Abstract
In resectable non-small cell lung cancer (NSCLC), a minimally invasive surgical approach is considered standard. Robotic-assisted thoracic surgery (RATS) and video-assisted thoracoscopic surgery (VATS) are two such approaches that have demonstrated comparable clinical outcomes on conventional postoperative endpoints. Potential differences in perioperative biological surgical stress remain incompletely characterized. Acute-phase inflammatory biomarkers may provide objective insight beyond conventional postoperative endpoints. We performed a single-center retrospective cohort study of patients with NSCLC undergoing minimally invasive pulmonary resection. Paired preoperative and early postoperative (48 h) inflammatory markers were analyzed. The primary endpoints were perioperative changes in C-reactive protein (CRP) and in the CRP-to-albumin ratio (CAR). Secondary endpoints included postoperative complications, persistent air leak, and hospital length of stay (LOS). Associations between changes in inflammatory markers and clinical outcomes were evaluated using multivariable analyses. A total of 137 patients were included, with complete paired inflammatory data available for 112 patients (RATS n = 52; VATS n = 60). Patients who underwent RATS had significantly smaller postoperative increases in CRP and CAR than patients who underwent VATS (median ΔCRP: 2.79 vs. 4.99 mg/dL, p = 0.005; median ΔCAR: 0.64 vs. 1.11, p = 0.004). This occurred despite significantly greater intraoperative blood loss, longer surgical time, and a higher incidence of systematic lymphadenectomy in the RATS group. These associations remained significant, and their magnitude increased, after adjustment for intraoperative blood loss, surgical time, and number of dissected lymph nodes, and persisted in a sensitivity analysis restricted to anatomical resections. Surgical approach was not independently associated with postoperative complications or LOS, but greater perioperative increases in CRP and CAR were significantly associated with prolonged LOS. The early postoperative acute-phase inflammatory response was significantly less pronounced following RATS than VATS, independently of measured indicators of surgical invasiveness and despite more extensive lymphadenectomy in the RATS group. Perioperative trajectories of CRP-based indices, particularly CAR, may serve as sensitive markers of biological surgical stress beyond conventional clinical endpoints.