Complications and Learning Curves for Video-Assisted Thoracic Surgery Lobectomy

doi:10.1016/j.thorsurg.2008.04.004

Thoracic Surgery Clinics

Volume 18, Issue 3, August 2008, Pages 275-280

https://doi.org/10.1016/j.thorsurg.2008.04.004 Get rights and content

Launching new techniques into a medical practice involves the educational process to train surgeons about the new technique, a learning curve for surgeons as they introduce the new procedure to their patients, and comparison of the complications for the new and older techniques. This article addresses these issues, as well as the introduction of these new techniques into the practice of thoracic surgery.

Section snippets

Prerequisites to begin video-assisted thoracic surgery lobectomy

There are many methods for the introduction of new technology into a thoracic surgery practice. Surgeons can: read articles, atlases, and books; observe surgeons who do the procedure; attend Society of Thoracic Surgeons (STS) University; attend industry-supported courses; and study in animal and cadaver laboratories. An individual surgeon must find the best method or methods for that situation. A new stapler may simply require education by the representative for the company that manufactures

Introduction of new technology into practice

If the surgeon and the program have the necessary prerequisites, then development of a VATS lobectomy program may proceed. In the early 1990s, the few surgeons who first began to perform VATS lobectomies were breaking new ground and had to develop the techniques for the procedure. Today, the momentum for converting open lobectomies to VATS lobectomies is growing, and there are many options for acquiring the skills and knowledge for performing VATS lobectomies.

Some thoracic surgeons learn how to

Learning curve for video-assisted thoracic surgery lobectomy

The learning curve for VATS lobectomy varies considerably. Basically, the surgeon needs to pursue any or all of the aforementioned options to gain the appropriate skills to perform the operation safely for the patient. For some, there is a natural transition from posterolateral thoracotomy to anterior thoracotomy and finally to VATS lobectomy. For the first step, the surgeon moves from posteriorly to anteriorly. The anterior, muscle-sparing thoracotomy starts at the anterior edge of the

Complications after video-assisted thoracic surgery lobectomy

Published series show that VATS lobectomy has gained international acceptance [1], [2], [3], [4]; however, less than 10% of lobectomies are currently performed with VATS because most thoracic surgeons are still not comfortable with the technique. The author and colleagues' experience with 1,100 VATS lobectomies, pneumonectomies, and segmentectomies over a 12-year period showed a mean length of hospital stay at 4.78 days and median length of hospital stay at 3 days. The mortality rate was 0.8%,

Video-assisted thoracic surgery versus thoracotomy for lobectomy

The evidence is mounting that a VATS lobectomy may have advantages over a lobectomy by thoracotomy. Opponents believe that a VATS lobectomy is unsafe, an incomplete cancer operation, and offers no advantage over a thoracotomy for lobectomy. Proponents believe that VATS lobectomy is a safe and effective treatment for lung cancer. The medical literature supports the latter position, and the number of surgeons who hold the negative belief is decreasing.

As the literature shows benefit to the

Concerns unique to video-assisted thoracic surgery lobectomy

The biggest concerns regarding VATS lobectomy center on three issues: risk and management of intraoperative bleeding, tumor recurrence in the incision, and the adequacy of the cancer operation. The chances of these issues occurring appear to be small.

Some surgeons are concerned that dissection can be more difficult, so bleeding from the pulmonary artery can occur more easily and be more difficult to control by VATS than by thoracotomy [18]. However, several series have demonstrated that

Consensus statement regarding video-assisted thoracic surgery lobectomy

The consensus panel of the International Society of Minimally Invasive Cardiothoracic Surgery (ISMICS) made the following statements and recommendations regarding VATS for lobectomy in patients with clinical stage I non-small lung cancer [24]:

VATS can be recommended to reduce the overall postoperative complications (class IIa, level A evidence).
VATS can be recommended to reduce pain and overall improved functionality over the short term (class IIa, level B evidence).
VATS can be recommended to

Summary

Surgery remains the mainstay for the treatment of lung cancer. While pulmonary resection has been safe for years, there is a trend toward minimally invasive (VATS) pulmonary resections. Studies have now shown that standard complete cancer operations performed via VATS offer patients a shorter hospital stay and quicker recovery without compromising the cure rate for an operation performed via a thoracotomy.

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Video-assisted thoracic surgery lobectomy: experience with 1,100 cases
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Long term survival after video-assisted thoracoscopic surgery lobectomy for stage 1 lung cancer
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Complication rate after thoracoscopic and conventional lobectomy

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Cited by (97)

Bibliometric analysis of 40 most cited articles comparing video-assisted thoracic surgery and robotic-assisted thoracic surgery in lung cancer (1997–2021)
2023, Heliyon
In recent years, conventional thoracoscopic surgery has been accepted as the traditional treatment method in the non-small cell lung cancer (NSCLC). VATS and RATS, which are the techniques of this surgical method, have been increasing their effectiveness and applicability of late years. The aim of this bibliometric analysis is to evaluate the importance and efficiency of articles comparing VATS and RATS techniques.
Studies comparing VATS and RATS published between 1997 and 2021 were identified in the Web of Science database (accessed on 31. 12. 2021). The 40 most cited studies were analyzed in terms of publication years, country of study, authors, institutions that the authors were affiliated with, journal, journal address and impact factor.
While an article was cited a maximum of 187 times when the citations made by the authors were excluded from the analysis, it was observed that all publications were cited a total of 1946 times. It was seen that an average of 51. 30 ± 47. 73 (8–187) articles were cited. In the 25-year, the highest number of publications was reached in 2019, while eight articles were published this year. The Annals of Thoracic Surgery (n = 13, 32. 5 %) was the journal in which the articles in the list were published the most. Most of the articles in our study (n = 31, 77.5 %) were published in US journals. While many studies presented more than one topic and analysis, the topic of most interest in 19 (47.5 %) studies was postoperative complications.
This bibliometric analysis reflects important and qualified articles comparing VATS and RATS technique in thoracic surgery, but it can also be used to explain or explain the performance and results of these techniques, their positive and negative aspects, and their superiority over each other.
Advances in Surgical Techniques for Lung Cancer
2023, Hematology/Oncology Clinics of North America
Surgeon Experience Is Associated With Prolonged Air Leak After Robotic-assisted Pulmonary Lobectomy
2022, Annals of Thoracic Surgery
Citation Excerpt :
Furthermore, when adjusted for age and sex, the odds for PAL decreased by 15% for every 10 additional lobectomies our surgeons performed robotically (OR, 0.85; 95% CI, 0.74-0.99; P = .0384). Previous studies have suggested that robotic lobectomy learning curve is 18 to 20 cases, largely on the basis of surgeon comfort.11,29-31 Although surgeon comfort and adaptability are important, we have shown objective data that an experience of 50 cases is an important benchmark and is related directly to surgeon proficiency.
Prolonged air leak (PAL) (>5 days) after robotic-assisted pulmonary lobectomy is a significant complication. This study aimed to determine patient- and surgeon-related factors that can predict PAL after robotic lobectomy for lung cancer.
This study was a retrospective review of a single-center experience of robotic-assisted lobectomy for lung cancer. Perioperative variables, including surgeon case experience, patient demographics, diffusion capacity of lung for carbon monoxide, forced expiratory volume in 1 second, body mass index, and smoking status were evaluated.
A total of 305 robotic-assisted lobectomies performed by 4 surgeons met inclusion criteria from June 2016 to February 2019. The 30-day postoperative mortality was 1.2%. PAL developed in 27 of 305 (8.8%) patients. Surgeons’ robotic experience was grouped by 10-case increments. When adjusted for age and sex, the odds for PAL decreased by 15% for every 10 robotic lobectomies the surgeons performed (odds ratio [OR], 0.85; 95% CI, 0.74-0.99; P = .0384). Logistic regression models showed a linear transition curve at the 50th case. Female sex (OR, 2.62; 95% CI, 1.03-6.69; P = .0314) and younger age (OR, 0.61; 95% CI, 0.41-0.91; P = .0184) were statistically significant risk factors for PAL. Cumulative sum analysis similarly showed a strong association between experience and PAL. Preoperative diffusing capacity of lung for carbon monoxide, forced expiratory volume in 1 second, body mass index, and smoking status were not statistically significant predictive factors.
These results show that surgeon robotic case experience is associated with the rate of postoperative PAL: as the number of robotic lobectomies increases, the rate of PAL significantly decreases. It is imperative to emphasize that a learning curve exists for this approach that directly affects patient outcomes.
Consensus for Thoracoscopic Left Upper Lobectomy—Essential Components and Targets for Simulation
2021, Annals of Thoracic Surgery
Simulation-based training is a valuable component of cardiothoracic surgical education. Effective curriculum development requires consensus on procedural components and focused attention on specific learning objectives. Through use of a Delphi process, we established consensus on the steps of video-assisted thoracoscopic surgery (VATS) left upper lobectomy and identified targets for simulation.
Experienced thoracic surgeons were randomly selected for participation. Surgeons voted and commented on the necessity of individual steps comprising VATS left upper lobectomy. Steps with greater than 80% of participants in agreement of their necessity were determined to have established “consensus.” Participants voted on the physical or cognitive complexity of each, or both, and chose steps most amenable to focused simulation.
Thirty thoracic surgeons responded and joined in the voting process. Twenty operative steps were identified, with surgeons reaching consensus on the necessity of 19. Components deemed most difficult and amenable to simulation included those related to dissection and division of the bronchus, artery, and vein.
Through a Delphi process, surgeons with a variety of practice patterns can achieve consensus on the operative steps of left upper lobectomy and agreement on those most appropriate for simulation. This information can be implemented in the development of targeted simulation for VATS lobectomy.
Crisis of confidence in cardiothoracic trainees: National trends in the use of minimally invasive esophagectomy
2021, JTCVS Open
Citation Excerpt :
Although the path to proficiency in minimally invasive esophagectomy is not clearly defined, lessons from VATS lobectomy may offer valuable guidance. McKenna and colleagues suggest a minimum of 50 cases to address the learning curve—a requirement that may be challenging to achieve in some training programs.8 The development of simulation and assessment tools may allow trainees to develop manual and cognitive skills without dependence on clinical volume.9,10
Commentary: Minimally invasive sleeve lobectomy: Time to roll up our “sleeves” and learn something new?
2021, Journal of Thoracic and Cardiovascular Surgery

View all citing articles on Scopus

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Complications and Learning Curves for Video-Assisted Thoracic Surgery Lobectomy

Section snippets

Prerequisites to begin video-assisted thoracic surgery lobectomy

Introduction of new technology into practice

Learning curve for video-assisted thoracic surgery lobectomy

Complications after video-assisted thoracic surgery lobectomy

Video-assisted thoracic surgery versus thoracotomy for lobectomy

Concerns unique to video-assisted thoracic surgery lobectomy

Consensus statement regarding video-assisted thoracic surgery lobectomy

Summary

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Ann Thorac Surg

Semin Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma

Eur J Cardiothorac Surg

Long term survival after video-assisted thoracoscopic surgery lobectomy for stage 1 lung cancer

Ann Thorac Cardiovasc Surg

Major pulmonary resection by video assisted mini-thoracotomy. Initial experience in 35 patients

Eur J Cardiothorac Surg

Complication rate after thoracoscopic and conventional lobectomy

Zentralbl Chir