18773 Bulgarelli Maqueda.mp4 (663.25 MB)

Out of the Cage (OTC) RATS Lobectomy: A Non-Intercostal Approach for Lung Resections

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posted on 2022-12-12, 19:10 authored by Luciano Bulgarelli Maqueda, Pedro Guimarães Rocha Lima, Omniyah Alashgar, Feras Abu-Reida, Moishe Liberman


The goal of minimally invasive surgery (MIS) is to reduce surgical trauma to patients (1–5). The latest advances in MIS, as well as the increased availability of robotic platforms, are increasing the worldwide use of robotic assisted thoracoscopic surgery (RATS) in the treatment of lung cancer. Recently, major pulmonary resections were reported to be feasible through uniportal RATS, with the goal of minimizing the surgical trauma of the multiportal RATS approach (6). However, both strategies involve intercostal incisions, potentially injuring the intercostal bundles. Furthermore, major pulmonary resections performed via subxiphoid and subcostal incisions have been reported to be feasible and associated with lower postoperative pain compared to intercostal approaches (7, 8). 

The authors of this article decided to develop a nonintercostal approach for robotic lobectomies, aiming to avoid intercostal instrumentation. This video describes a case of a right upper lobectomy, which is one of the cases in the first series of outside the cage (OTC) RATS lobectomies.

The Surgery

The patient was an eighty-four-year-old man with a forty-pack-a-year smoking history. He was referred for a growing part-solid 18 mm RUL nodule. The lesion showed a 1.2 SUV on the PET scan and no signs of mediastinal or distant metastasis.  

Under general anesthesia and single-lung ventilation, the patient was positioned in lateral decubitus. A 4 cm anterior subcostal incision was performed lateral to the xiphoid process and parallel to the costal cartilage margin. Afterward, the abdominal muscles were partially divided using cautery until the transversus abdominus fascia was reached. At that point, blunt dissection was used to create a subcostal tunnel to access the pleural cavity under endoscopic vision. Following this, a second subcostal incision was performed posteriorly below the tenth rib, where a 12 mm trocar was inserted under thoracoscopic vision.

The Davinci Xi surgical cart was positioned at the front of the patient. Robotic arm one was extended caudally and posteriorly. Subsequently, robotic arms two, three, and four were extended caudally and anteriorly toward the anterior subcostal incision. The docking of the camera was done first in arm two with a thirty-degree down setting at the posterior angle of this incision. Afterward, a tip-up fenestrated forceps was inserted in arm one under vision through the posterior port. Following this, arm three was docked in the middle of the anterior subcostal wound medial to the camera. Lastly, arm four was docked and placed on the medial angle of the wound. 

Once the arms were in position, a Maryland bipolar forceps was placed in arm three and a hook in arm four. One of the advantages presented by the Xi system is the possibility of easily interchanging the instruments, camera, and trocars between arms. In this case, the staplers were used in arms one and three. The assistant surgeon used a curved suction through the anterior port, facilitating the dissection and keeping a smoke clear vision. The lobectomy was completed by a standard fissure last anterior approach. The drain was inserted via the posterior port incision.

The patient had an uneventful postoperative course and was discharged on postoperative day one. The pathology report confirmed a pT1b N0 M0 R0 NSCLC.


The OTC RATS lobectomy is a viable approach to MIS lobectomy that may be associated with benefits in the postoperative period, including reduced pain and earlier return to baseline. It may also be associated with reduced incidence of chronic pain because of lack of intercostal incisions and nerve trauma. Further studies are needed to assess its safety and actual clinical relevance.


1. Harris CG, James RS, Tian DH, Yan TD, Doyle MP, Gonzalez-Rivas D, Cao C. Systematic review and meta-analysis of uniportal versus multiportal video-assisted thoracoscopic lobectomy for lung cancer. Ann Cardiothorac Surg. 2016;5(2):76–84.

2. Shigemura N, Akashi A, Funaki S, Nakagiri T, Inoue M, Sawabata N, Shiono H, Minami M, Takeuchi Y, Okumura M, Sawa Y. Longterm outcomes after a variety of video-assisted thoracoscopic lobectomy approaches for clinical stage IA lung cancer: a multiinstitutional study. J Thorac Cardiovasc Surg. 2006;132:507–12.

3. Zhu Y, Liang M, Wu W, Zheng J, Zheng W, Guo Z, Zheng B, Xu G, Chen C. Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer. Ann Translat Med. 2015;3(7):92. 

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6. Gonzalez-Rivas D, Bosinceanu M, Motas N, Manolache V. Uniportal robotic-assisted thoracic surgery for lung resections. Eur J Cardiothorac Surg. 2022 Aug 3;62(3):ezac410. doi: 10.1093/ejcts/ezac410. PMID: 35951763.

7. Gonzalez-Rivas, D., Akar, F.A., Lei, J. (2019). Subxiphoid Uniportal Video-Assisted Thoracoscopic Surgery. In: Gonzalez-Rivas, D., Ng, C., Rocco, G., D’Amico, T. (eds) Atlas of Uniportal Video Assisted Thoracic Surgery. Springer, Singapore. https://doi.org/10.1007/978-981-13-2604-2_36. 

8. Cai Haomin, Xie Dong, Sawalhi Samer Al, Jiang Lei, Zhu Yuming, Jiang Gening, Zhao Deping. Subxiphoid versus intercostal uniportal video-assisted thoracoscopic surgery for bilateral lung resections: a single-institution experience. Eur J Cardiothorac Surg. 2019.


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