Robotic, Minimally Invasive, and High-Complexity Thoracic and Foregut Surgery at the UPMC Heart and Vascular Institute
October 17, 2025
The Division of Thoracic and Foregut Surgery in the UPMC Heart and Vascular Institute provides comprehensive, high-volume, and highly specialized care for benign and malignant conditions of the chest and upper gastrointestinal tract. Under the leadership of Ryan Levy, MD, FACS, chief of the Division of Thoracic and Foregut Surgery, Department of Cardiothoracic Surgery; associate professor of Thoracic Surgery; vice chair of Thoracic Expansion and Community Outreach; and chief of Thoracic Surgery at UPMC Passavant and UPMC Hamot, the Division continues to expand its minimally invasive and robotic-assisted techniques, multidisciplinary patient care programs, and its commitment to improving long-term thoracic outcomes across the entire UPMC Heart and Vascular Institute footprint.
The Division’s innovation and technical leadership is driving the ongoing expansion of complex thoracic surgery services for local and regional patients, and those referred from out-of-state for consultation and care.
Lung Nodule Localization and Minimally Invasive Lung Cancer Surgery
One of the Division’s most active areas of clinical care and research is in the management of indeterminate pulmonary nodules and early-stage lung cancer. In collaboration with the Division of Pulmonary Medicine and UPMC Hillman Cancer Center, the UPMC Heart and Vascular Institute has built one of the largest and most mature robotic bronchoscopy programs in the United States, currently performing more than 600 procedures annually across UPMC Heart and Vascular Institute sites. The technology is being leveraged for early diagnosis, targeted biopsy, and precise preoperative lesion marking.
Dr. Levy and colleagues also are national leaders in the early adoption and use of intraoperative immunofluorescence techniques, including the Cytalux® platform, which uses a folate receptor-targeted agent to localize small or difficult-to-visualize nodules intraoperatively at the cellular and molecular level. The UPMC Heart and Vascular Institute has completed more than 150 cases using the Cytalux approach and have presented outcomes at national meetings.
The use of technologies like Cytalux localization methods support the UPMC Heart and Vascular Institute’s emphasis on sublobar resection and segmentectomy as lung-preserving alternatives to lobectomy in patients with early-stage disease. The application of robotic bronchoscopy and fluorescence-guided surgery enables precise targeting of lesions while minimizing disruption to surrounding lung parenchyma.
“The Cytalux platform allows us to identify and resect very small, peripheral lung nodules that would previously have required a more extensive resection or might have been deemed unresectable,” says Dr. Levy.
Dr. Levy and colleagues also published findings on their use of intraoperative molecular imaging in June 2025 in JTCVS Techniques.1 The study evaluated the Division’s use of the folate receptor–targeted fluorescent agent, pafolacianine, to aid in the localization of small or difficult-to-visualize lung lesions during minimally invasive resection. Most patients underwent segmentectomy or wedge resection using robotic or thoracoscopic techniques, and all had complete resection with negative margins. The findings support the Division’s strategy of pairing localization technologies with parenchymal-sparing approaches to improve precision and preserve lung function.
Minimally Invasive Esophagectomy for Cancer
The UPMC Heart and Vascular Institute continues to be one of the nation’s most experienced centers for minimally invasive esophagectomy (MIE). Performing more than 100 procedures a year, the program has consistently been a clinical leader in the development and use of laparoscopic, video-assisted (VATS), and robotic approaches for esophagectomy.
“This is a procedure we have been pioneering dating back 20 years, and the minimally invasive paradigm for esophagectomy started in Pittsburgh and continues to be perfected here,” Dr. Levy says.
The UPMC Heart and Vascular Institute’s high procedural volume and institutional expertise make it a referral destination for patients with esophageal cancer who are looking for less invasive options and shorter recovery times. These cases are managed through a coordinated and multidisciplinary approach.
Giant Paraesophageal Hernia: Restoring Anatomy Without Fundoplication
Among benign foregut conditions, giant paraesophageal hernia is a challenging anatomic problem requiring surgical repair. These cases often involve herniation of the majority of the stomach into the thoracic cavity, causing symptoms including early satiety, vomiting, chest pain, anemia, and dyspnea. In the past, these patients were managed with traditional antireflux operations like the Nissen fundoplication, a surgery designed to eliminate heartburn and acid reflux symptoms.
To address this clinical gap, surgeons in the UPMC Heart and Vascular Institute have developed a "restoration of normal anatomy" approach that involves laparoscopic or robotic hernia repair followed by a modified gastropexy and recreation of a normal gastric anatomy. This technique avoids the need for a Nissen fundoplication and the accompanying potential side effects.
“This is a different surgical paradigm for giant paraesophageal hernia repair than what has been traditionally done, and the results we have been able to achieve with this approach to date have been outstanding,” Dr. Levy says.
The technique has generated national interest, with other high-volume centers now adopting the UPMC Heart and Vascular Institute approach.
Evan Alicuben, MD, assistant professor of Cardiothoracic Surgery and director for Thoracic Surgery Clinical Research, has led the research effort to publish a series of studies evaluating outcomes of the anatomy-preserving approach to giant paraesophageal hernia. In a study2 of more than 100 patients, Dr. Alicuben and colleagues found low rates of perioperative complications and excellent symptom relief at short-term follow-up. Another recent study3 tracking long-term outcomes showed that most patients continued to do well five years after surgery, with minimal recurrence and no reoperations for reflux. Additionally, the team extended this approach to urgent cases involving incarcerated hernias, which also showed favorable outcomes data4, including a low recurrence rate and no need for antireflux procedures postoperatively. These recent published studies support the technique’s durability and applicability across a wide range of clinical presentations.
Robotic First-Rib Resection and Minimally Invasive Chest Wall Surgery
The UPMC Heart and Vascular Institute now performs robotic first rib resections through four small incisions, which reduces morbidity and largely avoids visible scars from larger incisions. The team is led Tadeusz Witek, MD, assistant professor of Cardiothoracic Surgery, who directs the program.
“This approach has made a tremendous difference for our patients. Just recently, we treated a teenage softball pitcher with disabling symptoms, and she was able to return to activity much faster,” Dr. Levy says.
The team also has extended this experience with first rib resections to robotic-assisted resection of Pancoast tumors that invade the first or second ribs. Over the past two years, UPMC thoracic surgeons have performed six of these complex hybrid procedures combining chest wall and pulmonary resection in a single, minimally invasive approach.
Complex Reoperative Surgery for Postesophagectomy
In addition to high-volume primary procedures, the Division is a national referral center for complex reoperative esophageal surgery. Patients who have undergone prior esophagectomy may experience debilitating symptoms due to suboptimal conduit anatomy or herniation of gastric conduits.
“These are patients who are often told to just live with their anatomy because they are fortunate that their cancer was resected, but they continue to have reflux, regurgitation, or difficulty eating,” Dr. Levy says. “In our approach, these patients may have surgical options. We see these cases from across the country and can potentially offer reconstruction to restore function and quality of life.”
This clinical effort is spearheaded by James D. Luketich, MD, FACS, the Henry T. Bahnson Professor of Cardiothoracic Surgery, and Dr. Alicuben.
The Division also handles a high volume of revisional antireflux surgeries, managing complications or prior failed procedures. Omar Awais, DO, associate professor of Cardiothoracic Surgery and clinical director of Thoracic Surgery, is one of the primary thoracic surgical leaders of this program. Dr. Awais and colleagues recently published one of the largest thoracic surgical series in the literature on revisional antireflux surgery.5 Surgical plans for these cases are highly individualized based on the patient’s anatomy, prior interventions, symptom severity, and their long-term goals of care.
Access Across the UPMC Heart and Vascular Institute
While many high-complexity cases are conducted at the UPMC Heart and Vascular Center’s primary locations in Pittsburgh, thoracic and foregut services are integrated throughout the UPMC Heart and Vascular Institute, enabling broad geographic access for patients. Robotic bronchoscopy, esophageal diagnostics, and minimally invasive procedures are available at multiple locations, with coordinated referral pathways that ensure continuity of care.
“We’re not just doing these operations in one hospital,” Dr. Levy says. “Our goal is to deliver high-quality, specialized thoracic surgery throughout the UPMC network. This keeps patients closer to home and avoids all the downsides of needing to travel long distances for care.”
Patient Referrals and Consultation
To refer a patient for consultation, please email HVIReferral@upmc.edu.
References and Further Reading
- Baker N, Alicuben ET, Sarkaria IS, Ajabshir N, Levy RM. Real-world Localization of Cancer in Lungs With a Commercially Available Folate Receptor–targeted Fluorescent Agent for Intraoperative Molecular Imaging. JTCVS Tech. 2025; 31: 161-168.
- Liang S, Luketich JD, Aranda-Michel E, et al. An Alternative Approach to Repair of Giant Paraesophageal Hernia in Selected Patients With Minimal History of Reflux: Analysis of Outcomes in More Than 100 patients. JTCVS Open. 2025; 26: 243-254.
- Alicuben ET, Luketich JD, Levy RM, et al. Long-term Follow-up of Giant Paraesophageal Hernia Repair With Restoration of Normal Anatomy Without Fundoplication. Ann Thorac Surg. 2025. Articles in Press, August 06.
- Alicuben ET, Luketich JD, Levy RM, et al. Restoration of Normal Anatomy Without Fundoplication in Non-Elective Incarcerated Giant Paraesophageal Hernia Repair. Surg Endosc. 2025; 39: 6102–6107.
- Zhang D, Luketich J, Collison C, et al. Analysis of Outcomes of Reoperative Fundoplication in More Than 500 After Failed Primary Antireflux Surgery: Experience Over Two Decades. JTCVS Open. 2025 Jun 27: S0022-5223(25)00544-6. Online ahead of print.
