Over the past two decades, advancements in minimally invasive thoracic surgery, from video-assisted thoracoscopic surgery to multiport robotic-assisted thoracic surgery, have enabled surgeons to treat lung cancer and other thoracic malignancies with better localization and quicker patient recoveries. Now, single-port robotics is emerging as the next evolution, with NewYork-Presbyterian and Weill Cornell Medicine leading the way in technique, research, and training the next generation of surgeons.
Cardiothoracic surgeons Benjamin Lee, M.D., Jeffrey Port, M.D., and Jonathan Villena-Vargas, M.D., have established one of the country’s highest-volume single-port thoracic programs, performing everything from lung resections for lung cancer, diaphragmatic repairs, and chest wall resections to being among the first to perform single-port esophagectomies for esophageal cancer in the United States.
“We’ve helped each other learn the nuances of single-port surgery by sharing our experiences, which is what has enabled us to gain expertise in a relatively short amount of time,” says Dr. Lee, who is also chief of thoracic surgery at NewYork-Presbyterian Queens. “And that, in turn, allows for improved outcomes.”
“It's been a natural transition for us, given our extensive experience with the multiport standard platform,” says Dr. Port. “We have gone from simple wedge resections to some of the most complex thoracic surgeries. We are now approaching even more challenging, larger cases, including esophageal cancer, mediastinal masses, and procedures done after chemotherapy.”
We’ve helped each other learn the nuances of single-port surgery by sharing our experiences. That, in turn, allows for improved outcomes.
— Dr. Benjamin Lee
How Single-Port Surgery Impacts Patient Outcomes
Single-port robotic surgery works much like an arm with multiple fingers, routing the camera and all other instrumentation through a single incision rather than the four to five incisions required for multiport robotic-assisted thoracic surgery. In many cases, patients can be discharged the next day.
In single-port surgery, the “fingers” of the robot are all routed through an approximately 4-centimeter incision.
While multiport surgery is still minimally invasive, the intercostal incisions can cause persistent postoperative nerve pain due to rib movement. By contrast, single-port surgery uses a single subcostal or subxiphoid incision below the rib cage and through the diaphragm, avoiding the intercostal nerves. “This technology moves the incision outside of the chest cavity,” says Dr. Lee. “When our patients come back at three, six, and nine months, they are not complaining about the nerve pain that our traditional robotic surgery patients may experience.”
A study co-authored by the physicians and published recently in the European Journal of Cardiothoracic Surgery reviewed 98 single-port lung resections performed at NewYork-Presbyterian and Weill Cornell Medicine to understand the approach’s impact on patient recovery. Outcomes were consistently positive: zero entry-related complications, only a 1.4% conversion-to-open rate, a median estimated blood loss of 10 milliliters, and 0% 30-day mortality. Additional research published in the Journal of Thoracic and Cardiovascular Surgery also found that single-port surgery significantly reduced the need for opioids: “By postoperative day two, the patients were requiring half as many pain medications as with the traditional robotic surgeries,” says Dr. Villena-Vargas.
“Our goal for this research was to see if we were achieving outcomes that were equally as good as with the surgeries we’ve done in the past,” he adds. “But looking at the data, we see that single port really does enable a quicker recovery. Along with achieving that standard of care, if we can get patients back to their daily lives a little quicker, that’s ultimately our goal.”
Looking at the data, we see that single port really does enable a quicker recovery. If we can get patients back to their daily lives a little quicker, that’s ultimately our goal.
— Dr. Jonathan Villena-Vargas
Innovating and Standardizing Training and Technique
Because single-port surgery concentrates the benefits of robotics — dexterity, visualization, and wristed instrumentation — into a single incision about 4 centimeters wide, the transition from multiport to single port has a distinct learning curve, requiring surgeons to relearn instrument choreography to avoid collisions. “What makes it more difficult is that, even though you now have ‘fingers,’ your air space is tighter, so you have to navigate through a tighter court,” explains Dr. Port.
To aid with visualization and access, the surgeons start the procedure by insufflating the chest with carbon dioxide using a Veress needle in the fifth intercostal space at the mid-axillary line — a technique they have standardized and now train other physicians in. “One of the greatest technical challenges we have with the operation is access to the chest cavity. The technique that we developed simplifies that,” says Dr. Lee. “Now, using a Veress needle has really become the standard approach across the country.”
Cardiothoracic surgeons at NewYork-Presbyterian and Weill Cornell Medicine standardized CO2 insufflation as a safe approach for entry in single-port robotic thoracic surgery. The procedure involves A) placing a Veress needle through the fifth intercoastal space at the mid-axillary line; B) making a 4-centimeter incision along the subcostal margin at least 10 centimeters from the xiphoid process to enter the diaphragm; and C) placing three to four interrupted stay sutures under tension to flatten the diaphragm and to use later for closure.
The surgeons’ collective experience has made them leaders in training not only physicians at NewYork-Presbyterian and Weill Cornell Medicine but also across the country. In addition to proctoring cases both locally and in other cities, the team provides hands-on training for their cardiothoracic fellows and developed a stepwise credentialing curriculum, with one of their fellows becoming the first in the country to be certified in it.
“As one of the few centers in America with a dual console robot, our fellows were learning by being side-by-side with us,” says Dr. Lee “We had the ability to teach them not only regular robotic thoracic surgery but also single port.”
To continue advancing single-port surgery and its adoption, next steps include multi-institutional validation of techniques and outcomes, publication of learning-curve data, and refinement of instrumentation for lobectomy-level cases. Earlier disease detection could also extend single-port candidacy to a broader population of patients who may not have previously qualified for surgery. “Our combination of clinical excellence and academic rigor is what really allows us to set the standard for single-port thoracic surgery, where there once was none,” says Dr. Villena-Vargas.
Single-port surgery represents the state-of-the-art, and we’re committed to bringing that to more patients.
— Dr. Jeffrey Port
Although the team views single-port surgery as complementary to, and not a replacement for, multiport and open approaches, their goal is to offer the most minimally invasive approach whenever possible without compromising oncological values.
“Surgery remains one of the best ways to treat cancer, so we want to continue to innovate technique and increase the number of patients who qualify,” says Dr. Port. “But the fact that single-port surgery offers the possibility of a patient to be cured of their lung cancer through a single incision is an incredible advancement in the over 20 years that I’ve been doing thoracic surgery. It represents the state-of-the-art, and we’re committed to bringing that to more patients.”
