Building a Safe Learning Curve for Subcostal Robotic Lung Surgery

Jonathan Villena-Vargas, MD discusses how his institution builds a safe learning curve for surgeons adopting the subcostal robotic approach to thoracic surgery, and shares data showing the technique holds up even in technically demanding, neoadjuvant-treated lung cancer cases.

Villena-Vargas explains that although the subcostal approach has generated considerable excitement among thoracic surgeons because the rationale is intuitive, adopting it responsibly takes more than performing the operation. He emphasizes a team approach as the right way to bring any new surgical technique into practice, one built around a central question: are patients actually doing better as a result? His institution answers that question with a structured, hands-on training model. Surgeons interested in the technique first come to observe cases in person, and once they begin performing the procedure themselves, Villena-Vargas and his colleagues travel to proctor them directly at their own institution, rather than leaving them to adopt the approach unsupervised.

That gradual learning curve is paired with an academic rigor more often applied to new drugs than new operations. Villena-Vargas describes prospectively publishing data not just on the technical learning curve itself, but on real patient outcomes tied to it, including how much pain medication patients need afterward and how quickly they return to work and to their normal daily activities. This outcomes-first approach, he argues, is what should govern the adoption of any new technology or technique, not just enthusiasm for the concept.

Because the subcostal approach received FDA approval relatively recently, the thoracic surgery community is still working out best practices around it, and some surgeons have limited its use to only the most straightforward tumors. Villena-Vargas pushes back on that caution: his own experience includes technically demanding resections in patients who received neoadjuvant chemotherapy or immunotherapy before surgery, cases that are inherently more complex to operate on, and he reports the approach has remained safe even in this higher-risk population.

The conversation also situates surgery within the broader, increasingly multimodal treatment of early-stage non–small cell lung cancer, where chemotherapy, targeted therapy, and immunotherapy are used alongside resection rather than surgery standing alone as the sole cure.