Analgesic Management of Robot-Assisted Surgery for Mediastinal Tumors: A Review of Pain Mechanisms, Regional Anesthesia, and Multimodal Analgesia

Background: Robot-assisted thoracic surgery (RATS) for mediastinal tumors is a minimally invasive approach that offers three-dimensional magnified visualization, tremor filtration, and articulated instruments. Although it is expected to reduce postoperative pain compared with open surgery, pain may still arise from intercostal ports, subxiphoid incisions and chest tubes. Therefore, a consistent multimodal analgesic strategy is needed from the intraoperative to the postoperative period, tailored to the surgical approach and port placement. Objective: This review aims to characterize the mechanisms underlying postoperative pain after RATS for mediastinal tumors and to examine the current evidence and clinical indications for systemic analgesics and regional analgesic techniques, including thoracic epidural analgesia (TEA), peripheral nerve blocks, and local wound infiltration. Conclusions: Routine use of TEA may not be necessary for all patients undergoing RATS for medi-astinal tumors. In most cases, a multimodal analgesic regimen based on acetaminophen, nonsteroidal anti-inflammatory drugs, or cyclooxygenase-2 selective inhibitors, supplemented with a single-shot regional block or local wound infiltration according to the surgical approach and port placement, appears reasonable. However, individualized analgesic strategies incorporating continuous regional analgesia should be considered in patients undergoing extensive thymectomy, those requiring ports across multiple intercostal spaces, those at risk of conversion to open surgery, and those with severe preoperative pain or an increased risk of chronic postoperative pain.