Rethinking Postoperative Pain in the Era of Robotic Thoracic Surgery: A Surgeon’s Perspective on Functional Recovery and Potential Oncologic Implications

Persistent postoperative pain remains an incompletely resolved problem after minimally invasive thoracic surgery, despite expectations that robot-assisted thoracic surgery (RATS) would meaningfully outperform video-assisted thoracoscopic surgery (VATS) in analgesia. This narrative review synthesizes evidence from randomized trials, cohort studies, and meta-analyses comparing acute and chronic pain outcomes between VATS and RATS, examines mechanisms and surgically modifiable risk factors underlying intercostal nerve injury and pain chronification, and evaluates the emerging concept of Return to Intended Oncologic Treatment (RIOT) as a perioperative endpoint linking pain control to oncologic recovery. Across randomized and propensity-matched comparisons, RATS has generally failed to demonstrate superior pain outcomes relative to VATS, and several studies suggest multiport robotic platforms may produce greater early pain than uniportal thoracoscopic approaches. Port number, operative time, and drainage duration emerge as modifiable surgical predictors of chronic pain, while inadequately controlled acute pain compromises functional recovery and is associated with delayed RIOT; direct evidence that pain independently influences RIOT or long-term survival remains limited, and this link should currently be regarded as a plausible, testable hypothesis rather than an established causal pathway. We conclude that, on the comparative evidence available to date, robotic instrumentation has not shown a consistent, clinically meaningful reduction in pain burden relative to VATS, and that pain management should be reframed as a shared surgical-anesthetic target relevant to oncologic recovery rather than a comfort-oriented endpoint alone. Emerging robotic platforms warrant evaluation against this expanded outcome set.