Robotic-assisted thoracic surgery in children: A systematic review and meta-analysis

Robot-assisted thoracic surgery (RATS) has emerged as an innovative alternative to conventional video-assisted thoracoscopic surgery (VATS) in pediatric patients. Although individual case series have described its feasibility and safety, no systematic synthesis has previously addressed its role in children.

We conducted a systematic review and meta-analysis in accordance with PRISMA guidelines, registered in PROSPERO (CRD420251091235). A comprehensive search of PubMed, CINAHL, Web of Science, and EMBASE was performed to identify studies reporting pediatric RATS. For the quantitative synthesis, random-effects meta-analyses were applied with restricted maximum likelihood (REML) estimation, and confidence intervals were adjusted using either the Knapp-Hartung (HKSJ) or modified Knapp-Hartung (mKH) methods to account for small-sample uncertainty.

Thirty-six studies encompassing 936 patients were included; 638 underwent RATS. Indications included tracheobronchial procedures, pulmonary resections, diaphragmatic anomalies, mediastinal tumors, and thymic disorders. Qualitative synthesis demonstrated high feasibility, versatility, and favorable safety, with a 1.8 % conversion rate and complication rates of 5.6 %. Quantitative synthesis included 4 studies comparing pulmonary resections, and revealed longer operative times for RATS compared to VATS (mean difference 26.4 min, 95 % CI: 3.26 to 49.47; p = 0.04). However, RATS significantly reduced hospital stay (-0.70 days, 95 % CI: -1.22 to -0.17; p = 0.02) and showed a nonsignificant trend toward shorter chest tube duration. Complication rates did not differ significantly between groups (RR 1.16; 95 % CI: 0.83 to 1.63; p = 0.39).

RATS may be considered a safe and effective minimally invasive technique for selected pediatric thoracic conditions, offering enhanced precision and versatility. Current evidence, although limited by the small number of studies, suggests a potentially beneficial profile for RATS. Larger prospective multicenter studies are needed to confirm long-term results and optimize patient selection.