Outside The Cage (OTC) Subcostal RATS Lobectomy, Technical Aspects and Results of the First Series of a Novel Approach
Luciano Bulgarelli Maqueda, Pedro Guimarães Rocha Lima, Feras Abu-Reida, Omniyah Alashgar, Evangelos Koliakos, Maxime Têtu, Gabriel Dayan, Basil Nasir, Pasquale Ferraro, Moishe Liberman.
Centre Hospitalier de l'Université de Montréal (CHUM), Montreal, QC, Canada.
BACKGROUND:
The goal of minimally invasive surgery (MIS) is to reduce trauma to patients and improve their post-operative outcomes. The latest advances in MIS and robotic platforms are spreading worldwide the use of robotic assisted thoracic surgery (RATS) applied to the treatment of lung cancer. Major pulmonary resections were recently reported to be feasible through a single incision RATS with the objective of minimizing the surgical trauma of the traditional multi-portal RATS approach. Withal, both strategies require intercostal incisions potentially provoking immediate and chronic pain derived from intercostal nerves injury, with resulting consequences. Furthermore, major pulmonary resections have been reported feasible through subxiphoid and subcostal incisions with claims of lower postoperative pain compared to intercostal approaches.We used this data as an impetus to develop a non-intercostal outside the thoracic cage (OTC) approach for RATS lobectomy, avoiding intercostal instrumentation which could imply a positive impact in patients’ postoperative recovery. Herein we describe the technical aspects and results of the first reported series of OTC RATS lobectomies.
METHODS:
Retrospective analysis of a series of OTC subcostal RATS lobectomy cases performed at CHUM for lung cancer treatment between August and December 2022.
RESULTS:
A total of 10 cases were analyzed, the median age of the patients was 63yo [55-84], with a mean IMC of 29 [24-45], an ASA score II-III and a preoperative clinical stage I (≤cT2N0M0). Surgical procedures were uneventful with no conversions of the surgical technique. The mean operative time was 132,6 minutes [98-223], with a 25% decrease between the first and second half of the cases. The median length of stay was 2 days. Two patients with severe COPD experienced prolonged air leak requiring being discharged with Heimlich valves that were removed after in the follow up visits. There were no pain related complications or readmissions and no 30 day mortality was observed in the series.
CONCLUSIONS:
In our series, OTC RATS subcostal lobectomy was feasible and safe. This series served as pilot study for an undergoing phase I clinical trial to prospectively assess the safety of the technique as well as its actual clinical relevance. 
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