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

Pulmonary lobectomy via a minimally invasive surgery (MIS) approach represents the current standard of care in early-stage non-small cell lung cancer. However, MIS has mostly relied on intercostal incisions, with the inherent risk of intercostal nerve injury. As a result, several non-intercostal approaches were developed. However, published data on the subject remain scarce. We aim to review existing non-intercostal MIS lobectomy techniques to specifically assess their feasibility and safety. Systematic review from 2010-2025. The outcomes for feasibility and safety were conversion rate and 30-day mortality, respectively. A total of 17 studies were included in the qualitative synthesis. From a combined total of 2376 patients included in the study, 66% (n = 1570) underwent a non-intercostal lobectomy. Among these, 83.5% (n = 1312) were performed via a subxiphoid approach, 15% (n = 236) via subcostal incisions. Among the studies that reported on outcomes, conversion rate and mortality were reported, respectively, as 4.3% (n = 53/1228) and 0.4% (n = 1/259) for subxiphoid approach, 1.4% (n = 2/140) and 0.7% (n = 1/140) for subcostal incisions. There has been growing interest in various non-intercostal approaches to pulmonary lobectomy over the past decade. Notably, recent studies suggest a shift toward higher-quality research and a transition from subxiphoid video-assisted to subcostal robotic-assisted thoracic surgery techniques. Among these, Outside the Cage (OTC) RATS robotic-assisted thoracic surgery emerges as the only fully non-intercostal reproducible robotic approach. Despite encouraging early data, further efforts are required to rigorously evaluate potential benefits. Nonetheless, the evidence to date suggests that it could be both feasible and safe to step "outside the cage."