Robotic thoracic surgery: association between operative time and complications in 454 patients

The relationship between operative time and postoperative complications in robotic-assisted thoracic surgery (RATS) remains unclear. This study analyzes that association, focusing on prolonged air leak (PAL) and other early complications.

A retrospective observational study was conducted on 454 consecutive patients with non-small cell lung cancer who underwent robotic-assisted anatomical pulmonary resection between 2019 and 2024. The association between operative time and the incidence of PAL was evaluated, as well as other postoperative complications within the first 30 days. We applied a logistic regression model adjusted for age, BMI, FEV₁, DLCO, smoking status, neoadjuvant therapy, tumor size and type of resection, assessing its discriminative ability using pseudo R² and ROC curve analysis.

The incidence of PAL was 33.3%. Operative time was longer in PAL cases (210 vs 190 min; Mann-Whitney P = .006). In the multivariable model, operative time was not an independent predictor of PAL (OR 1.003 per min; P = .081), whereas higher BMI was protective (OR 0.935; P = .007) and FEV₁ showed a borderline protective association (OR 0.989; P = .059); segmentectomy had lower odds than lobectomy (OR 0.379; P = .006). Model performance was AUC = 0.676 with Nagelkerke's R² = 0.105. Weak correlations were observed between operative time and respiratory failure, reoperation, and readmission. No differences in PAL or other complications were found according to the number of ports used (uniportal, biportal, multiportal).

In RATS, operative time appears to be a surrogate of case complexity rather than a stand-alone target. Prevention of PAL should prioritize modifiable technical and perioperative factors and preoperative optimization within ERAS pathways, supported by a multifactorial risk assessment approach.