Robotic-Assisted Thoracic Surgery vs. Video-Assisted Thoracoscopic Surgery in Children: A Systematic Review and Meta-Analysis

Introduction: Robotic-assisted thoracic surgery (RATS) has emerged as an innovative alternative to conventional video-assisted thoracoscopic surgery (VATS) in pediatric patients. Although individual case series have described its feasibility and safety, no systematic synthesis has previously addressed its role in children. Methods: We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines, registered in PROSPERO (CRD420251091235). A comprehensive search of PubMed, CINAHL, Web of Science, and EMBASE was performed to identify studies reporting pediatric RATS. Quality and Risk of bias were assessed using the MINORS and ROBINS-I tools respectively. For the quantitative synthesis, random-effects models meta-analyses were applied with restricted maximum likelihood (REML) estimation, and confidence intervals were adjusted using either the Knapp–Hartung (HKSJ) or the modified Knapp–Hartung (mKH) methods to account for small-sample uncertainty. Results: Thirty-six studies encompassing 936 patients were included; 638 underwent RATS. Reported indications included tracheobronchial procedures, pulmonary resections, congenital diaphragmatic anomalies, mediastinal tumors and thymic disorders. Qualitative synthesis demonstrated high feasibility, versatility across pathologies, and favorable safety, with a 1.8% conversion rate and low complication rates (5.6%). Quantitative synthesis revealed longer operative times for RATS compared to VATS (mean difference 26.4 minutes, 95% CI: 3.26 to 49.47; p=0.04). However, RATS significantly reduced hospital stay (–0.70 days, 95% CI: –1.22 to –0.17; p=0.02) and showed a nonsignificant trend toward shorter chest tube duration. Complication rates did not differ significantly between groups (RR 1.16; 95% CI: 0.83 to 1.63; p=0.39). Conclusions: RATS may be considered as a safe and effective minimally invasive technique for selected pediatric thoracic conditions, offering enhanced precision and versatility. Current evidence, although very limited due to the low number of studies, presents a potentially beneficial profile for RATS, although larger prospective multicenter studies are needed to confirm long-term results and optimize patient selection.