From VATS to RATS: Extending Minimally Invasive Approaches to Advanced and Complex Lung Cancer Resections

Abstract Background Minimally invasive techniques have become central to the surgical management of non-small cell lung cancer (NSCLC). While video-assisted thoracoscopic surgery (VATS) is well established, robotic-assisted thoracic surgery (RATS) has emerged as a complementary platform with potential advantages in complex anatomical resections. Aims This study aims to report the impact of implementing a comprehensive RATS program in a high-volume single-center setting, focusing on the changes in surgical approach, perioperative outcomes, and the feasibility of minimally invasive surgery for complex cases. Methods Consecutive patients undergoing anatomical pulmonary resections for primary lung cancer or pulmonary metastases were analyzed across two periods: a pre-RATS era (two years prior to RATS introduction) and a RATS era (two years after implementation). Surgeons were experienced in VATS before transitioning to RATS. Cohorts were propensity-matched for age, sex, and oncological stage. Primary endpoints included surgical approach, perioperative outcomes, and feasibility of minimally invasive surgery in complex cases (post-induction therapy, sleeve resections). Results A total of 873 patients were included (pre-RATS: n=448; RATS era: n=425). Case mix and procedural distribution were comparable between groups. Following RATS implementation, the proportion of open resections significantly decreased (21.9% vs 12.7%, p0.001), as did conversion rates (3.9% vs 3.0%, p=0.025). Minimally invasive surgery was increasingly feasible after induction therapy (31.7% vs 63.3%, p=0.005) and for sleeve lobectomies (18% vs 43%, p=0.011). Operative time and postoperative outcomes, including length of stay, drainage duration, and complication rates, were similar between groups. Conclusion Implementation of a RATS program in a high-volume center is safe and effective and is associated with reduced thoracotomy rates. Importantly, RATS facilitates the extension of minimally invasive approaches to more complex and locally advanced lung cancer resections, supporting its role in the modern multimodal treatment era.