Feasibility of Minimally Invasive Surgery After Chemo-Immunotherapy in Locally Advanced and Oligometastatic NSCLC: Technical Aspects and Surgical Outcomes

Background: In patients with non-small cell lung cancer (NSCLC) treated with neoadjuvant chemo-immunotherapy, pulmonary resection can be technically demanding because of hilar/mediastinal inflammation and fibrosis, potentially limiting the use of minimally invasive surgery (MIS). We report our single-center experience with MIS anatomical lung resections after neoadjuvant chemo-immunotherapy. Methods: We retrospectively collected consecutive NSCLC patients who underwent neoadjuvant chemo-immunotherapy followed by anatomical lung resection with an intended MIS approach at our institution between May 2018 and October 2025. Primary endpoints were feasibility and safety (conversion rate, intraoperative and postoperative complications, need for reoperation, and 30-day mortality). Results: Fifty-two patients were included. Mean age was 65.9 ± 8.6 years; 27 (51.9%) were male. Median Charlson Comorbidity Index was 3 (IQR 2–4). Most patients had clinical stage III disease (IIIA 40.4%, IIIB 30.8%). Conversion to open surgery occurred in 7 cases (13.5%). One intraoperative complication was recorded (1.9%). Anatomical resections were predominantly lobectomies (including combined/extended lobectomies) (88.4%); sleeve resections accounted for 11.5%, and bilobectomy for 7.7%. Postoperative complications occurred in 13 patients (25.0%); reoperation for complications was required in 1 case (1.9%). No deaths were recorded in the dataset. Pathological response showed pCR in 22 patients (42.3%) and MPR in 10 (19.2%). Conclusion: In our experience, minimally invasive anatomical lung resection after neoadjuvant chemo-immunotherapy for NSCLC is feasible, with an acceptable conversion rate and manageable morbidity, and is associated with a substantial rate of pathological response. Careful patient selection and surgical expertise remain essential.