Complex lung segmentectomy: comparative perioperative outcomes of robotic and video-assisted approaches

Segmentectomy is the standard treatment for small peripheral non-small cell lung cancer. While video-assisted thoracoscopic surgery (VATS) and robot-assisted thoracic surgery (RATS) are widely used, evidence focusing on complex segmentectomy (CS) is limited. Therefore, we aimed to compare the perioperative outcomes of VATS and RATS for segmentectomy, focusing on CS. We retrospectively reviewed 497 segmentectomies performed at Shinshu University Hospital (January 2020 and February 2025). After excluding cases of thoracotomy, benign tumors, and prior lung resection, 391 patients (268 CS) were included. Propensity score matching (PSM) generated 159 VATS–RATS pairs for all segmentectomies and 99 pairs for CS. The perioperative outcomes and complications were compared. For all segmentectomies, the operative time was longer with RATS (median, 219 vs. 192 min; p < 0.001), whereas blood loss, drainage duration, length of stay, reoperation, and readmission were comparable. Although not significantly different, arrhythmia incidence was less frequent in the RATS group after PSM (1.9% vs. 5.7%; p = 0.077). In CS, RATS had longer operative time (220 vs. 189 min; p < 0.001) but fewer Clavien–Dindo grade ≥ 2 complications (10.1% vs. 20.2%; p = 0.047) and arrhythmia incidences (1.0% vs. 7.1%; p = 0.030). No 90-day mortalities were observed. Despite longer operative times, RATS achieved perioperative outcomes comparable to VATS and was associated with a lower incidence of postoperative arrhythmia, particularly in CS, potentially related to a reduced extent of lung resection.