectomy patients in our study developed A-fib postoperatively (2.1%) compared to both sublobar resection groups. Our findings are consistent with others who reported A-fib incidence ranging from 5.2–18.8% following VATS lobectomies (38-40). Postoperative A-fib has been positively linked to pleural adhesions, making their onset more likely to follow anatomic resections due to direct lung and heart manipulation, as well as hilar and lymph node dissection (39,41,42).

We found median operative times for segmentectomies more comparable to lobectomies than to wedge resections. Given the greater anatomic complexity and lymph node dissection associated with segmentectomies, higher postoperative complication rates were anticipated in comparison to wedge resection. However, we found patients in the segmentectomy group had a 72% lower likelihood of experiencing major complications compared to those receiving wedge resections. Although the association did not reach statistical significance, reduced risk associated with segmentectomies was an unexpected finding. This conflicts prior reports, including a recent review by Xiu et al. that observed significantly lowered odds associated with wedge resections as opposed to segmentectomies (26).

Surgical approach was not specified in their analysis of multiple studies. Previous studies traditionally juxtaposed VATS and open approaches, and inclusion of robotic platforms in these comparisons are slowly growing. The robotic system for lung resections is gaining adoption, offering a minimally invasive platform that addresses several technical limitations of conventional VATS (43). These include enhanced three-dimensional visualization, improved instrument articulation, and superior ergonomics, which collectively contribute to more precise dissection, lower conversion rates to thoracotomies, and a greater number of harvested lymph nodes, all believed to enhance patient outcomes (14,15,44,45). The robotic system additionally offers an enhanced view of resection margins that benefits segmentectomies specifically (46). Contrasting with Xiu et al., other studies found segmentectomies had similar long-term outcomes to lobectomies and comparable, if not improved, postoperative results with wedge resections (26-29). Our study supports segmentectomies representing an optimal middle ground for surgical candidates in both short- and long-term trajectories.

Despite longer operative times and higher cumulative complication rates, lobectomies did not experience significantly more life-threatening complications or mortality. This suggests that, when performed robotically, lobectomy remains a safe and effective surgical approach. Additionally, robot-assisted platforms may lend greater advantages and reduced complications following segmentectomies. Furthermore, the low incidence of life-threatening complications such as ARDS, respiratory failure, and absence of ventilatory indications across all procedure types further supports the short-term safety profile of robotic lung resection.

Limitations to this study include its retrospective design and a large percentage of Asian patients limiting generalizability. A predominantly Asian cohort also carried potential to deflate overall complication rates, although this did not impact our adjusted odds of major complications (47). In addition, our outcomes reflect the experience of a single surgeon, which may not accurately represent reproducible outcomes achievable by surgeons of differing levels of experience. This analysis was restricted to early postoperative outcomes and did not assess long-term oncologic metrics such as disease-free or overall survival. Future studies incorporating diverse population data and longer follow-up are needed to validate these findings and assess the broader clinical implications.

Conclusions

As the adoption of robotic-assisted pulmonary resection continues to expand, the need for detailed, procedure-specific outcome data becomes increasingly important. In this large, single-surgeon cohort, patients in the lobar group did not experience significantly greater complications or deaths in the first postoperative month. Segmentectomy demonstrated an improved short-term complication profile to wedge resections, suggesting it may serve as a favorable intermediary option in selected patients. Overall, robotic-assisted lobectomies appear to be a safe and effective surgical modality, with manageable morbidity and mortality.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://vats.amegroups.com/article/view/10.21037/vats-25-43/rc

Data Sharing Statement: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-43/dss

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-25-43/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-25-43/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. This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. The study was approved by the Institutional Review Board of Northwell Health (No. 24-0797). Individual consent for this retrospective study was waived.

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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