A narrative review of minimally invasive pneumonectomy: evolution, evidence, and emerging techniques

Introduction

Lung cancer remains the leading cause of cancer-related mortality in the United States, with over 238,000 new cases diagnosed each year. Approximately 56,000 to 57,000 lung cancer surgeries are performed each year in the United States (1). Pneumonectomy—the surgical removal of an entire lung—is typically reserved for patients with locally or regionally advanced lung cancer or other severe pulmonary diseases (2). However, with significant advances in systemic treatment guided by molecular profiling and genomic testing, coupled with evolution in minimally invasive surgery, parenchymal-sparing techniques, the number of pneumonectomies performed annually continues to decline (3-5).

The field of thoracic surgery has experienced a transformative shift towards minimally invasive approaches, particularly video-assisted thoracoscopic surgery (VATS), which has become the standard minimally invasive technique for lung resection in many centers, and robotic-assisted thoracoscopic surgery (RATS). Among these, robotic platforms have revolutionized lung resection, in part by offering enhanced dexterity, articulation and precision within a magnified, stable three-dimensional environment. Consequently, increasingly complex and advanced lung cancer operations are now being performed using robotic platforms with retrospective data reporting lower conversion rates to thoracotomy as compared to conventional VATS techniques (2,6-9).

Beyond surgical technique, advances in imaging, immunotherapies, treatment planning and monitoring have reshaped multidisciplinary lung cancer management (10,11). These monumental advances in thoracic oncology have led to the decrease in the total amount of pneumonectomies being performed. In patients with stage III non-small cell lung cancer (NSCLC), 18F-fluorodeoxyglucose positron emission tomography-computed tomography (¹⁸F-FDG PET-CT)-based radiotherapy planning has been shown to improve target delineation and potentially reduce radiation exposure to healthy tissues, which enhances local control and treatment precision (12). Such developments highlight the importance of integrating surgical innovation with contemporary imaging and oncologic strategies when evaluating the role of pneumonectomy in the modern era.

Artificial intelligence (AI) has also emerged as a promising adjunct in cardiothoracic surgery. Applications include automated radiologic interpretation, intraoperative navigation, surgical workflow optimization, and outcome prediction models. Recent studies have demonstrated the potential of AI-driven algorithms to assist in preoperative planning, risk stratification, and surgical guidance, offering ways to further refine minimally invasive lung resection and perioperative management (13-16).

The surge of minimally invasive modalities such as VATS and RATS has introduced alternative techniques and controversy in the surgical management of performing a pneumonectomy, which was a procedure which was previously only completed with an open technique. While minimally invasive techniques have demonstrated feasibility in selected cases, questions remain regarding appropriate patient selection, comparative oncologic efficacy, and the reproducibility of outcomes across institutions (17). Prior reviews have largely focused on either technical feasibility or isolated institutional experiences, leaving gaps regarding the changing role of emerging technologies, including robotics and AI, in pneumonectomy (7-9,17).

Therefore, the objective of this narrative review is to examine the evolution of minimally invasive pneumonectomy, synthesize current evidence regarding thoracoscopic and robotic approaches, and discuss perioperative considerations including patient selection, physiologic assessment, anesthetic management, and surgical outcomes. Particular attention is given to emerging techniques, limitations of current evidence, and future directions for research. Cases from our institution were also illustrated in this review. We present this article in accordance with the Narrative Review reporting checklist (available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-55/rc).

Methods

A literature search was conducted in August 2025 to identify studies relevant to minimally invasive pneumonectomy and perioperative management of lung resection. The databases PubMed/MEDLINE, Scopus, and Web of Science were searched using combinations of Medical Subject Headings (MeSH) and free-text terms including “pneumonectomy”, “lung cancer surgery”, “minimally invasive pneumonectomy”, “video-assisted thoracoscopic surgery”, “VATS”, “robotic-assisted thoracic surgery”, “RATS”, “thoracoscopic lung resection”, and “robotic lung surgery”. Additional terms related to perioperative management such as “preoperative assessment”, “physiologic assessment”, “anesthesia”, and “postoperative outcomes” were also used. The search included studies published from January 1990 through August 2025. The inclusion of “older” articles was to outline the evolution of the field and the emergence of minimally invasive pneumonectomy. Reference lists of relevant articles and review papers were manually screened to identify additional publications not captured by the initial database search. Both original research studies and review articles addressing surgical techniques, perioperative considerations, and outcomes of pneumonectomy were included. Studies not relevant to lung resection surgery or not available in English were excluded. The search strategy protocol is summarized in Table 1.

Evolution of the procedure

The history of pneumonectomy dates back to the late 19th century. In 1895, Dr. William Macewen performed what is considered the first pneumonectomy by “shelling out” a lung affected by tuberculosis and bacterial infection—an event that marked a pivotal milestone in the early development of thoracic surgery (18). A few decades later, in 1931, Dr. Rudolph Nissen performed the first “true” anatomical lung removal in a young girl suffering from chronic bronchiectasis. Dr. Nissen employed hilar ligation to devascularize the lung, allowing it to necrose and subsequently slough off (18). One year later, Dr. Cameron Haight replicated and refined this approach by separately ligating two left lobes in a 13-year-old patient (18). During this early period, pneumonectomy was primarily indicated for infectious diseases such as bronchiectasis.

A major turning point occurred in 1933 when Dr. Evarts Graham performed the first pneumonectomy for primary lung cancer (18). The patient’s tumor was localized at the orifice of the left upper lobe bronchus, prompting Dr. Graham to proceed with complete lung removal in order to obtain negative surgical margins. To further address potential residual disease, he implanted radon seeds in the hilar region (2). This operation established the foundation for modern oncologic lung surgery and cemented ‘open’ pneumonectomy as the standard surgical treatment for advanced lung cancer for much of the 20th century. Indeed, pneumonectomy accounted for approximately 30% of all lung resections until the late 20th century.

The advent of minimally invasive surgery in the early 1990s marked another paradigm shift in thoracic surgery. The introduction of VATS initially served diagnostic and supportive roles, such as lysis of adhesions, direct visualization of the thorax, and cancer staging prior to resection. As a result, VATS was initially a diagnostic and supportive tool. However, this changed in 1995 when Craig and Walker reported the case series of first VATS pneumonectomy, four left-sided and two-right sided, performed in patients with centrally located bronchogenic carcinoma invading the hilar region (19). Since then, multiple case reports and small series have documented the feasibility and safety of VATS pneumonectomy across different clinical contexts (20). In 2013, the first single-incision (uniportal) VATS pneumonectomy was reported, further advancing the minimally invasive frontier (20). Over time, the percentage of successful VATS completion increased substantially; one institution reported an improvement from 26% in the first half of the series to 63% in the latter half (20).

Robotic-assisted thoracic surgery (RATS) has since emerged as another significant innovation in minimally invasive pneumonectomy. Shah et al. [2025] queried patients who underwent pneumonectomy using data from the National Cancer Database [2015–2020], and found that short- and long-term survival outcomes were comparable among patients undergoing pneumonectomy via VATS, RATS, or open techniques (21). Although these findings suggest oncologic equivalence, the retrospective design and potential selection bias highlight the need for cautious interpretation of the findings. Over the past 3 decades, thoracic surgery has progressed from isolated case reports to multi-institutional series documenting the safety and feasibility of minimally invasive pneumonectomy, underscoring the remarkable evolution of surgical management in advanced lung cancer.

Preoperative assessment

Pneumonectomy results in profound and potentially life-threatening physiologic alterations; therefore, a meticulous preoperative evaluation is essential to ensure appropriate patient selection and to optimize perioperative and survival outcomes. Notably, the principles of preoperative assessment are largely consistent across open, VATS, and RATS approaches.

Indications and contraindications

The primary indication for pneumonectomy is centrally or locally advanced NSCLC in which an R0 (margin-negative) resection cannot be achieved with parenchymal-sparing techniques such as lobectomy, segmentectomy, or sleeve resection.

Contraindications include inadequate cardiopulmonary reserve, multi-station N2, N3 nodal disease, and tumors that remain unresectable despite pneumonectomy. Relative contraindications include significant comorbidities, contralateral lung compromise, or severe pulmonary hypertension that would preclude adequate postoperative lung function.

Oncologic assessment

Preoperative oncologic evaluation typically begins with contrast-enhanced, high-resolution CT of the chest and upper abdomen, and whole body PET-CT to delineate tumor extent, assess hilar and mediastinal involvement, assess for extrathoracic disease or distant metastasis and determine resectability. Brain magnetic resonance imaging (MRI; with and without contrast) is also obtained to evaluate for brain metastasis in locally advanced lung cancers. In addition to imaging, accurate mediastinal staging is commonly performed using endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) of mediastinal/hilar lymph nodes, endoscopic ultrasound (EUS), or when indicated, cervical mediastinoscopy. Mediastinal staging is a critical component of the staging workup, defining operability and guiding treatment sequencing. In patients with locally advanced disease, neoadjuvant therapy (chemotherapy + immunotherapy, or chemotherapy + radiation) may be employed to improve long-term outcomes (22). Patients who demonstrate no radiologic or clinical evidence of disease progression after induction therapy may become suitable candidates for curative surgery.

Once oncologic candidacy is established, the next step is to assess whether the patient has the physiologic reserve to tolerate a pneumonectomy.

Physiologic assessment

Compared with parenchymal-sparing lung resections, pneumonectomy carries higher morbidity and mortality due to the abrupt and irreversible loss of functional lung parenchyma and the resultant hemodynamic burden on the right ventricle. Pneumonectomy results in a sudden and dramatic reduction in the substantial portion of alveolar capillary surface area for gas exchange and the pulmonary vascular bed. The latter increases right ventricular afterload, which can precipitate right heart strain and failure (23). The resultant hemodynamic stress significantly increases pulmonary vascular resistance and predisposes to right-sided heart failure. The initial evaluation of a patient focuses on performance status, comorbidities, and symptom burden. The Eastern Cooperative Oncology Group (ECOG) scale remains a strong predictor of postoperative outcomes: patients with an ECOG score of 0–1 generally tolerate thoracic surgery well, whereas higher scores correlate with markedly increased perioperative and 1-year mortality (24). Patients should be counseled on smoking cessation at least 4–6 weeks before surgery to optimize pulmonary function and reduce the risk of perioperative respiratory complications.

Pulmonary function testing (PFT) remains the cornerstone of physiologic evaluation. Forced expiratory volume in one second (FEV₁) and diffusing capacity of the lung for carbon monoxide (DLCO) are measured and predicted postoperative (PPO) values are then calculated, based on intended volume of lung resection, to estimate residual lung function. Patients with PPO FEV₁ and DLCO greater than 40% are generally considered acceptable candidates, while those with values below this threshold face a substantially increased risk of perioperative cardiopulmonary complications and mortality.

Functional assessment, such as the 6-minute walk test or stair-climbing assessment, offers simple, practical evaluations of exercise tolerance. When results are equivocal or borderline, cardiopulmonary exercise testing (CPET) with measurement of maximal oxygen consumption (VO₂ max) provides an objective measure of patients’ true physiologic reserve. A VO₂ max >20 mL/kg/min (or >75% predicted) suggest acceptable operative risk, while those with lower VO₂ max need to undergo further preoperative testing in order to adequately risk stratify (25).

For patients with marginal pulmonary reserve, quantitative perfusion scintigraphy, using planar or single-photon emission computed tomography (SPECT), can determine the functional contribution of each lung or lobe to refine risk estimates (26,27). This is particularly valuable in patients with prior lung resections, radiotherapy, or heterogeneous lung parenchymal disease; and especially when pneumonectomy is planned for a large hilar tumor with compressive/invasive effects resulting in mismatched vascular shunting and/or dead space volumes.

Because pneumonectomy imposes significant hemodynamic stress, preoperative cardiac evaluation is critical. All patients should undergo electrocardiography and a comprehensive risk assessment. Echocardiography is recommended for patients with known cardiac disease, pulmonary hypertension, or borderline functional capacity to evaluate right ventricular function and estimate pulmonary pressures. When indicated, additional stress testing or right heart catheterization can further define operative risk. In patients with borderline cardiopulmonary reserve, right heart catheterization with temporary unilateral pulmonary artery occlusion may further refine risk stratification by simulating the hemodynamic effects of pneumonectomy and identifying those at increased risk for postoperative cardiopulmonary complications (28).

Optimal preoperative assessment for pneumonectomy integrates oncologic staging, cardiopulmonary testing, and functional performance evaluation to identify patients who can achieve both complete resection and acceptable postoperative recovery. Advances in imaging, staging techniques, and physiologic risk stratification have refined patient selection and improved perioperative outcomes. Despite these advances, pneumonectomy remains among the most physiologically demanding operations in thoracic surgery, underscoring the need for rigorous preoperative assessment and multidisciplinary evaluation.

Anesthesia considerations

Several key factors such as hemodynamic monitoring, ventilation strategy, fluid balance and cardiac function require meticulous attention to ensure optimal patient outcomes. Patients should have adequate vascular access, including an arterial catheter for accurate hemodynamic monitoring and a central venous catheter for administration of vasopressors, fluids, or blood products as needed. If transfusion becomes necessary, patients should be typed and screened preoperatively, with at least two units of packed red blood cells available.

Following endotracheal intubation, using either a double-lumen endotracheal tube (DLT) or a single-lumen endotracheal tube with a bronchial blocker, flexible fiberoptic bronchoscopy must be performed to confirm correct placement and adequate lung isolation. When isolating the right lung with a DLT for a left pneumonectomy, it is critical to ensure that the takeoff of the right upper lobe bronchus remains unobstructed. Left-sided pneumonectomy requires particular attention to bronchial management, as retraction of the left main bronchus can make creation of a short bronchial stump challenging. To facilitate proximal division of the bronchus, use of a left-sided DLT may be advantageous, with withdrawal of the tube under bronchoscopic guidance until bronchial transection can be performed flush with the carina. If use of a double-lumen tube is technically difficult, a bronchial blocker may serve as an effective alternative.

Once satisfactory lung isolation is achieved, single-lung ventilation should be initiated before incision to assess the patient’s tolerance. Lung-protective ventilation strategies are essential, with tidal volumes of 5–6 mL/kg and a positive end-expiratory pressure (PEEP) of 5 cmH₂O, while maintaining peak airway pressures <35 cmH₂O (29). Patients requiring higher ventilatory pressures are at increased risk for postoperative pneumonectomy-related complications (30).

Prudent fluid management is paramount during pneumonectomy. Intraoperative fluid administration should generally be limited to 1–2 mL/kg/h, with a net positive balance not exceeding 1.5 L in the first 24 hours to minimize postoperative pulmonary complications (29,31). Excessive intraoperative fluid administration, including transfusion of blood products, has been associated with an increased risk of postoperative right-sided heart failure following pneumonectomy (32).

Close communication between the surgical and anesthesia teams is critical during pneumonectomy. Prior to definitively ligating the pulmonary artery, a pulmonary artery test clamp is routinely performed to evaluate for hemodynamic instability. A sudden increase in pulmonary artery pressure can lead to acute right ventricular strain which in turn could cause decreased left ventricular preload and precipitate hypotension. Intraoperative transesophageal echocardiogram (TEE) is a useful adjunct which may provide additional real-time assessment of the cardiac response to single lung ventilation or pulmonary artery clamping, allowing evaluation of right ventricular size, septal position, contractility and pulmonary artery pressures (33). In patients with evidence of right ventricular strain, whether during single lung ventilation or after clamping or dividing the pulmonary artery, inhaled pulmonary vasodilators, such as nitric oxide or inhaled prostacyclin, selectively decrease pulmonary hypertension while preserving systemic vascular resistance (34,35).

The dynamic physiologic alterations that occur during pneumonectomy demand strategic management of the patients’ oxygenation, fluids, and cardiac function relying on close collaboration between the anesthesia and the surgical teams to achieve optimal outcomes.

Outcomes, benefits, and limitations of minimally invasive pneumonectomy

Meaningful assessment of minimally invasive pneumonectomy requires direct comparison with open pneumonectomy to accurately evaluate its outcomes and potential benefits. Hennon et al. [2019] analyzed 4,938 pneumonectomies from 2010–2014 using the National Cancer Database, and they determined that 30-day mortality rates for minimally invasive pneumonectomy and open approaches were 6.8% and 6.7% (P=0.9), respectively (36). Additionally, the 90-day mortality rates for minimally invasive approach and open approach were 12.3% vs. 11.9% (P=0.86), respectively (36). Hennon et al. [2019] also determined that the mean number of lymph nodes examined in the minimally invasive group (17.1±0.4) was higher than the open group (16.1±0.2; P=0.034) (36). Similarly, Shah et al. [2025] also used data from the National Cancer Database from 2015–2020, and they found no difference in 30 day or 90-day mortality rates among VATS, RATS, and open pneumonectomy groups after propensity matching across 3,784 patients (21). In addition, Trope et al. [2025] reviewed 5,750 patients from the National Cancer Database, and they determined that the open pneumonectomy group, minimally invasive pneumonectomy group, and converted groups all had similar 5-year survival rates (45.2%, 48.3%, and 43.3%, respectively) (37). A 2021 propensity-matched study from China also showed no difference in recurrence-free survival or overall survival rates for uniportal VATS versus open pneumonectomy (38).

Perioperative mortality rates of VATS pneumonectomy are also comparable to those of open pneumonectomy. A 2022 Shanghai based study illustrated that no differences were observed with respect to major complication rates and 30-day mortality rates for both the VATS group and the open pneumonectomy group (4). In select circumstances, intraoperative challenges may necessitate conversion from VATS or RATS to an open approach. The Shanghai study also reported that conversion to open thoracotomy during VATS did not worsen 30-day outcomes (4). Likewise, Hennon et al. [2019] also found that successful completion of VATS pneumonectomy did not result in increased complications or perioperative deaths (36). These studies suggest that in well selected patients, minimally invasive pneumonectomy is feasible and can be safely performed, without increasing perioperative morbidity or mortality.

Minimally invasive approaches for pneumonectomy confer potential benefits of decreased postoperative pain and faster recovery owing to smaller incisions (20). Liu et al. [2016] conducted a retrospective study and evaluated 32 VATS pneumonectomies versus 64 open thoracotomies, and they found no difference in hospital length of stay, estimated blood loss, dissected lymph node numbers/stations, and transfusion rates (39). A study by Luo et al. [2022] also discovered that the VATS group had a lower major complication rate in lower-stage tumors resected (7.6%) compared to the open group (20.6%) in pT2 cancers (4). Overall, multiple studies have demonstrated that minimally invasive pneumonectomy yields postoperative outcomes comparable to those of open pneumonectomy, as detailed in Table 2, however, further research is warranted to determine whether minimally invasive pneumonectomy consistently confer superior results.

Despite its advantages, minimally invasive pneumonectomy remains a technically demanding procedure that requires substantial surgeon expertise and experience. Conversion to open surgery from VATS is common, and Shah et al. [2025] found 29.5% of attempted MIS pneumonectomies converted to thoracotomy (21). Additionally, Hennon et al. [2019] conducted a National Cancer Database analysis, and they also reported a 36.7% conversion rate (36). A multicenter 2025 U.S. study by Trope et al. [2025] also reported that 31.6% of minimally invasive attempts needed conversion (37). Trope et al. [2025] also determined that mid-volume centers had a greater risk of conversion than high-volume centers (odds ratio =4.16) while neoadjuvant therapy was associated with lower risk for conversion, likely attributable to being performed at higher volume centers (37). While conversion to open surgery is sometimes necessary, outcomes may be influenced by the circumstances prompting conversion rather than the conversion itself. Trope et al. [2025] highlighted that the median survival years for the conversion is 3.71 while the median survival group for the open group and the minimally invasive pneumonectomy group is 3.85 and 4.84, respectively (37). It is therefore imperative that patients should be carefully selected for minimally invasive surgery based on surgeon’s experience and after various predictors of conversions are carefully assessed. This may help avoid long-term adverse outcomes (37).

Other limitations of minimally invasive pneumonectomy parallel the inherent risks associated with pneumonectomy, including but not limited to, intraoperative blood loss, atrial fibrillation, infectious complications, bronchopleural fistulas, and perioperative mortality (20). These risks may be further accentuated in technically challenging cases, particularly when surgeons encounter large and centrally located tumors involving the hilum, or when central vascular control of the main pulmonary artery is needed (20). Bronchopleural fistula remains one of the most feared complications following pneumonectomy. In one of the largest single institutional study, Luo et al. [2022] reported perioperative outcomes in 583 consecutive pneumonectomy, with observed incidence of bronchopleural fistulas in 16.7% of right-sided VATS cases (vs. 0% left) and 6.5% of right-sided open cases, underscoring the technical as well as anatomic factors predisposing to stump dehiscence (4). Operative duration also represents a well-recognized limitation of minimally invasive techniques; Hennon et al. [2018] reported 187.5 min for VATS vs. 146 min for open surgery (20). Nevertheless, in the same study, Hennon et al. [2018] also emphasized that successful completion of VATS pneumonectomy significantly improved over time from 26% to 63%, reflecting a clear learning curve phenomenon (20). It is reasonable to anticipate that with greater surgeon training and experience in minimally invasive techniques, procedural standardization across multiple institutes, operative efficiency and perioperative outcomes will continue to improve. However, the current body of evidence remains limited and further multicenter studies are needed to better define benefits, risks and long term oncologic and survival outcomes of minimally invasive pneumonectomy.

An important consideration when comparing RATS and VATS is economic feasibility. To date, there are no direct cost analyses specifically comparing RATS and VATS pneumonectomy; however, cost inferences can be drawn from lobectomy data. The available evidence remains heterogeneous. The BRAVO trial, a randomized controlled study, demonstrated no significant difference in overall cost between RATS and VATS when accounting for hospital stay and 90-day readmissions (40). Similarly, retrospective analyses have reported comparable costs between the two approaches (41). In contrast, several systematic reviews and meta-analyses suggest that VATS remains more cost-effective than RATS, largely due to higher operative and equipment-related expenses associated with robotic platforms (42,43). These findings highlight the importance of considering economic factors alongside clinical outcomes when selecting the optimal surgical approach.

Technical approach: an institutional perspective

Robotic right pneumonectomy

To illustrate our institutional approach to robotic-assisted right pneumonectomy, we present the case of a 64-year-old man, an active smoker at diagnosis, with a large right hilar papillary squamous cell carcinoma encasing the bronchus intermedius (Video 1). He initially presented with post-obstructive pneumonia requiring bronchoscopic debulking and stent placement. Mediastinal staging with EBUS-TBNA demonstrated N1 disease, and he completed induction chemoimmunotherapy with carboplatin, paclitaxel, and pembrolizumab. He tolerated therapy well with good functional status (ECOG 0) and remained largely asymptomatic. PFT showed an FEV₁ of 2.1 L (59% predicted) and DLCO of 20.6 mL/min/mmHg (74% predicted). Echocardiography revealed normal right-sided heart function with an ejection fraction of 52%. Post-treatment PET-CT demonstrated persistent right hilar disease without distant metastasis, and repeat EBUS-TBNA was negative for malignancy, confirming the absence of N2 disease. Given these findings, after a multidisciplinary discussion, the decision was made to proceed with a robotic right pneumonectomy.

In the operating room, flexible bronchoscopy confirmed a patent stent in the bronchus intermedius and no involvement of the proximal right mainstem bronchus. After placement in the left lateral decubitus position, robotic ports were inserted along the seventh intercostal space with an assistant port in the ninth space. Upon entering the chest, dense adhesions were encountered requiring a complete decortication before docking. Multiple frozen sections of the adhesions were negative for tumor. These adhesions were gradually taken down using a combination of blunt and cautery dissection, allowing complete mobilization of the lung.

Once the robot was docked, anterior dissection was started. The phrenic nerve was identified and the pericardium appeared free of disease. Along the posterior hilum, a large infrahilar mass was noted to be densely adherent to the esophagus. The inferior pulmonary ligament was divided, and the inferior pulmonary vein was dissected circumferentially. The superior pulmonary vein was then dissected. While mobilizing the lung, a mediastinal lymphadenectomy was completed and frozen section analysis of mediastinal nodes was negative.

During the dissection of the superior pulmonary vein, it became evident that bulky N1 lymphadenopathy encased the truncus anterior and proximal right main pulmonary artery, making extrapericardial control unsafe. For this reason, we proceeded with intrapericardial dissection. The pericardium was opened parallel and lateral to the right phrenic nerve, and the main pulmonary artery was exposed between the superior vena cava (SVC) and ascending aorta. Division of the azygos vein at the confluence with the SVC allowed for improved dissection of the SVC off of the right main pulmonary artery. The pulmonary artery was dissected intrapericardially and after confirming stable hemodynamics with a clamp test, the artery was divided with a vascular stapler. The superior and inferior pulmonary veins were then divided with separate vascular loads.

Dissection along the airway revealed dense tumor adherence to the posterior hilum and azygos vein. The azygos vein was divided again inferiorly and left attached to the specimen. After completing circumferential mobilization, the right mainstem bronchus was divided flush with the carina using a handheld green-load stapler and the bronchial stump was buttressed with the pericardial fat pad. The specimen, including the lung, hilar tumor, and attached azygos segment, was removed in an endoscopic retrieval bag through an enlarged anterior incision.

A 28 Fr chest tube was placed. After undocking, intraoperative esophagogastroduodenoscopy (EGD) was performed to confirm esophageal integrity; no injury was noted. The patient tolerated the procedure well. Final pathology demonstrated an ypT4N1M0 squamous cell carcinoma involving the right and middle lobes, with 2 of 20 lymph nodes positive and all margins negative. Postoperative recovery was unremarkable, and the patient started adjuvant pembrolizumab 6 weeks after surgery.

Robotic left pneumonectomy

To demonstrate our approach to robotic-assisted left pneumonectomy, we describe the case of a 71-year-old woman with a left hilar squamous cell carcinoma obstructing the left lower lobe bronchus. Initial staging with PET-CT revealed no evidence of distant disease. EBUS-TBNA was negative for mediastinal lymph node involvement, and upper endoscopy with EUS showed no esophageal invasion. Transthoracic echocardiography revealed a preserved ejection fraction of 67% with a mildly elevated right ventricular systolic pressure of 41 mmHg, but was otherwise unremarkable. After multidisciplinary discussion, the decision was made to proceed with neoadjuvant chemoimmunotherapy of cisplatin, gemcitabine, and pembrolizumab, to be followed by surgical resection. She tolerated neoadjuvant treatment well and maintained good performance status (ECOG 0).

In the operating room, a DLT was positioned and confirmed with a flexible bronchoscopy. The patient was then placed in the right lateral decubitus position, and robotic ports were inserted along the eighth intercostal space with an assistant port at the tenth space. Upon entering the pleural space, the left lower lobe was found to be adherent both to the chest wall and to the posterior mediastinum. These adhesions were taken down using cautery and bipolar dissection, allowing full mobilization of the lung.

After docking the robot, dissection began anteriorly and posteriorly. The inferior pulmonary ligament was divided, and stations 9 and 7 lymph nodes were removed and the inferior pulmonary vein was circumferentially dissected. The posterior hilum was dissected, and the lung was retracted to expose the aortopulmonary window, allowing visualization of the left main pulmonary artery. The fissure was developed using bipolar cautery and blunt dissection until the interlobar pulmonary artery was clearly identified.

During the anterior hilar dissection, it became evident that the tumor was abutting the superior pulmonary vein, raising concern that a sleeve left lower lobectomy would not yield a negative proximal margin. Given this intraoperative finding, the decision was made to proceed with a left pneumonectomy. The left main pulmonary artery was circumferentially mobilized, and after a brief clamp test confirming hemodynamic stability, it was divided with a vascular stapler. The superior pulmonary vein was then carefully dissected off the pulmonary artery and divided using a robotic vascular stapler, followed by division of the inferior pulmonary vein. Finally, the left mainstem bronchus was divided flush with a handheld green-load stapler and buttressed with the pericardial fat pad. The specimen was then removed in an endoscopic retrieval bag through an enlarged anterior port.

A 28 Fr chest tube was placed toward the apex. The patient tolerated the procedure well and final pathology revealed an ypT2bN1 invasive squamous cell carcinoma with negative margins. The patient recovered uneventfully, returning to an ECOG performance status of 0 at follow-up. Postoperatively, her oncologist started pembrolizumab as part of the adjuvant treatment plan.

Additional technical considerations

The port placement in both right and left pneumonectomies follows the standard placement for robotic resections including wedge, lobectomy, lymphadenectomy, and pneumonectomy with port placement along the 7^th or 8^th intercostal space (44).

It is important to recognize that, in minimally invasive left pneumonectomy, exposure and retraction of the left main bronchus may be challenging, particularly when attempting to create the shortest possible bronchial stump. Appropriate airway management with a left-sided DLT or bronchial blocker is critical to ensure that the proximal left main bronchus is not obstructed prior to dissection. In addition, sharp transection of the main bronchus under direct visualization may further help minimize stump length. Following this, robotic bronchial closure or bronchoplasty may be performed with reinforcement using vascularized tissue such as pericardial fat, thymic tissue, pleura, or intercostal muscle.

Specimen extraction is often a criticism of minimally invasive pneumonectomy, given concerns that a large incision may still be required for removal of the specimen. In our practice, we use a specimen retrieval bag and orient the lung longitudinally, then enlarge one of the robotic port incisions to approximately 5 cm to facilitate extraction. If there is concern for rib fracture during removal, a portion of the rib cephalad to the incision may be sharply resected to allow safe specimen extraction, although this is rarely necessary.

An additional technical consideration applicable to both right- and left-sided pneumonectomy is the use of a balanced chest tube to reduce the risk of post-pneumonectomy pulmonary edema and significant postoperative mediastinal shift. This is routinely employed in our practice.

Strengths and limitations

This review summarizes the evolution of minimally invasive pneumonectomy and the current evidence supporting thoracoscopic and robotic approaches. We critically examined studies comparing minimally invasive pneumonectomy with open pneumonectomy, with particular attention to operative time, blood loss, lymph node harvest, perioperative morbidity, mortality, and oncologic outcomes. Key perioperative considerations were also discussed, and the feasibility of minimally invasive pneumonectomy was illustrated through robotic-assisted cases performed at our institution.

This review has several inherent limitations. Most notably, the available literature lacks high-level evidence, including randomized controlled trials. Such trials would be difficult to conduct given the declining and relatively infrequent use of pneumonectomy in contemporary thoracic surgery. Much of the existing evidence is retrospective and therefore subject to selection bias, particularly because patients selected for minimally invasive pneumonectomy may differ substantially from those undergoing open surgery. In addition, relatively few studies directly compare outcomes between minimally invasive and open pneumonectomy. Consequently, further multicenter studies are needed to better define the safety, benefits, limitations, and long-term oncologic outcomes of minimally invasive pneumonectomy.

Conclusions

Minimally invasive pneumonectomy (VATS/RATS) is a feasible approach for carefully chosen patients with advanced lung cancer. Across numerous reports, it has achieved short- and long-term outcomes equivalent to traditional pneumonectomy. The potential benefits of VATS and RATS (smaller incisions, less pain, quicker recovery, better survival rates) are appealing, but further evidence is needed. The main limitations for VATS and RATS pneumonectomy involve technical difficulty and high conversion risk, illustrating the importance of surgeon experience and patient selection. As techniques and VATS devices improve, minimally invasive pneumonectomy may become safer and more widely incorporated into thoracic surgery. The future of minimally invasive pneumonectomy is promising since the current literature demonstrates that successful completion of VATS and RATS pneumonectomy yields similar outcomes compared to open surgery. Nevertheless, further research is needed to verify the advantages and limitations of minimally invasive pneumonectomy, thereby providing a clearer foundation for its future application.

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-2025-1-55/rc

Peer Review File: Available at https://vats.amegroups.com/article/view/10.21037/vats-2025-1-55/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-2025-1-55/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. Written informed consent was obtained from the patient for publication of this article and accompanying video. A copy of the written consent is available for review by the editorial office of this journal.

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