Shall We Step Outside the Cage? Non-Intercostal Approaches to Pulmonary Lobectomy

Area of Science:

• Thoracic Surgery
• Surgical Oncology
• Minimally Invasive Surgery

Background:

• Minimally invasive surgery (MIS) is standard for early-stage non-small cell lung cancer (NSCLC).
• Intercostal incisions in MIS lobectomy carry risks of nerve injury.
• Non-intercostal approaches aim to mitigate these risks, but data is limited.

Purpose of the Study:

• To review non-intercostal MIS lobectomy techniques.
• To assess the feasibility and safety of these approaches.

Main Methods:

• Systematic review of studies published between 2010 and 2025.
• Outcomes assessed: conversion rate (feasibility) and 30-day mortality (safety).

Main Results:

• 17 studies included, 66% of 2376 patients had non-intercostal lobectomy.
• Subxiphoid (SX) approach: 83.5% of non-intercostal cases; conversion rate 4.3%, mortality 0.4%.
• Subcostal (SC) approach: 15% of non-intercostal cases; conversion rate 1.4%, mortality 0.7%.

Conclusions:

• Growing interest in non-intercostal pulmonary lobectomy techniques.
• Trend towards robotic-assisted subcostal techniques (RATS).
• Outside the Cage (OTC) RATS is a fully non-intercostal robotic approach; further evaluation needed but shows feasibility and safety.