Is RATS Superior to VATS in Thoracic Autonomic Nervous System Surgery?

Technological development in the field of robotics has meant that, in recent years, more and more thoracic surgery departments have adopted this type of approach at the expense of VATS, and today robotic surgery boasts numerous applications in malignant and benign thoracic pathology. Because autonomic nervous system surgery is a high-precision surgery, it is conceivable that the application of RATS could lead to improved outcomes and reduced side effects, but its feasibility has not yet been thoroughly studied. This review identified three main areas of application: (1) standard thoracic sympathectomy, (2) selective procedures, and (3) nerve reconstruction. Regarding standard sympathectomy and its usual areas of application, such as the management of hyperhidrosis and some cardiac and vascular conditions, the use of RATS is almost anecdotal. Instead, its impact can be decisive if we consider selective techniques such as ramicotomy, optimizing selective surgery of the communicating gray branches, which appears to reduce the incidence of compensatory sweating only when performed with the utmost care. Regarding sympathetic nerve reconstruction, there are several studies, although not conclusive, that point to it as a possible solution to reverse surgical nerve interruption. In conclusion, the characteristics of RATS might make it preferable to other techniques and, particularly, VATS, but to date, the data in the literature are too weak to draw any evidence.