Robotic vs. video-assisted thoracoscopic surgery: a retrospective analysis of safety and length of stay during initial implementation of a robotic program

Introduction

Background

Since the early 2000s, robotic-assisted thoracoscopic surgery (RATS) has emerged as a widely adopted alternative surgical approach to video-assisted thoracoscopic surgery (VATS). RATS offers several technical advantages, including three-dimensional visualization, enhanced instrument articulation, and improved surgical ergonomics. However, limitations such as absence of haptic feedback persist (1). As such, there remains clinical equipoise regarding the superior approach to thoracic surgical procedures. Furthermore, the implementation of novel surgical technologies is often associated with a learning curve, during which increased adverse event rates may be observed.

Rationale and knowledge gap

For lung resections, multiple retrospective studies have compared the length of stay (LOS) and adverse events in VATS vs. RATS cohorts in both single- and multi-center contexts internationally. While some studies have demonstrated equivalent morbidity rates in both groups, others have demonstrated improved rates of conversion, LOS, postoperative chest drainage, pain, and cardiac arrhythmia in RATS groups (2-12). A meta-analysis of RCTs comparing RATS and VATS lung resections demonstrated no difference in conversion rates, complications, and LOS. The reported median LOS in these studies ranges from 2 to 11 days (13).

For mediastinal mass resections, multiple retrospective cohort studies suggest a potential decrease in LOS, postoperative chest drainage time, conversions, adverse events, and positive margins in RATS groups (14-16). One meta-analysis of RCTs demonstrated a 0.9-day difference in LOS, favouring RATS. The reported median LOS in these studies was 2–7 days (17). The only study that compares VATS and RATS in the Canadian context, is the RAVAL study, although this data is combined with that of other centers in the U.S. and France. This study demonstrates similar adverse event rates, conversion rates and LOS between groups, reporting a median LOS of 3 days (18).

At our high-volume Canadian thoracic surgery center, a comprehensive enhanced recovery after surgery (ERAS) program has been successfully implemented, resulting in short LOS following VATS mediastinal and lung resections. Essential elements of our ERAS program include preoperative (education by our nurse navigators as well as educational booklets), intraoperative (euvolemic resuscitation, lung-protective ventilation), and postoperative components (early Foley catheter removal, routine physiotherapy evaluation, early mobilization, D50 pleurodesis to prevent prolonged air leak, home care with ambulatory drainage devices for patients with prolonged air leak). Given this optimized baseline performance, previously published RATS vs. VATS studies may not be generalizable to our center.

Objective

Therefore, we sought to examine safety and hospital LOS associated with RATS compared to VATS during the initial implementation of a RATS program at our institution. In a publicly funded healthcare context, such healthcare utilization data are essential to inform evidence-based resource allocation and surgical innovation adoption. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2787/rc).

Methods

This study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments. This study was completed within the framework of quality improvement and was exempted from formal review by the Ontario Health Science Network Research Ethics Board. Informed consent from participants was not required, as de-identified retrospective data was used in this quality improvement study.

Surgical technique

At The Ottawa Hospital, three surgeons began performing RATS for lung and mediastinal mass resections in April 2022, using the Da Vinci Xi robotic surgical system. Two of the surgeons had over a decade of experience performing ~100 minimally invasive lung resections per year, and the third surgeon completed a dedicated robotic fellowship prior to starting the program at our centre. The initial four cases were done with the support of a proctor. The following twenty cases were performed with two surgeons present. Cases were performed in a standardized fashion. For lung cases, the patient was positioned in lateral decubitus position, with four robotic ports in the eighth intercostal space, and one 15 mm assistant port in the tenth intercostal space. Carbon dioxide (CO₂) insufflation was used routinely to enhance visualization. VATS lung resections were completed in both a multiportal and uniportal fashion, depending on surgeon preference. No CO₂ insufflation was used for VATS lung resections. RATS mediastinal resections were performed in the supine position with a roll placed under the patient’s spine, using three robotic ports. VATS mediastinal resections were completed in a multiportal or uniportal subxiphoid fashion depending on the surgeon. The robotic instruments used included the long bipolar cautery, tip up fenestrated grasper, the cadiere forceps, and occasionally, the medium clip applier. No specific criteria were used to select cases for RATS vs. VATS approach: cases were scheduled for the robotic approach by administrators based on robot availability.

Data collection

Data on consecutive VATS and RATS cases completed by three surgeons from April 2022 to November 2024 were extracted from the institution’s electronic medical record. Variables collected included age, sex, Charlson Comorbidity Index (CCI), lung cancer stage, Eastern Cooperative Oncology Group (ECOG) performance status, diffusing capacity of the lungs for carbon monoxide (DLCO), forced expiratory volume in one second (FEV₁), conversion to VATS/open, adverse events (graded according to the Clavien Dindo classification), and surgeon. The proportion of patients with prolonged air leak, specifically, was recorded, with prolonged air leak being defined as air leak >5 days, as per the Society of Thoracic Surgeons General Thoracic Surgery Database definition (19).

Statistical analysis

Median and interquartile ranges (IQR) were calculated for continuous variables, and proportions were calculated for categorical variables. Given that the LOS variable was highly skewed, it was log-transformed, and a multiple linear regression was performed to control for covariates [VATS vs. RATS, procedure (wedge vs. segmentectomy vs. lobectomy), lead surgeon, patient sex, smoking history, conversion status, CCI, age, FEV₁ and DLCO]. Adverse event rates and prolonged air leak rates were compared using the Chi-squared test between RATS and VATS groups.

Results

In the lung resection cohort, there were 119 patients in the RATS group and 390 patients in the VATS group. Demographic characteristics are presented in Table 1. There were more lobectomies compared to wedges in the RATS group. There were also more resections performed for malignancy in the RATS group (93%) vs. the VATS group (87%). The median LOS for RATS lung resection was 3 days (IQR: 1–5 days), and for VATS lung resection was 2 days (IQR: 1–5 days), as displayed in Table 2.

Cases were converted in 11% of RATS cases (9% to VATS, 2% to open), and in 3% of VATS cases. Using the VALT classification (20), the leading reason for conversion in RATS cases was challenging anatomy (n=8), followed by technical factors (n=1), vascular issues (n=2), and lymph node-related factors (n=2). Anatomical challenges included incomplete fissures, dense adhesions, calcified nodes, and fused hilar structures. Technical limitations involved stapler alignment difficulties, robotic arm crowding, and reduced instrument articulation. A small number of cases were converted for efficiency after prolonged dissection. Vascular events included two cases with pulmonary artery injury—both were converted to VATS and controlled successfully with VATS approach. Overall, most RATS conversions were elective and precautionary rather than emergent. In the VATS lung resection cohort, conversions were primarily due to anatomical factors (n=8) or pulmonary artery injury (n=5). Anatomical reasons included difficult fissures, large adherent tumors, and challenging hilar lymph node dissections. All five cases of pulmonary artery injury were converted to thoracotomy and controlled successfully.

Multiple linear regression demonstrated no statistically significant difference between the LOS in VATS and RATS lung resection groups. However, lack of conversion, higher FEV₁, and segmentectomy/wedge resection, significantly predicted decreased LOS. The results of the multiple linear regression are displayed in Figure 1 and Table 3. The rate of adverse events in the RATS group was 29% vs. 39% in the VATS group, which was not statistically significant, χ²[degree of freedom (df) =1, n=509] =3.36, P=0.07. The rate of prolonged air leak was 15% in the RATS group and 17% in the VATS group, χ²(df =1, n=509) =0.23, P=0.63. Specific to lobectomies, there was a trend towards lower prolonged air leak rates in the RATS vs. VATS groups (18 vs. 26%), although this was not statistically significant, χ²(df =1, n=290) =2.18, P=0.14.

Figure 1 Effect of covariates on length of stay in lung resections. CCI, Charlson Comorbidity Index; DLCO, diffusing capacity of the lungs for carbon monoxide; FEV1, forced expiratory volume in one second; VATS, video assisted thoracoscopic surgery.

In the mediastinal resection group, there were 41 RATS patients and 19 VATS patients. Demographic characteristics are presented in Table 4 and were similar between groups. The median LOS for a RATS mediastinal mass resection was 1 day (IQR: 1–2 days), and for a VATS mediastinal mass resection was 2 days (IQR: 2–5 days), as displayed in Table 5. Cases were converted in 10% of RATS cases (8% to VATS, 2% to open), and in 5% of VATS cases. All RATS cases were converted non-urgently, two of which were due to technical factors and two due to anatomical factors (the patient requiring pericardial resection and reconstruction). The VATS case converted to sternotomy was due to anatomical factors. Multiple linear regression demonstrated a statistically significant difference between the LOS in VATS and RATS mediastinal mass resection groups (Figure 2 and Table 6). Lack of conversion and no smoking history also predicted significantly decreased LOS. The rate of adverse events in the RATS group was 29% vs. 26% in the VATS group, which was not statistically significant, χ²(df =1, n=60) =0.00, P>0.99.

Figure 2 Effect of covariates on length of stay in mediastinal mass resections. CCI, Charlson Comorbidity Index; VATS, video assisted thoracoscopic surgery.

Discussion

Key findings

With the growing adoption of RATS over the past two decades, it is essential to evaluate its impact on patient-centered outcomes, particularly during the early phase of implementation. While prior studies have reported equivalent or superior outcomes with RATS compared to VATS, evidence from the Canadian healthcare context remains limited (18,21-23). Importantly, our high-volume center operates within a comprehensive ERAS framework, where baseline morbidity and LOS are already lower than commonly reported in the literature. This context raises a critical question: does the introduction of a novel surgical platform, such as RATS, enhance or compromise these optimized outcomes during its early adoption?

In this study, we demonstrated equivalent LOS and adverse event rates in RATS vs. VATS lung resections, during the initial implementation of RATS at our institution. Our findings provide early evidence that, despite the known learning curve—estimated at 20–60 cases per surgeon—RATS can be implemented without negatively impacting safety or LOS through the framework of proctorship and second surgeon support during initial implementation (24-26). Moreover, although the RATS lobectomy group trended towards a decreased rate of prolonged air leak and adverse events, which may be attributed to improved robotic visualization, this was not statistically significant. This must be further examined with a larger sample size, and as the surgeons surpass their learning curve. Additionally, we demonstrated that RATS decreased LOS by 1 day in mediastinal mass resection cases, even in the context of already short LOS times at baseline. At the same time, we demonstrated similar adverse event rates in both groups.

Strengths and limitations

The limitations of this study include the retrospective, single center nature of the study. As a result, there may have been a selection bias for the types of cases selected for RATS vs. VATS, although the regression analysis controlled for baseline differences in the groups. Additionally, the study sample size is small, which precludes meaningful examination of differences in adverse events. Further, at the time of our study, our surgeons were highly experienced in VATS, but still early in their learning curve for RATS. Consequently, differences in adverse event rates and LOS may change once equivalent proficiency in both approaches is achieved.

Comparison with similar research

Our findings are consistent with previously published literature that has demonstrated RATS to be at least equivalent to VATS in terms of adverse event rates. Previous literature has suggested that RATS lung resections may have a decreased LOS compared to VATS (2-12). However, this was not the case at our institution. This is likely because the reported LOS in the literature for VATS lung resections is wide (2–11 days), whereas our median LOS for a VATS lung resection was already short (median: 2 days, IQR: 1–5 days). Nevertheless, the newly introduced RATS approach was able to match our established LOS outcomes (median: 3 days, IQR: 1–5 days).

For mediastinal resections, our findings confirm a decreased LOS in RATS mediastinal mass resections compared to VATS (from median of 2 days to 1 day), in the context of an already optimized ERAS context. This is consistent with the recent meta-analysis which found a 0.9-day improvement in LOS for the RATS group, although the reported LOS was between 2 and 7 days in these studies (17). This finding has the potential to save as much as $1,600/patient, potentially offsetting the capital costs of RATS, and demonstrates that RATS can further benefit institutions that have already implemented a highly efficient VATS ERAS program (27).

Implications and actions needed

Future work should examine oncologic quality of surgery (e.g., number of lymph node stations examined, disease-free and overall survival), short- and long-term postoperative pain levels, volume and duration of chest drainage, and readmission rates, in these groups. As well, future work may compare patient-important outcomes for the cases performed during and after the learning curve, now that our surgeons have completed their initial 20–60 RATS cases. Ultimately, these results are relevant for informing surgical practice and resource allocation in publicly funded healthcare systems (28).

Conclusions

This study demonstrates that, during the initial adoption of RATS at a Canadian tertiary care center, robotic and video-assisted thoracic surgical approaches were equivalent with respect to safety. In mediastinal cases, RATS was associated with a one-day reduction in LOS. A trend towards lower rates of adverse events and prolonged air leak was observed in the RATS group, though further investigation with larger cohorts is needed to confirm these findings. Ongoing research is warranted to evaluate surgical quality and patient-important outcomes between RATS and VATS within the Canadian healthcare context.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2787/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2787/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2787/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-1-2787/coif). N.A. reports support from the AATS Intuitive Robotics Fellowship funded by Intuitive. P.V. reports receiving payment from Intuitive for a training course and from Stryker for a lecture. The other 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. This study was completed within the framework of quality improvement and was exempted from formal review by the Ontario Health Science Network Research Ethics Board. Informed consent from participants was not required, as de-identified retrospective data was used in this quality improvement study.

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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