Robotic thoracic surgery: what is different in anesthesia?

Robotic-assisted thoracic surgery (RATS) has emerged as a transformative approach in thoracic surgery, enabling enhanced precision and minimally invasive treatment for lung, esophageal, and mediastinal resections. These advances introduce unique anesthetic challenges requiring tailored strategies to ensure patient safety and surgical success.

Key challenges include intrathoracic carbon dioxide insufflation, prolonged one-lung ventilation, and complex positioning. Special considerations apply to high-risk groups such as patients with myasthenia gravis, obesity, and frailty. Advances in anesthetic management include individualized lung isolation with double-lumen tubes or bronchial blockers, protective ventilation with permissive hypercapnia, and restrictive fluid strategies supported by invasive monitoring. Deep neuromuscular blockade is often needed to maintain stability during robotic manipulation. Multimodal regional anesthesia and enhanced recovery after surgery (ERAS) pathways are increasingly applied, improving analgesia, reducing opioid exposure, and facilitating early extubation and mobilization. Novel approaches such as subpleural anesthetic infusion, continuous airway visualization devices, and perioperative artificial intelligence (AI) applications are being explored.

RATS present distinct anesthetic challenges and opportunities. Integration of tailored airway and ventilation strategies, vigilant hemodynamic management, regional analgesia, and ERAS principles is essential. Future priorities include AI-supported monitoring, simulation-based training, and global consensus frameworks to standardize anesthetic practice.