Dr. Port: For many years, it was thought that you couldn't even take out a part of the lung or the lung itself. It was biologically impossible. A patient couldn't recover from that, and that wasn't very long ago.
Erin: That's Dr. Jeffrey Port, professor of thoracic surgery at NewYork-Presbyterian and Weill Cornell Medicine. He specializes in thoracic surgical oncology, particularly surgical treatment of lung cancer.
Dr. Port: That was, uh, you know, 1940s and 1950s. That's not, that's not really distant history.
Erin: Over the course of his career, Dr. Port has observed significant advancements in thoracic surgery and has played an important role in its evolution. Early in his training, while working with a cardiac surgeon, he observed that a specialization in thoracic surgery was largely absent across major surgical programs.
Dr. Port: Most academic centers had no dedicated thoracic surgeon. By the time I finished, um, almost every academic center realized things were getting complex.
Erin: Thoracic surgery hadn't developed as a subspecialty, but the need was clear at a time when the death rates for lung cancer were extremely high. Today, even though the rate has fallen, a lung cancer diagnosis remains severe.
Dr. Port: Lung cancer really has the greatest mortality of all cancers. It is incredibly deadly for both men and women. More women will die this year from lung cancer than breast cancer, uterine cancer, and GYN cancer all combined, but yet it doesn't get that kind of attention.
Erin: When Dr. Port first started to focus on thoracic oncology, the surgical techniques followed the procedures for open heart surgery. They were, as Dr. Port puts it now, maximally invasive.
Dr. Port: So when I first started, obviously everything was done open, so that was an incision between the ribs when you spread the ribs. And, and patients recover well from that, but it's tough. It's really super tough. I mean, it's many weeks of recovery, it's discomfort, it's narcotic use for many weeks.
Erin: So he set out to pioneer new techniques in thoracic surgery and the surgical treatment of lung cancer.
Dr. Port: But you had to be able to adapt, and thoracic surgery definitely gives you that opportunity. You can look at operations you're doing and constantly ask how you can make this more strategic or less invasive.
Erin: I'm Erin Welsh, and this is Advances in Care, a podcast about groundbreaking developments in modern medicine. In this episode, I speak with Dr. Jeffrey Port about his pioneering use of robotics in single port thoracic surgery and how that's transforming surgical techniques for doctors and outcomes for patients.
Erin: Dr. Port, thank you so much for joining me today. It's great to have you here.
Dr. Port: My pleasure. Thank you for having me.
Erin: I'm excited to talk with you today about the field of thoracic surgery, which has come a long way over the course of your career, and especially to hear about your development of single port surgical techniques. And there's a story of a patient of yours that really illustrates what makes your work in thoracic surgery so incredible. I understand that he had been told his condition was inoperable, but he eventually found his way to NewYork-Presbyterian, and to you, you were able to operate and save his life. Could you describe your side of that case for us?
Dr. Port: Yeah. So the gentleman came in with a tumor that was essentially involving the aorta and the heart and requiring cardiopulmonary bypass to safely remove these tumors. He represents a very typical case of somebody who had his care locally and then ultimately was told that sort of this is the extent of what we can offer and took it upon himself not to-- that not to be the final a-answer. And through word of mouth and discussions and doing his research, he found us here and was surprised to find that we could offer something that was not offered locally, and that was the ability to radically resect a tumor that he thought was, quote unquote, unresectable. It may be that technically you can remove something with a knife or with a scissors, but they didn't have the confidence that they had the right approach to, to support someone through with X from start to finish.
Erin: Yeah, that's, that's amazing. What does the deployment of advanced robotics look like in your work treating complex lung cancers like this?
Dr. Port: The robotics for me has really been a better way of offering even more strategic, minimally invasive surgery with a high degree of confidence around locating lesions, being able to remove these really, I would say, efficiently and effectively. The robotic program has really given us the opportunity to offer the sub lobar or less than lobe operations. We can really spare a lot of lung, and we can go into an operation with a lot of confidence now that we're gonna be able to see these lesions not convert to an open operation. And that doesn't exist in all places. That's something I'm very proud that we've developed here at NewYork-Presbyterian Cornell.
Erin: What is a typical robotic surgery like, and how does the single port approach you've developed improve on that?
Dr. Port: The mainstay of, uh, robotics is essentially a robot which has four arms. You can use three or four of them to do your surgery through, uh, eight millimeter incisions, and it offers the opportunity to have a lot of dexterity. Single port offers the opportunity to minimize the surgery even further. The incisions now go from four incisions to one incision. So it's a single incision. It's done under the rib cage, which is fascinating. So standard robotics is done usually between the ribs. The ribs are incredibly sensitive, even though the incisions are small in the multi-port. What we've known is that heavy equipment that levers itself on ribs, especially in women who are smaller, the rib spaces are not that wide, can create a lot of trauma. And so the thought is, is that taking that out of the equation and putting the equipment below the rib cage would also reduce the discomfort. Instead of having four arms and hands, now we have one arm with many little fingers, so like four fingers, and it can go through one incision. And through that incision, you have to do the same operation that you were doing through multiple different ports. That penetrates through the diaphragm. So you make a small incision in the diaphragm, and then you're able to look into the chest through the diaphragm and work through this small hole. That's the basis of single port surgery in thoracic right now.
Erin: That's pretty amazing, especially considering robotic surgery is still a relatively new way of operating. I'm curious to know more about how your team has managed to play an active role in growing single port procedures.
Dr. Port: We've been lucky enough to be the first centers to use these devices, and there's a lot of complexity in the engineering there because these devices have to have multiple hinges or elbows, and they have to be able to cross over because of the compact space. It also takes surgical training to, to use these devices 'cause it's not necessarily intuitive the way a, a standard robot is. Certain movements you perform create different experiences on the screen, and it takes a little bit of time to train through that.
Erin: It definitely seems like there has been a rapid and successful adoption of this technology. How has the patient experience changed with robotics?
Dr. Port: When it comes to the day-to-day management of something like lung cancer, there's no one who takes care of these patients better than a full service center like ours, an academic center. These patients may need cath lab services, cardiology services. In really radical resections, we have the ability to do bypass and vascular surgery, and so I can't tell you how many times patients have been seen first in consultation, have been told there's nothing that can be done, and they come here, and we offer the most extreme. And so at both extremes, whether it be the most minimally invasive or the most maximally invasive, the offerings here, I think, are unparalleled in the ability to take care of all those patients on that spectrum.
Erin: And how about patient outcomes? How does the continued innovation and training in these techniques change the results for patients?
Dr. Port: The more you do these operations through smaller incisions, less exposure, the better it often is for the patient and for their outcomes. When we started, the accepted time in the ho- hospital for a lung cancer patient was up to 12 days. It seems crazy at this point, but that wasn't very long ago. And then it became five and six days, and now I can tell you that most of our patients leave within two-point-something days, and some of our patients even leave the next day.
Erin: What indicates whether a patient might be a good candidate for a robotic surgery?
Dr. Port: Yeah, so we are constantly expanding the indications as the technology improves. Probably over 75, 80% of my practice is minimally invasive robotics, and so in the beginning, it was smaller tumors. It was patients who had tumors that were, um, didn't spread to lymph nodes. And now I would say there's very few patients that can't have robotic or minimally invasive surgery.
Erin: That's amazing that most patients are now candidates for minimally invasive procedures, and I imagine that means that most patients are now able to recover more easily. Can you speak to what that recovery looks like for patients who undergo single-port surgery compared to either, like, a multi-port approach or just traditional surgical approaches?
Dr. Port: So we're sending patients home usually on post-op day one or two, which is earlier than multi-port, but we're also noticing that a good percentage of the patients are really limiting their narcotic use. And so it's not only the length of stay, but it's the narcotic use. It's the recovery time. It's back to work. It seems early, yet it seems to be enhanced with the single-port approach.
Erin: In your opinion, what has made the development of single-port techniques possible, both in terms of the expertise in treating the lungs but also in the infrastructure around you?
Dr. Port: Yeah. A single port represents the state-of-the-art, and what's made that possible is really a commitment here to the robotic program. We offer lobectomies. We offer what we call wedge resections and segmentectomies. All the complex procedures are duplicated with the single port, and we do it really well. I don't think there's many limitations in terms of what operation you can do with a single port. I think as the technology evolves, we'll be offering the full compendium of thoracic procedures.
Erin: This stands out as one of the only centers around the country to offer this sort of robotic thoracic surgery. I'd love to hear your thoughts on why you think Weill Cornell stands out as a leader in this space.
Dr. Port: You have to have a supportive staff and great nursing staff, the flexibility to do cases that are much more challenging 'cause you're learning. And so we, we have that here. We were early adopters of different techniques that allowed us to, for example, sample lymph nodes probably about 15 years ago with endoscopic ultrasound, which we were early, early adopters on. There's been, uh, innovations as it relates to sort of navigating to lesions to biopsy them endoscopically, and we were early adopters in these navigational bronchoscopy systems, which were not traditionally thought of as surgery. It's created a very fertile ground for innovation and for adoption.
Erin: How did that kind of push for innovation grow your program? Like, how many patients are you treating?
Dr. Port: Just to give you a handle on the volume, maybe two or three hundred of these cases have been done around the country. We just passed our hundred and, I think, thirtieth case, so we make up almost half the volume in the country through our one center.
Erin: I understand that your center also trains surgeons from around the country. Why has your department at NewYork-Presbyterian and Weill Cornell Medicine been such a leader in rapid development and training in single-port robotic surgery?
Dr. Port: We've created a partnership, uh, to be a center of excellence and a training facility. There's not many places where people can go and see two or three cases in a day, and so we've committed to supporting that, those efforts. And so now on a weekly basis, we've been hosting many surgeons from across the world who come in to see how this can be applied, not only the surgery itself, but the workflow, how the patient's positioned, how the nurses hand-- All these things are incredibly important. So they'll often bring even their nurses to see how things are done and how the workflow is affected.
Erin: Right. It can't just be the surgeons. That training for the whole team is so important. Looking to the future, how do you think the further development of robotic approaches has the potential to continue reshaping thoracic surgery?
Dr. Port: I think if you want to empower a thoracic surgeon to do more minimally invasive surgery, then you have to, at the same time, improve the diagnostics, the imaging, and the localization. So ideally, a robotic platform in the next 10 years has some sort of built-in guidance systems and imaging structures that allow you to see into the patient and know where these tumors are located and feel confident that you're gonna take out this small area. I think that would be part and parcel, would be a huge improv-improvement for robotics.
Erin: Moving away from robotics for a minute, let's reflect more on thoracic surgery overall. Would you speak to what makes this unique as a specialty and why it's a field where you've seen so much innovation in treatment?
Dr. Port: It's very different from patient to patient. Even though the tumor sizes may be the same and the CAT scan looks the same, each person may have a different panel, which would suggest a different response to therapy. You really almost choose your own experience now based on really complex genetics. We know that which patients, based on certain markers, are gonna respond to immunotherapy. And so you really custom tailor the therapy not only on the stage, but also on the genetic results that are from the patient. So the, the surgeon really has to be up to date on that. We're not just technicians. You have to know who's gonna benefit from taking a pause and getting therapy up front, who needs to go to the operating room, who needs to be biopsied, what have you. And then ultimately, unlike most surgical specialties, I don't know if a surgical specialty like this, I see my patients for life. So I see my patients every six months with CAT scans and then annually after that, which is daunting, and they could be, at the same time, very rewarding to see these patients and have that kind of relationship.
Erin: You spoke earlier about the environment at NewYork-Presbyterian and Weill Cornell Medicine. Would you say a little bit more about why this team-based, multidisciplinary approach here makes this the best place to receive care for these complex cardiopulmonary conditions?
Dr. Port: While we are definitely leading the way in terms of minimally invasive surgery for the smallest, earliest lesions, when a thoracic surgeon is referred a patient with early stage disease, stage one disease, where isolated cancer hasn't spread to lymph nodes, the cure rate here at Cornell can be incredibly high. It can approach as almost 100%. We also pride ourselves in being able to take care of some of the most difficult cases that require maximal invasion, and that would be even cardiopulmonary bypass and cardiac resections and aortic, uh, replacements. We often see patients who have, uh, very large centrally located tumors, often sarcomas, often that present in, uh, in younger patients, and these tumors often will involve, uh, great vessel invasion, cardiac structures that can be invaded. And many times these patients have been told that there's really, uh, there is no opportunity for removal, and they'll come to our center, and we will discuss a plan that involves putting patients on bypass, often removing and replacing large cardiac structures, aortic replacements. Even cardiac valve replacements and cardiac involvement can sometimes necessitate resection of parts of the heart as well. And so these cases are incredibly challenging and require incredible support but can be very fulfilling.
Erin: I can only imagine. And would you say a little bit more about what it means to you to be doing this work?
Dr. Port: There are days when you're doing, um... You know, we joke around that if every day is exciting, you're probably doing something wrong. But when you do something where you feel like you're one of a few places that, that exists, it's obviously even more special. Not necessarily something you want to do every day, but, um, it definitely is an incredible feeling where you help somebody out that may not have had that opportunity anywhere else. You know, we live for those days, and those days are incredible when they, when they occur.
Erin: What has been the biggest factor in your program's success, and what does it mean to you to help so many patients like this?
Dr. Port: It's just a commitment we've made over the years, and I think it's been recognized recently by the fact that we get patients from all over the country now, and even from the world, where they come back with tumor recurrences that require radical resections, often with cardiac, thoracic, and even plastic surgery reconstruction, and that's a very common undertaking for us in our service. It's incredibly satisfying. You want to do great things for people, and it's an example of where you really go the extra distance, essentially, to offer an operation that requires multi-specialty and disciplines to participate and to achieve a success. And so that's not something that's easily duplicated in many hospitals.
Erin: Well, Dr. Port, it has been such a pleasure to chat with you today about the promising future of thoracic surgery. Thank you so much.
Dr. Port: Thank you so much for the opportunity.
Erin: Thanks so much to Dr. Jeffrey Port for diving into his work pioneering single-port robotic surgery and exploring the innovations that have helped his program excel in treating the most complex thoracic conditions. I'm Erin Welsh. Advances in Care is a production of NewYork-Presbyterian Hospital. As a reminder, the views shared on this podcast solely reflect the expertise and experience of our guests.
Erin: To listen to more episodes of Advances in Care, be sure to follow and subscribe on Apple Podcasts, Spotify, or wherever you get your podcasts. And to learn more about the latest medical innovations from the pioneering physicians at NewYork-Presbyterian, go to nyp.org/advances.
