Early outcomes of subcostal four-arm robotic pulmonary resection and mediastinal lymph node dissection for non-small cell lung cancer.

We report the early outcomes of subcostal robot-assisted thoracic surgery (subRATS) for non-small cell lung cancer (NSCLC). We conducted a prospective, single-arm cohort study at Seoul National University Bundang Hospital beginning in June 2022 to evaluate the feasibility of subRATS for pulmonary resection in NSCLC. This interim analysis assessed outcomes in consecutive patients from June 2022 to June 2025. The operative times for a subgroup of patients who underwent lobectomy were also analyzed using cumulative sum (CUSUM) analysis to assess procedural reproducibility. A total of 102 patients were included, with a mean age of 63.3 years. Lobectomy was performed in 79 patients and segmentectomy in 21 patients. Systematic mediastinal lymph node (LN) dissection was completed in 47 patients. Nodal upstaging occurred in 11 cases, with eight patients upstaged to N2 disease. The mean console time was 106.6 min, and the average postoperative hospital stay was 3.6 days. Postoperative complications of Clavien-Dindo grade III or higher were observed in 4 patients: one 30-day mortality due to postoperative myocardial infarction, one conversion to thoracotomy due to bleeding, and two cases of transient recurrent laryngeal nerve injury. No postoperative diaphragmatic abnormalities were observed. CUSUM analysis identified the 31st case as the turning point on the learning curve, after which marked reductions in operative time, estimated blood loss, and length of hospital stay were achieved. SubRATS is feasible and reproducible for pulmonary resection and mediastinal LN dissection in patients with NSCLC, with the added advantage of sparing the intercostal nerve.