Non-intubated awake versus intubated anesthesia for uniportal video-asssisted thoracoscopic surgery: a systematic review and meta-analysis

Abstract Background Uniportal video-assisted thoracoscopic surgery (uniVATS) minimizes surgical trauma while maintaining efficacy. Although traditionally performed under intubated general anesthesia, non-intubated awake techniques may reduce airway complications and enhance recovery. This systematic review and meta-analysis compared perioperative outcomes between non-intubated awake and intubated anesthesia in adult uniVATS. Following PRISMA 2020, PubMed, Web of Science, Scopus, Ovid, and Cochrane Library were searched on 16 December 2025. Eligible studies compared non-intubated awake with intubated general anesthesia in uniVATS patients and reported perioperative or postoperative outcomes. Two reviewers independently screened studies, extracted data, and assessed quality using RoB 2 for randomized controlled trials and the Newcastle–Ottawa Scale for observational studies. Meta-analyses were conducted using RevMan 5.4 and R with random-effects and fixed-effects models. Heterogeneity was assessed by I². Effect estimates was expressed as risk ratio (RR) or mean difference (MD) with 95% confidence interval (95% CI). Results Fourteen studies (6 randomized controlled trials and 8 observational) including 2,054 patients were analyzed. Pooled analysis of 7 studies showed that non-intubated anesthesia significantly reduced total postoperative complications (RR = 0.47, 95% CI 0.32–0.69, P = 0.0001, I² = 0%), postoperative pulmonary complications (RR = 0.49, 95% CI 0.34–0.69, P < 0.0001, I² = 0%), and mortality (RR = 0.21, 95% CI 0.07–0.66, P = 0.007, I² = 0%). Secondary outcomes significantly favoring non-intubated anesthesia included shorter chest tube duration (MD = − 0.41 days, I² = 0%), reduced awakening time (MD = − 5.44 min, I² = 60%), and lower sore throat frequency (RR = 0.31, I² = 78%). Intraoperative hypoxemia had a borderline non-significant increase with non-intubated anesthesia (RR = 1.92, P = 0.05, I² = 19%). Non-significant outcomes comprised Operative and anesthetic durations, postoperative pain, hospital length of stay, procedure-related cost, patient satisfaction, and re-operation rates. showed extreme heterogeneity with inconsistent direction of effect. Sensitivity analyses confirmed robust findings for primary outcomes though mortality was influenced by a single study. Subgroup analyses by study design and procedure type consistently favored non-intubated anesthesia without significant heterogeneity. Conclusions Non-intubated uniVATS reduces postoperative morbidity; however, recovery benefits remain uncertain, supporting its use in appropriately selected patients.