RATS of the chest affects—similar to VATS approaches—not only the respiratory but also the cardiovascular system. Preoperative patient evaluation for RATS therefore parallels that for VATS [
20]. It is crucial to assess patients carefully regarding preexisting cardiovascular or respiratory disease in order to detect any issues that might jeopardize the outcome and to ensure the optimal anesthetic regime [
20]. Electrocariography is performed for cardiac evaluation. If signs of cardiac malperfusion are detected, further examinations like cardiac ultrasound or coronary angiography are needed [
21‐
22]. Furthermore assessment of right ventricular function can be useful [
23]. Pulmonary evaluation should include a chest X-ray and any computed tomography testing needed for surgical assessment and planning. Any signs of emphysema, pulmonary obstruction, or infection must be taken into consideration when assessing the pulmonary reserve. Lung function tests are required before thoracic surgery [
24]. Here, pCO
2, FEV
1, and diffusion capacity for carbomonoxide are the main parameters that must be considered. As far as capillary blood gases are concerned, the partial pressure of carbon dioxide (
pCO
2) and for oxygen (
pO
2) are of interest as they reflect the preoperative ventilatory state of the patient. The pH highlights whether the patient is acidotic or alkalotic. Acidosis can be due to the retention of CO
2 or the accumulation of acidotic metabolites, whereas alkalosis can be caused by hyperventilation or renal diseases. Other laboratory findings of interest are the inflammatory state of the patient, pictured by C-reactive protein, interleukins, and leukocytes, as well as the metabolic situation including blood glucose and triglycerides along with the thyroid status [
25‐
27]. As in any other preoperative evaluation, hints towards a difficult management of the airway must be noted (Mallampati score, previous anesthetic management, thyro-mental gap, deviation or compression of the trachea seen in X-rays) [
28‐
30]. Thoracic CT imaging done in diagnostics and planning of the surgery is also useful for the anesthetist [
27]. If the patient shows extraordinary high anxiety, a sedating premedication with benzodiazepines is administered as long as there are no contraindications [
31]. Finally, the different modalities for postoperative pain control should be discussed with the patient to identify a suitable strategy for the individual patient and prepare the required interventions, if needed (e.g., epidural catheter or patient-controlled intravenous analgesia) [
6]. In most RATS interventions, multimodal analgesics combined with local anesthesia of the surgical incisions are considered sufficient for pain control [
32,
22]. Intercostal nerve blockade and submuscular analgesic depositories may be applied additionally [
33,
34]. Especially patients with an increased surgical likelihood for conversion to thoracotomy should be counselled very differentiated.