Is robotic thoracic surgery associated with lower postoperative pain after lung cancer resection? A systematic review and meta-analysis of pain trajectories and recovery

Abstract

Background
This study aimed to evaluate postoperative pain evolution and perioperative rehabilitation in patients undergoing multiportal robotic-assisted thoracic surgery (RATS) versus video-assisted thoracic surgery (VATS) for lung cancer. The primary focus was to delineate the impact of these two surgical modalities on recovery trajectories.


Main body of the abstract

We systematically queried PubMed, Embase, Web of Science, and the Cochrane Library through January 2026. Adhering to PRISMA 2020 criteria, 18 studies (
N
 = 2,940) comparing multiportal RATS versus VATS were identified. The primary endpoint was acute pain intensity on postoperative day (POD) 1. Secondary metrics encompassed extended pain evolution (from POD 3 to discharge), drainage duration, postoperative morbidity, and length of stay. Data synthesis was performed using a random-effects model. Evidence certainty was assessed via the GRADE framework. No significant difference was observed in the primary pooled analysis of POD 1 pain (mean difference [MD]: 0.09; 95% CI: -0.62 to 0.79;
P
 = 0.81), which remained non-significant after sensitivity adjustment (MD: 0.00; 95% CI: -0.34 to 0.35;
P
 = 0.98). RATS also demonstrated comparable extended pain intensity from POD 3 onwards (MD: -0.11; 95% CI: -0.47 to 0.25;
P
 = 0.54). RATS exhibited a non-significant trend toward shorter drainage periods initially (MD: -0.29 days; 95% CI: -0.59 to 0.02;
P
 = 0.06), which became statistically significant after sensitivity adjustment for outlier exclusion (MD: -0.41 days; 95% CI: -0.63 to -0.18;
P
 = 0.0005). Furthermore, RATS significantly reduced length of stay (MD: -0.84 days; 95% CI: -1.06 to -0.63;
P
 < 0.00001). The incidence of overall morbidity was statistically comparable between both cohorts (risk ratio [RR]: 0.88; 95% CI: 0.74 to 1.04;
P
 = 0.13).



Short conclusion
Multiportal RATS achieved equivalent postoperative pain control at POD 1 compared to multiportal VATS, though clinical recovery efficiency proved superior. These advantages likely stem from technical precision and earlier tube removal. However, due to the predominance of retrospective data, these findings are underpinned by very low evidence certainty.