Non-intubated robot-assisted anatomic lung resection under spontaneous ventilation: a single center initial experience

Abstract Background Non-tracheally intubated (NTI) robot-assisted thoracic surgery (RATS) for lung cancer resection has been only anecdotally reported, and evidence regarding feasibility is still lacking. This study aims at evaluating feasibility of NTI-RATS anatomic lung resection for early-stage lung cancer. Results This retrospective single-institution feasibility study of prospectively collected data included patients undergoing anatomic NTI-RATS lung resections. The study was approved by our institutional ethical committee. All procedures included careful patient selection, thoracic epidural anesthesia, temporary phrenic and vagal nerve blocks and 4-port RATS approach. Feasibility was defined as the possibility to accomplish the whole procedure by RATS without need of conversion to open-surgery or trachealintubation with double lumen intubation according to predefined criteria. Perioperative blood gases and cerebral oxygen saturation were evaluated at predefined time points whereas recovery time was calculated according to standardized criteria. Post-operative protocol allowed to start feeding and mobilizing within 4 h after surgery. Between January and July 2026, 15 consecutive NTI-RATS anatomic lung resections were performed (12 lobectomies and 3 segmentectomies) with only one conversion to general anesthesia due to excessive mediastinal movement. We documented a median intra-operative PaCO₂ increment (+56.1% p<0.001), which returned close to baseline values 30 minutes after awakening. No patient met the criteria for cerebral desaturation throughout the procedure despite a slight median decrement (-10.1%, p<0.001) at the onset of surgical pneumothorax. Resection with free margins was achieved in all cases. Early feeding and mobilization were possible in all instances. There was no 30-day mortality and only one minor postoperative morbidity due to atrial fibrillation. Conclusions NTI-RATS anatomic lung resection proved feasible in the vast majority (93.3%, 14/15, 95% confidence interval 68.1%-99.8%) in a highly selected population of patients with early-stage NSCLC.