Impact of Targeted Perioperative Rehabilitation on Neuromuscular Recovery after Minimally Invasive Thoracic Surgery: A Comparison of UVATS and RATS

Abstract

Starting point: Minimally invasive thoracic surgical approaches currently represent the standard method of surgical treatment in thoracic surgery. Uniportal video-assisted thoracoscopy (UVATS) and robot-assisted thoracic surgery (RATS) provide, in comparison with open approaches, lower surgical trauma, less postoperative pain, shorter hospitalization, and faster recovery. Despite these benefits, the area of postoperative functional and neuromuscular recovery after minimally invasive thoracic surgery remains insufficiently explored. Data are particularly limited regarding how individual surgical approaches influence the function of the chest wall muscles and what significance targeted rehabilitation has in this process. The aim of this study was to objectively evaluate and compare the effect of targeted rehabilitation on postoperative recovery after minimally invasive thoracic surgery, specifically after uniportal video-assisted thoracic surgery (UVATS) and robot-assisted thoracic surgery (RATS), using objective measurements of muscle strength and the electrical activity of selected chest wall muscles. In parallel, a standardized educational and rehabilitation program was developed and clinically implemented.

Methods: A prospective clinical study was conducted at thoracic surgery deparment, Jessenius Faculty of Medicine, Comenius University and Martin university hospital, between 2024 and 2025. A total of 25 patients undergoing minimally invasive surgery were included in the study, of whom 12 patients were in the RATS group and 13 patients in the UVATS group. The final analyzed cohort consisted of 17 patients. Within the study, a standardized rehabilitation program was developed and implemented, consisting of preoperative education, an individual session with a physiotherapist, an instructional video, a mobile application, and a unified rehabilitation protocol. Electrical activity of the m. serratus anterior and m. latissimus dorsi was measured using surface electromyography, and muscle strength was assessed using a dynamometer. Measurements were performed preoperatively (M1), postoperatively before discharge (M2), and four weeks after surgery (M3), on both the operated and non-operated sides. Electromyographic signals were processed and normalized to the maximal voluntary contraction of the respective muscle. To assess asymmetry of muscle strength between the operated and non-operated sides, the Peak Force %Diff parameter was used. Statistical analysis included the calculation of basic descriptive characteristics and the use of parametric or non- parametric tests according to the distribution of the data. The level of statistical significance was set at p < 0.05.

Results: In the UVATS group, a more favorable trend of early functional recovery was observed compared to the RATS group. In the evaluation of maximal muscle strength, the UVATS group showed a return to preoperative values, or a slight exceedance of these values, following a transient postoperative decline, whereas in the RATS group a postoperative deficit persisted even after four weeks. The most pronounced and statistically significant differences were observed in the evaluation of lateral muscle strength asymmetry, where the UVATS group achieved a faster return to muscle symmetry between the operated and non-operated side. RMS values (root mean square, the mean quadratic value of the EMG signal) demonstrated a postoperative increasing trend in both groups, with a more pronounced increase in electrical activity observed in the UVATS group. On the non-operated side, an increase in RMS values was recorded, which may indicate contralateral neuromuscular adaptive mechanisms. However, several observed trends did not reach statistical significance.

Conclusions: The presented study supports the importance of structured perioperative rehabilitation and prehabilitation as an integral part of modern thoracic surgical care. The combination of a minimally invasive surgical approach, objective functional assessment using dynamometry and surface electromyography, and targeted rehabilitation represents a promising approach to optimizing early postoperative recovery. The obtained results suggest that UVATS may be associated with a more favorable profile of neuromuscular recovery in the early postoperative period compared to RATS; however, definitive confirmation of this conclusion requires further research.