Single-Port robotic surgery at Penn Thoracic Surgery

In an effort led by thoracic surgeons Doraid Jarrar, MD, FACS, FCCP, and Jarrod Predina, MD, single-port robotic surgery has been introduced at Penn Thoracic Surgery for lung and mediastinal procedures.

Recently approved for thoracic surgery, the Da Vinci single-port (SP) system (Intuitive Surgery) places all the instruments of the current multi-port systems into one port, approximately an inch in diameter.

As with multi-port systems, the SP instrumentation includes cutting, cautery, forceps, sewing, and retraction tools in addition to a 3D camera and stapler. Notably, the SP system permits surgeons to reach structures in the mediastinum and left and right chest from an access point below the rib cage.

In a recent interview, Drs. Jarrar and Predina, who have performed hundreds of multi-port robotic surgeries between them, explain the introduction of single-port surgery.

“What we noticed about multi-port surgery personally, and in discussions with surgeons across the country, was that some patients can still have incisional pain after thoracic surgeries,” says Dr. Jarrar.

This postoperative pain is linked to the anatomy of the ribcage, explains Dr. Predina. “A transthoracic approach is the standard for pulmonary resections, which means access between the ribs, and the spaces between the ribs—the intercostal spaces—are lined with motor and sensory nerves.”

Perhaps the greatest advantage of the SP system is its capacity to avoid intercostal access, making it ideal for the diminution of pain in thoracic surgery.

Enter the SP system

The SP system was designed to minimize surgical pain, partly by reducing the effect of torque in its single-port configuration, but primarily by avoiding the ribcage altogether.

“The single-port uses a subxiphoid incision below the rib cage so surgeons enter the chest above the diaphragm to get into the chest cavity,” says Dr. Jarrar. Early SP surgeries at Penn Thoracic Surgery have explored the System’s use in pulmonary and thymus procedures.

“Lung surgery patients are particularly sensitive to pain,” says Dr. Predina. “So we intend that the SP System will serve as an option for select pulmonary procedures.”

Given the learning curve, both Drs. Predina and Jarrar acknowledge that single-port is currently a partner rather than a replacement for multi-port robotic thoracic surgery.

The SP System offers unique advantages for mediastinal (thymus) procedures, as well.

“With a multi-port system, the approach is from the left or right, but the thymus is a midline organ,” Dr. Jarrar says. "The single-port system allows an approach from the midline, and this allows excellent visualization of the phrenic nerves on both sides to avoid injury.”

In the final estimation, however, perhaps the SP System’s advantages can best be explained in equivalencies.

“What we’ve noticed in our surgeries is that the SP is a great way to achieve the same surgical outcome with one incision rather than four or five,” says Dr. Predina. “That it allows us to accomplish this with less perioperative pain only adds to this advantage.”

SP is one of a spectrum of options for thoracic surgery at Penn Medicine

Ultimately each patient and case is unique and the surgical approach needs to be tailored toward the individual patient. In certain cases, open surgery is the best approach; in other cases, a multiport or single-port approach may be used. Since the Division of Thoracic Surgery at Penn Medicine has extensive experience with even the most complex cases, the most appropriate surgical approach will be offered to the patient after consultation.

Referrals for robotic surgery at Penn Thoracic Surgery

Physicians wishing to discuss patient referrals for robotic surgery at Penn Thoracic Surgery may contact Drs. Predina and Jarrar at 215-662-7878, or may write Dr. Predina at Jarrod.Predina@pennmedicine.upenn.edu, and Dr. Jarrar at Doraid.Jarrar@pennmedicine.upenn.edu.