Management of serious complications in robotic-assisted thoracoscopic surgery

Background: Numerous studies have shown robotic-assisted thoracoscopic surgery (RATS) to be a safe alternative to video-assisted thoracoscopic surgery, and its use has been widely adopted and continues to increase. However, there are a number of potential serious complications that necessitate conversion to thoracotomy. We reviewed our experience with the management and outcomes of such complications in a high-volume robotic center. Methods: We performed a retrospective review of all major robotic resections (single surgeon, single center) performed between May 2018 and June 2025. Serious complications were defined as any major vascular or bronchial injury, erroneous transection, and any other event resulting in an extra procedure beyond the planned operation. Results: Between May 2018 and June 2025, a total of 1480 major RATS cases were performed. We identified 25 serious complications (17 intraoperative and 8 postoperative). Intraoperative complications included 13 major vascular injuries (including 1 transection of the main pulmonary artery requiring an arterial sleeve), 1 cardiac injury, and 3 bronchial injuries (1 occurring during intubation). Interestingly, these resulted in only 10 (59%) conversions to open surgery, with the rest managed robotically. There were no intraoperative deaths and 2 in-hospital deaths among patients with serious complications. Conclusions: RATS is safe and the risk of serious complications is low, and these complications do not always necessitate conversion. However, vigilance, understanding, and preparation for potential complications are key for surgeons as well as the entire robotic theater team. This ensures that complications can be dealt with efficiently and decisively, enhancing patient safety and optimizing surgical outcomes.