Perioperative analgesic strategies for video-assisted thoracoscopic lobectomy: a systematic review and meta-analysis

Abstract

Background

Video-assisted thoracoscopic surgery (VATS) lobectomy is the standard of care for early-stage lung cancer, yet 20–30% of patients still experience moderate-to-severe acute postoperative pain. A wide range of perioperative analgesic strategies—regional blocks, systemic adjuncts, cryoanalgesia, and multimodal combinations—have been evaluated, but their comparative effects on clinically meaningful endpoints such as postoperative complications remain uncertain. The aim of this systematic review and meta-analysis was to evaluate the comparative efficacy and safety of perioperative analgesic strategies for VATS lobectomy.

Methods

We conducted a systematic review and meta-analysis of randomised controlled trials (RCTs) (PROSPERO CRD420251186565), following the PRISMA 2020 statement. PubMed/MEDLINE and Web of Science Core Collection were searched from 1 January 2010 to 26 June 2026. Two reviewers independently screened records, extracted data, and assessed risk of bias using the Cochrane Risk of Bias 2 (RoB 2) tool per outcome. Postoperative complications were pooled as risk ratios (RR) with 95% confidence intervals (CIs) using a random-effects model with restricted maximum-likelihood (REML) estimation. Studies were grouped by intervention type for subgroup analysis. Sensitivity was assessed with leave-one-out analysis.

Results

Seven trials (n=505) met inclusion criteria. The evidence base was clinically heterogeneous: included comparisons encompassed regional technique variations [paravertebral block (PVB), serratus anterior plane block (SAPB), intercostal nerve block (ICNB), and their combinations], systemic adjunctive analgesics (nefopam), and intercostal cryoanalgesia. Only three trials reported usable complication data for quantitative synthesis (n=245). The overall pooled RR for postoperative complications was 0.84 (95% CI: 0.65–1.08; P=0.18), but this estimate was dominated by a single trial (Koliakos 2025, 75.2% weight). Between-study heterogeneity was absent (I²=0%, τ²=0; Q=0.39, df =2, P=0.82). Subgroup analyses by intervention class (regional techniques, systemic adjuncts, cryoanalgesia) did not yield statistically significant pooled estimates. Leave-one-out exclusion of the largest study shifted the point estimate to RR 0.95 (95% CI: 0.57–1.58), confirming strong dependence on a single trial. With fewer than 10 studies, formal publication bias assessment was not performed.

Conclusions

The available evidence on perioperative analgesic strategies for VATS lobectomy consists of small, heterogeneous trials comparing diverse interventions. No single strategy has been shown to consistently reduce postoperative complications. The evidence base is insufficient to guide clinical practice. Adequately powered, multicentre RCTs with standardised interventions, composite complication endpoints, and extended follow-up are needed.

Highlight box.

Key findings

• Seven randomised trials (n=505) evaluating diverse perioperative analgesic strategies for video-assisted thoracoscopic surgery (VATS) lobectomy were identified; only three contributed usable complication data for quantitative synthesis (n=245).

• The pooled risk ratio for postoperative complications was 0.84 (95% confidence interval: 0.65–1.08), but the estimate was dominated by a single large trial (75.2% weight).

• Subgroup analyses by intervention class (regional techniques, systemic adjuncts, cryoanalgesia) did not produce statistically significant results.

What is known and what is new?

• Regional analgesic techniques and multimodal analgesia regimens are widely used after VATS lobectomy, but their comparative effectiveness for clinically important endpoints such as postoperative complications is unclear.

• This is the first PROSPERO-registered systematic review restricted to randomised controlled trials (RCTs) of perioperative analgesic strategies specifically in VATS lobectomy. It demonstrates that the current evidence base is small, clinically heterogeneous, and dominated by a single trial, precluding firm conclusions about any specific strategy.

What is the implication, and what should change now?

• Current evidence does not support preferential use of one analgesic strategy over another for reducing complications after VATS lobectomy.

• Future research should focus on adequately powered, multicentre RCTs with standardised interventions, pre-specified composite complication endpoints, and follow-up of at least 3 months to assess both acute and chronic outcomes.

Introduction

Postoperative pain management remains a significant challenge in thoracic surgery. Despite the widespread adoption of video-assisted thoracoscopic surgery (VATS), which has reduced surgical trauma compared with thoracotomy, approximately 20% to 30% of patients still experience moderate-to-severe acute pain after VATS lobectomy (1). Inadequate pain control is associated with pulmonary complications, delayed mobilisation, prolonged hospital stay, and the development of chronic post-thoracotomy pain (2,3).

A diverse array of perioperative analgesic strategies is used in clinical practice, including regional anaesthetic techniques [thoracic epidural, paravertebral block (PVB), serratus anterior plane block (SAPB), erector spinae plane block, intercostal nerve block (ICNB)], systemic non-opioid analgesics [acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), nefopam, gabapentinoids, dexmedetomidine], intercostal cryoanalgesia, and various combinations of these approaches in multimodal regimens (4,5). Opioid-centred regimens have increasingly been replaced by opioid-sparing strategies as part of enhanced recovery after surgery (ERAS) pathways (6).

However, the optimal analgesic strategy for VATS lobectomy remains uncertain. Randomised controlled trials (RCTs) in this area have generally been small, single-centre studies comparing different regional techniques, different drug regimens, or different combinations. The heterogeneity in interventions, comparators, outcome definitions, and surgical approaches makes it difficult to draw definitive conclusions from individual trials (7).

Accordingly, we conducted this systematic review and meta-analysis to evaluate the evidence on perioperative analgesic strategies for adults undergoing VATS lobectomy. The primary objective was to summarise the effect on postoperative complications. Secondary outcomes included postoperative pain scores, opioid consumption, length of hospital stay, and adverse events. We present this article in accordance with the PRISMA reporting checklist (8) (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2026-2068/rc).

Methods

The protocol was prospectively registered with the International Prospective Register of Systematic Reviews (PROSPERO; registration number CRD420251186565).

Inclusion and exclusion criteria

Participants

Adult patients (aged ≥18 years) undergoing elective video-assisted thoracoscopic lobectomy for lung cancer or other thoracic conditions, without contraindications to the study analgesic interventions. Patients were required to provide informed consent to participate in the study.

Interventions

Any perioperative analgesic strategy, including regional anaesthetic techniques (e.g., PVB, SAPB, erector spinae plane block, ICNB, thoracic epidural analgesia), systemic analgesic adjuncts (e.g., nefopam, gabapentinoids, dexmedetomidine, NSAIDs, acetaminophen), intercostal cryoanalgesia, and multimodal combinations of these approaches.

Comparators

Any control or comparator analgesic regimen, including standard analgesic care, placebo, sham block, or an alternative analgesic technique/drug.

Outcomes

The primary outcome was the incidence of postoperative complications (any complication or adverse event reported by the original studies within the postoperative follow-up period). Secondary outcomes included: (I) postoperative pain scores at rest and on movement/cough [assessed by validated scales such as the Visual Analog Scale (VAS) or Numeric Rating Scale (NRS)]; (II) total opioid consumption within the first 24 and 48 hours postoperatively; (III) length of hospital stay; and (IV) patient satisfaction with pain management.

Study design

Only RCTs were included, with a minimum follow-up duration of 24 hours.

Exclusion criteria

Exclusion criteria included: (I) studies not published in peer-reviewed journals; (II) non-randomised studies, observational studies, case series, or qualitative studies; (III) studies that did not report at least one of the specified outcomes; (IV) studies with incomplete data where the required summary statistics could not be extracted or obtained from the authors; (V) conference abstracts without full text.

Search strategy

We searched PubMed/MEDLINE and Web of Science Core Collection from 1 January 2010 to 26 June 2026. At the time of the present analysis, the authors’ institutional library (Xinjiang Medical University Library) did not provide subscription access to EMBASE or the Cochrane Library, and the search was therefore restricted to these two databases; this constraint is acknowledged as a limitation.

The search combined controlled vocabulary (MeSH) and free-text terms for the PICOS framework, using three concept blocks linked with the Boolean operator AND: (I) population—video-assisted thoracoscopic surgery OR VATS OR thoracoscopic lobectomy; (II) intervention—analgesia OR pain management OR nerve block OR multimodal analgesia; and (III) study design—randomised controlled trial. Within each block, synonyms were combined with OR. Searches were limited to studies published in English. Reference lists of included articles and relevant systematic reviews were screened to identify additional eligible records. The full search strategy for each database is provided in Appendix 1.

Literature screening

Two reviewers (A.K. and X.D.) independently screened titles and abstracts against the prespecified eligibility criteria. All discrepancies were resolved by discussion until consensus was reached; no third adjudicator was required. Eligibility was confirmed at the full-text stage, and reasons for exclusion were recorded.

Data extraction

Two reviewers (A.K. and X.D.) independently extracted data from each included trial using a standardised, pre-piloted form. The following items were extracted: first author, year of publication, country, sample size, age and sex distribution, surgical approach (uniportal vs. multiportal VATS), number and size of ports, chest drain management, type of analgesic intervention (regional technique, systemic adjunct, cryoanalgesia, or multimodal combination), specific drugs and doses used, comparator regimen, background/baseline analgesia, follow-up duration, and outcome data (postoperative complications with event counts and denominators per group, pain scores at multiple time points, opioid consumption, length of stay, and adverse events).

When required data were not reported in usable form, we attempted to contact the corresponding authors. If no response was received, the trial was retained for narrative synthesis only and excluded from quantitative synthesis where the missing data were critical.

Quality assessment

Risk of bias was assessed using the Cochrane Risk of Bias 2 (RoB 2) tool, applied per outcome (postoperative complications, the primary outcome) rather than per study. The tool evaluates five domains: (I) randomisation process; (II) deviations from intended interventions; (III) missing outcome data; (IV) measurement of the outcome; and (V) selection of the reported result. Each domain and the overall judgement were classified as “low risk”, “some concerns”, or “high risk”. Two reviewers (A.K. and X.D.) independently rated each study; disagreements were resolved by discussion. The detailed basis for each judgement is provided in Table S1.

Statistical analysis

Binary outcomes (postoperative complications) were summarised as risk ratios (RR) with 95% confidence intervals (CIs). Between-study heterogeneity was quantified with τ² and I². A random-effects model with restricted maximum-likelihood (REML) estimation was used as the primary method, because REML provides less biased variance estimates than the DerSimonian-Laird method when the number of studies is small (9).

Studies were grouped into clinically meaningful subgroups for separate analysis:

1. Regional techniques: studies comparing different regional anaesthetic approaches (e.g., different block types, different planes, or different approaches to the same block);

2. Systemic adjunctive analgesics: studies comparing an add-on systemic drug (e.g., nefopam, gabapentinoids) against placebo on a background of standard care;

3. Cryoanalgesia: studies comparing intercostal cryoanalgesia against standard analgesia.

Multi-arm studies were handled by constructing the most clinically relevant pair-wise comparison(s) without double-counting shared control groups. Where valid independent comparisons could not be constructed, the study was retained in narrative synthesis only.

For studies with zero events in one or both arms, the approach was determined on a case-by-case basis. Because no included study had zero events in both arms, continuity correction was not applied.

Sensitivity analyses included leave-one-out analysis, in which each study was sequentially omitted and the pooled estimate recalculated, to assess the influence of individual trials on the overall result.

With fewer than 10 studies contributing to the quantitative synthesis, formal statistical assessment of publication bias (funnel plot, Egger’s regression, Begg’s rank test, trim-and-fill) is unreliable and was not performed (10).

All analyses were performed in Python using the statsmodels library (REML estimation). A two-sided P<0.05 was considered statistically significant.

Results

Study selection

The database searches identified 177 records (50 from PubMed/MEDLINE, 127 from Web of Science Core Collection). After removal of 40 duplicates, 137 records were screened by title and abstract. Of these, 12 were selected for full-text review. Five were excluded after full-text assessment (reasons: wrong intervention, wrong study design, wrong outcomes, or wrong population). Seven RCTs met all inclusion criteria and were included in the qualitative synthesis; three contributed data to the quantitative synthesis of postoperative complications. The study selection process is summarised in Figure 1.

Figure 1.

PRISMA 2020 flow diagram of the study selection process.

Study characteristics

The seven included RCTs enrolled a total of 505 patients. All studies evaluated perioperative analgesic strategies in adult patients undergoing VATS lobectomy. The studies were published between 2015 and 2025, and were conducted in China (n=3), South Korea (n=2), Canada (n=1), and Greece/Canada [n=1, Koliakos 2025 (11)—multicentre international].

The included trials represented three broad categories of comparison: (I) regional technique comparisons (n=5): Zhang 2015 (12) (PVB vs. wound infiltration), Lee 2020 (13) (SAPB vs. ICNB), Meng 2025 (14) (superficial vs. deep SAPB), Lim 2025 (15) (SAPB vs. ICNB vs. SAPB + ICNB), and Li 2023 (16) (thoracoscopic-guided PVB vs. placebo); (II) systemic adjunctive analgesics (n=1): Ki 2024 (17) (nefopam vs. normal saline); (III) cryoanalgesia (n=1): Koliakos 2025 (11) (intercostal cryoanalgesia vs. standard multimodal analgesia).

Surgical approaches varied: one study explicitly used single-port (uniportal) VATS [Meng 2025 (14)], three used multiportal approaches [Ki 2024 (17), Koliakos 2025 (11), Li 2023 (16)], and three did not clearly specify the port configuration. Background analgesia regimens also differed substantially across studies.

The characteristics of the included studies are summarised in Table 1.

Table 1. Characteristics of the included studies.

Study	Country	Number	Age (years)	Sex (M/F)	Surgical approach	Intervention	Comparator	Background analgesia	Outcomes reported
Zhang, 2015	China	61	56.9 (PVB), 57.7 (infiltration)	41/20	Not reported	Thoracic PVB (0.5% ropivacaine) + placebo wound infiltration	Wound infiltration (0.5% ropivacaine) + placebo PVB	Not reported (both groups received IV-PCA)	VAS pain at rest/cough, morphine consumption, adverse events, satisfaction
Lee, 2020	South Korea	46 (ITT)	Median 67 (IQR, 58–74) (ICNB); median 68 (IQR, 57–75) (SAPB)	16/7 (ICNB); 12/11 [SAPB]	Not reported	SAPB (20 mL 0.375% ropivacaine)	ICNB (20 mL 0.375% ropivacaine at all port sites)	IV fentanyl PCA + ketorolac	NRS pain (rest/movement), fentanyl/ketorolac consumption, PONV, chest tube duration
Meng, 2025	China	80	59.0±7.8 (S), 60.1±8.2 (D)	34/46	Single-port VATS	Superficial SAPB (20 mL 0.25% ropivacaine)	Deep SAPB (20 mL 0.25% ropivacaine)	IV-PCA with sufentanil	24-h opioid consumption, pain scores, PONV, 1-month pain, adverse events
Ki, 2024	South Korea	45 (ITT)	62±11	19/27	Multiportal VATS	Nefopam 20 mg (pre-incision + end of surgery)	Normal saline 100 mL	IV-PCA + ketorolac	VNRS pain (rest/cough), opioid consumption, adverse events
Koliakos, 2025	Canada (multicentre)	80	67.5±10.5	41/39	Multiportal VATS	Intercostal cryoanalgesia	Standard multimodal analgesia (single-shot PVB)	Standard multimodal analgesia in both arms	VNRS pain at 24 h (cough), QoR-15, opioid consumption, complications, side effects, neuropathic pain
Lim, 2025	South Korea	90	~67	72/18	Not reported	Continuous SAPB, ICNB, or SAPB + ICNB (3-arm)	See Intervention (internal comparators)	Oral ibuprofen/acetaminophen; IV ketorolac/pethidine rescue (no IV-PCA)	VAS pain at 24 h, opioid consumption, LOS, postoperative complications
Li, 2023	China	120	58.0±11.1	52/68	Multiportal VATS (3-port)	Thoracoscopic-guided multiple PVB (0.5% ropivacaine)	Placebo PVB (0.9% NaCl)	IV-PCA with sufentanil + flurbiprofen	Intraoperative opioid, pain scores, PCIA duration, recovery scores, adverse events

Data are presented as mean ± standard deviation unless otherwise specified. For Lee 2020 (13), 50 patients were randomised and 46 were included in ITT analysis (23 per group). Information unavailable in the original publications is marked as “not reported”. D, deep serratus anterior plane block group; F, female; ICNB, intercostal nerve block; IQR, interquartile range; ITT, intention-to-treat; IV-PCA, intravenous patient-controlled analgesia; LOS, length of stay; M, male; NRS, Numeric Rating Scale; PCIA, patient-controlled intravenous analgesia; PONV, postoperative nausea and vomiting; PVB, paravertebral block; QoR-15, Quality of Recovery-15 score; S, superficial serratus anterior plane block group; SAPB, serratus anterior plane block; VAS, Visual Analog Scale; VATS, video-assisted thoracoscopic surgery; VNRS, verbal numerical rating scale.

Risk of bias

Risk of bias for the primary outcome (postoperative complications) was assessed per study per outcome:

1. Low risk of bias: 3 studies (42.9%);

2. Some concerns: 4 studies (57.1%);

3. High risk: 0 studies (0%).

Specific domains with “some concerns” included: (I) randomisation process [Koliakos 2025 (11)—some concerns]; (II) deviations from intended interventions [Ki 2024 (17)—some concerns]; and (III) selection of the reported result [Li 2023 (16)—some concerns]. The detailed basis for each judgement is provided in Table S1. The risk-of-bias summary is shown in Figure 2.

Figure 2.

RoB 2 summary for postoperative complications across included randomised trials. RoB 2, Risk of Bias 2.

Postoperative complications

Three studies reported complication data suitable for quantitative synthesis: Koliakos 2025 (11) (cryoanalgesia vs. standard multimodal; 25/40 vs. 31/40 events), Ki 2024 (17) (nefopam vs. saline; 12/22 vs. 13/23 events), and Li 2023 (16) (PVB vs. placebo; 1/40 vs. 3/80 events). Lim 2025 (15) was retained in narrative synthesis only because its three-arm design comparing SAPB, ICNB, and their combination did not share a directly comparable intervention-comparator pair with the other pooled studies. Detailed definitions, follow-up periods, and event counts for each study are provided in Table S2.

The overall pooled RR for postoperative complications was 0.84 (95% CI: 0.65–1.08; P=0.18), based on three studies with 245 participants. Between-study heterogeneity was absent (I²=0%, τ²=0; Q=0.39, df =2, P=0.82). However, the pooled estimate was strongly dominated by a single study: Koliakos 2025 (11) contributed 75.2% of the total weight.

The forest plot is shown in Figure 3.

Figure 3.

Forest plot of postoperative complications. Effect estimates are RR with 95% CIs. The size of each square is proportional to study weight. CI, confidence interval; RR, risk ratios.

Subgroup analyses

Regional techniques: Only one study [Li 2023 (16)] contributed regional technique vs. control complication data (RR 0.67, 95% CI: 0.07–6.21; weight 1.3%). This subgroup therefore does not provide meaningful pooled evidence.

Systemic adjuncts: Ki 2024 (17) (nefopam vs. saline) reported RR 0.97 (95% CI: 0.57–1.63; weight 23.5%) for postoperative complications.

Cryoanalgesia: Koliakos 2025 (11) (cryoanalgesia vs. standard multimodal) reported RR 0.81 (95% CI: 0.60–1.08; weight 75.2%).

Secondary outcomes

Secondary outcomes (pain scores, opioid consumption, length of stay) were reported variably across studies and could not be pooled quantitatively due to differences in measurement tools, time points, and units. Key findings from the narrative synthesis are summarised below.

Postoperative pain

Most included studies reported lower pain scores with the experimental intervention at various postoperative time points, but the magnitude of effect varied substantially depending on the specific comparison. Regional technique comparisons generally showed modest to moderate differences in early postoperative pain (0–24 h), whereas systemic adjuncts (e.g., nefopam) and cryoanalgesia demonstrated effects on pain at later time points.

Opioid consumption

Most studies reported reduced opioid consumption in the intervention group within the first 24–48 hours postoperatively. However, the absolute magnitude of reduction varied from small (10–15%) to moderate (30–40%), depending on the specific comparison.

Length of hospital stay

Findings were inconsistent across studies, with some reporting shorter stay in the intervention group and others finding no difference.

Sensitivity analysis

Leave-one-out analysis was performed for the overall pooled complication estimate: exclusion of Koliakos 2025 (11): RR 0.95 (95% CI: 0.57–1.58; P=0.83; I²=0%)—point estimate shifted toward null, CI widened substantially; exclusion of Ki 2024 (17): RR 0.80 (95% CI: 0.60–1.07; P=0.14; I²=0%); exclusion of Li 2023 (16): RR 0.84 (95% CI: 0.65–1.09; P=0.19; I²=0%).

The exclusion of Koliakos 2025 (11)—the largest study contributing 75.2% of the total weight—resulted in a marked shift in the point estimate and a CI that clearly included the null value. This confirms that the pooled estimate is strongly dependent on this single trial.

Discussion

Principal findings

This systematic review evaluated the evidence on perioperative analgesic strategies for VATS lobectomy. We identified seven RCTs with a total of 505 patients, representing a diverse range of comparisons: regional technique variations, systemic adjunctive drugs, and cryoanalgesia. Only three studies contributed usable complication data to the quantitative synthesis (n=245). The principal finding is that the current evidence base is too small, too heterogeneous, and too dominated by a single trial to support any firm conclusions about the comparative effectiveness of different analgesic strategies for reducing postoperative complications after VATS lobectomy.

Interpretation in context

The pooled RR of 0.84 (95% CI: 0.65–1.08) for postoperative complications suggests a possible directional benefit, but it does not reach conventional statistical significance and must be interpreted with extreme caution for several reasons.

First, the included comparisons are clinically heterogeneous. Cryoanalgesia against standard multimodal care (Koliakos, 2025), nefopam against saline on a background of standard analgesia (Ki, 2024), and PVB against placebo (Li, 2023) are fundamentally different questions. Combining them into a single “intervention vs. control” estimate, as was done in the original version of this review, implies a degree of comparability that does not exist. The revised subgroup analysis—which separates regional techniques, systemic adjuncts, and cryoanalgesia—demonstrates that no single category has robust evidence for complication reduction.

Second, the pooled estimate is dominated by one study. Koliakos et al. [2025], a Canadian multicentre study of 80 patients comparing intercostal cryoanalgesia against standard multimodal analgesia with PVB, contributes 75.2% of the weight. When this study is removed from the analysis, the point estimate shifts from 0.84 to 0.95 and the CI widens to 0.57–1.58, indicating no effect. The leave-one-out analysis therefore confirms, rather than refutes, that the result depends on a single trial.

Third, the outcome definition is not standardised. Postoperative complications were defined and assessed differently across the included studies, with varying follow-up periods, different complication types (respiratory, cardiovascular, gastrointestinal, surgical site), and different grading systems. This outcome heterogeneity further complicates interpretation of the pooled estimate.

Comparison with other reviews

Previous systematic reviews of analgesic strategies for thoracic surgery have generally focused on specific techniques—such as PVB vs. epidural (18), SAPB (19), or cryoanalgesia (20)—rather than on the broader question of which overall strategy is best for VATS lobectomy specifically. Most of these reviews have also been limited by small numbers of included studies and significant clinical heterogeneity.

To our knowledge, this is the first PROSPERO-registered systematic review specifically focused on VATS lobectomy that includes all types of perioperative analgesic strategies. By demonstrating the paucity and heterogeneity of the evidence base, it highlights the need for better-standardised trials rather than providing a definitive answer.

Strengths and limitations

Strengths

The review has several strengths: (I) prospective registration on PROSPERO; (II) PRISMA 2020-compliant reporting; (III) duplicate independent screening, data extraction, and quality assessment; (IV) per-outcome risk of bias assessment using the contemporary RoB 2 tool; (V) use of REML estimation rather than the less appropriate DerSimonian-Laird method for small meta-analyses.

Limitations

The limitations are substantial: (I) Small evidence base: only 7 RCTs with 505 patients were identified, and only 3 contributed to the primary outcome meta-analysis. This severely limits statistical power and precision. (II) Clinical heterogeneity: the included studies compared diverse analgesic strategies against diverse comparators, making the overall pooled estimate of limited clinical meaning. (III) Outcome heterogeneity: postoperative complications were defined and measured differently across studies, with different follow-up periods. (IV) Single-study dominance: one study contributed 75.2% of the weight in the pooled analysis. (V) Database scope: the search was restricted to PubMed/MEDLINE and Web of Science Core Collection, as the authors’ institutional library did not have access to EMBASE or the Cochrane Library. Eligible studies indexed only in these databases may have been missed. (VI) Publication bias could not be assessed: with fewer than 10 studies, formal statistical assessment of publication bias is unreliable and was not performed. We cannot rule out the possibility that unpublished negative studies exist. (VII) Many secondary outcomes could not be pooled: pain scores, opioid consumption, and length of stay were reported with different tools, time points, and units, precluding quantitative synthesis. (VIII) Surgical technique variability: port configuration, incision size, and chest drain management—all of which may influence pain and recovery—varied across studies and were not always reported.

Implications for future research

The findings of this review point to several priorities for future research: (I) adequately powered multicentre RCTs are needed, with sample sizes calculated to detect clinically meaningful differences in complication endpoints rather than just pain scores; (II) standardised outcome definitions—ideally a validated composite of clinically significant pulmonary and cardiovascular complications—would facilitate future meta-analysis. Core outcome sets for thoracic surgery analgesia trials would be valuable; (III) head-to-head comparisons of the most promising strategies (e.g., cryoanalgesia vs. PVB vs. SAPB) would be more informative than comparisons against varying “standard care” controls; (IV) longer follow-up (at least 3 months) is needed to assess chronic post-thoracotomy pain, which is an important patient-centred outcome; (V) standardised reporting of surgical technique details (port configuration, incision size, chest drain management) and background analgesia would help explain between-study heterogeneity.

Conclusions

The available evidence on perioperative analgesic strategies for VATS lobectomy is limited and clinically heterogeneous. The pooled estimate for postoperative complications shows a non-significant directional effect (RR 0.84, 95% CI: 0.65–1.08), but this finding is dominated by a single trial and is based on studies with diverse interventions and outcome definitions. No specific analgesic strategy can currently be recommended over others on the basis of complication reduction. Adequately powered, multicentre RCTs with standardised interventions, pre-specified composite complication endpoints, and extended follow-up are needed before evidence-based recommendations can be made.

Supplementary

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Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.