Subcostal Robotic Surgery Cuts Thoracic Pain

Jonathan Villena-Vargas, MD, is an assistant professor of cardiothoracic surgery at New York-Presbyterian/Weill Cornell Medical Center. His team has adopted a subcostal, single-port robotic approach to thoracic surgery that avoids the intercostal nerves altogether, aiming to reduce the chronic pain historically associated with rib-based incisions. In an interview with Targeted Oncology^TM, Villena-Vargas discussed how subcostal robotic thoracic surgery compares with traditional approaches, its learning curve, and what it has meant for patient recovery.

Targeted Oncology: What is the standard procedure for thoracic surgery, and how has it evolved?

Jonathan Villena-Vargas, MD: Most thoracic surgery is approached in the chest for cancer surgery, such as lung. The traditional route is you go between the ribs. Several decades ago, what we'd have to do is a thoracotomy, which is an open procedure that's still done today, although more seldomly. That means you have to spread the ribs and go in through a lot of tissue to access the lung and/or other tissues in the chest. The problem with the thoracotomy approach is that it causes a lot of pain. You're going through a lot of muscle, and in addition to that, the nerve bundles that live within the ribs are what cause this prolonged pain. About half of patients will get something called postthoracotomy pain syndrome, in which you'll have chronic pain for about a year, if not longer.

Luckily, we advanced from that to something called minimally invasive, or video-assisted thoracoscopic, surgery [VATS]. That's when you put in a camera and/or instruments—whether it's a robot or just directly—between the ribs through keyhole incisions, which significantly decreases the trauma to the patient and decreases the rib spreading. The problem is that still about 15% to 40% of these patients will have that postthoracotomy pain syndrome, because you're going between the ribs and you can potentially damage those nerves.

What are the practical advantages of single-port robotic thoracic surgery for patients and surgeons?

It's not only just a single port, or a single incision, which is better than multiple incisions; it's actually a fundamentally different approach. It avoids the ribs altogether. We do something called a subcostal approach, meaning you go right underneath the rib margin and introduce the robot through there, through about a 1.5-inch incision. What that does is completely avoid the intercostal nerves, or the nerves that run between the ribs. And ideally, it completely abrogates that concept of post-thoracotomy pain, or any sort of pain that can happen with traditional routes of entry.

For the patients, what we've been seeing is that they recover faster, they have much less pain, and they're able to get to their quality of life much quicker, meaning they're able to return to work and/or do exercise at a much quicker rate. We've been studying this and showed about half the opiate use, or half the pain med use, at day 2 after the surgery. We're actively publishing this.

Is subcostal robotic thoracic surgery contraindicated for any patients?

It's a fundamentally new approach, and what that means is that there's a bit of a learning curve. When we took this on and started doing this as a team, we started with the more straightforward cases, meaning much smaller resections, patients who don't have any preoperative treatment or other things that make the surgery much more difficult. We're studying that learning curve now, and it takes about 23 cases or so for the surgeon to get comfortable and start doing the more difficult cases. So initially, it's more done for straightforward cases, but as you learn, you can do almost every single thoracic procedure this way.

What should surgeons considering this technique take away your research?

Like everything, it has to be taken on thoughtfully. A team approach is always a good approach, and you have to be able to study your outcomes—meaning, do your patients actually do better? There's a gradated learning curve for this. Initially, what we're doing is having people come and observe us, and then we go and proctor a lot of these surgeons who are trying to build this into their practice. In general, it's incredibly exciting, and across the country there's been a lot of excitement about this approach, because fundamentally, it makes sense to most thoracic surgeons.

But again, when you're taking on something new, it's not about just going out and doing it; it's about doing it thoughtfully. We have a nice educational program in which people come and observe us doing the surgery and our approach, and we also go proctor them at their own institution. Along the way, we're publishing multiple articles looking at not only the learning curve and how we do these things, but actual patient outcomes: are patients taking less pain medication, are they returning to work quicker, are they able to return to activities quicker? In general, what we do here is add that academic rigor to taking on any sort of new technology or approach.

What else should clinicians know about subcostal robotic thoracic surgery?

One of the important things is that this was only recently FDA approved, and people have just now started looking into it. I think people are trying to make the distinction of whether to just do very easy cases with this approach, because it's technically difficult. But what we've shown is that we're doing very technically difficult cases—cases where patients get neoadjuvant therapy, meaning these are patients who get immunotherapy or chemotherapy before surgery, so the surgery becomes more complex. What we're seeing is that this approach is safe even in those cases.

In general, a big message is that early-stage lung cancer is continuing to evolve and continuing to be this multimodality approach, where patients aren't just getting surgery; they're getting chemotherapy, targeted therapy, immunotherapy, and surgery is just one arm of this big approach to trying to cure these patients. Just as we study adverse effects, how patients recover, and make sure a chemotherapy or a new medication is safe, we're doing that with surgery as well. I think the concept that we're able to do this in these patients, in these settings, will continue to advance how quickly patients do, and how well patients do.