VATS lobectomy program: the trainee perspective

Starting a robotic thoracic surgery program: From wedge resection to sleeve lobectomy in six months. Initial conclusions

INTRODUCTION

Robot-assisted thoracic surgery (RATS) is a rapidly expanding technique. In our study, we aimed to analyze the results of the process to adopt robotic surgery in our Department of Thoracic Surgery.

METHODS

This is an intention-to-treat analysis of a series of consecutive patients operated on using the RATS approach in our hospital from January 2021 to March 2022. Data were registered for patient characteristics, type of surgery, operative times, conversion rate, chest tube duration, length of hospital stay and complications. The IBM SPSS® statistical software was used for the statistical analysis. A cumulative sum analysis of the operating time was performed to define the learning curve.

RESULTS

During the study period, 51 patients underwent robotic surgery, including pulmonary and non-pulmonary interventions. In addition, 15 patients (29.4%) underwent non-pulmonary interventions: one pleural (2%), 2 diaphragmatic (3.9%), and 12 mediastinal (23.5%). Among the mediastinal surgeries, one conversion was necessary (8.3%) for a complex vascular malformation, and 11 were completed by RATS, including 7 (58.3%) thymomas, 3 (25%) pleuro-pericardial cysts, and one (8.3%) neurogenic tumor. Mean operative time was 141 min (104-178), mean chest tube duration was 0.9 days (0-2), and mean length of stay was 1.45 days (1-2). Thirty-six patients underwent lung surgery (70.6%). The complete RATS resections (34; 94.4%) included: 3 wedge resections (11.1%), 2 segmentectomies (3.7%), 28 lobectomies (81.5%), and one sleeve lobectomy (3.7%). Mean surgery time was 194.56 min (141-247), chest tube duration was 3.92 days (1-8), and length of stay was 4.6 days (1-8). Complications occurred in 4 patients (11.1%). No 90-day mortalities were registered.

CONCLUSIONS

The implementation of RATS was achieved with good clinical results and operative times for all indications. A rapid learning curve was accomplished in short time. Previous VATS experience, patient selection, team training and program continuity are fundamental to successfully develop a RATS program.

What's new in minimally invasive thoracic surgery? Clinical application of augmented reality and learning opportunities in surgical simulation

Lung cancer represents the most lethal cancer worldwide. Surgery is the treatment of choice for early-stage non-small cell lung cancer, with an overall survival that can reach 90% at 5 years, but its detection is difficult to achieve due to the lack of symptoms. Screening programs are crucial to identify small cancer. Minimally invasive surgery has modified the therapeutical approach of these tumors, becoming the standard of care, with an important clinical yield in terms of reduction of postoperative pain and length of hospital stay. The aim of this mini-review is to explore and describe two important and innovative aspects in the context of "growing opportunities in minimally invasive thoracic surgery": the clinical application of augmented reality and its advantages for patient and surgeon, and the pedagogical issue through simulation-based training.

Human corpse model for video-assisted thoracoscopic lobectomy simulation and training

OBJECTIVES

Minimally invasive surgery simulation is an integral part of surgical education and skills acquisition. Our goal was to present a new video-assisted thoracic surgery simulation model based on the human corpse as an alternative to animal models.

METHODS

Selective cannulation of the cadaver heart was used to fill the pulmonary vessels with a gel to improve the visibility and tactile feedback of the vessels and to simulate any bleeding complications. During surgical simulation, the tutor fills out a questionnaire designed to evaluate the duration of the procedure, the correct completion of the surgical steps and the occurrence of complications. At the end of the simulation session, in order to compare the simulation to clinical practice, all the participants were asked to answer 5 questions using a scale from 1 to 10.

RESULTS

We have performed 2 hands-on sessions using 2 human corpses for each session. Each surgeon performed 1 lobectomy using video-assisted thoracoscopic surgery (VATS) first as the operator and at least 1 lobectomy as an assistant. The median operative time was 83 min in favour of surgeons who had previously performed more than 30 video-assisted lobectomies (P = 0.03). All the surgeons were able to complete all the steps of the procedure; surgeons who had performed fewer than 10 lobectomies required more support by the tutors than the other surgeons. The median total score was 40.5 (interquartile range 39-44.8).

CONCLUSIONS

We believe that this model includes most of the features necessary to validate a surgical simulator and allows realistic training for performing a VATS lobectomy. This model could be an effective alternative to anaesthetized animals for VATS lobectomy training and simulation.

Current role of uniportal video-assisted thoracic surgery for lung cancer treatment

The use of video-assisted thoracic surgery (VATS) as an approach for early-stage lung cancer treatment has revealed benefits compared to open surgery by minimizing trauma to the patients. This trend has brought the evolution of VATS to less and less invasive methods, eventually leading to the development of Uniportal VATS (UniVATS) technique. This new approach has shown to be resourceful, proving its feasibility even for complex oncological procedures. Furthermore, data is starting to express some benefits over multiport VATS, thus spurring on its development towards newer and more complex procedures. It is also been adopted by the surgical community achieving fast evolution and worldwide diffusion. Here, we review the evolution of UniVATS, its current state of evidence, some basic technical aspects, the present role it has in lung cancer treatment and the ongoing development of the technique.

RELEVANCE FOR PATIENTS

This article could help patients to understand how the UniVATS technique developed as part of the evolution of VATS, sharing its benefits and indications. Furthermore, patients would be able to understand technical aspects and the current applications of UniVATS for lung cancer treatment.

Uniportal VATS for non-small cell lung cancer

The video-assisted thoracic surgery (VATS) technique has evolved from its multiport origins to even less invasive approaches grounded in its proven benefits over open surgery for the treatment of early stage lung cancer. In this evolution process, the Uniportal VATS (UniVATS) strategy emerged. This technique is giving some evidence of benefits when compared to the multiport VATS and has been embraced by the surgical community spreading its geographical and surgical boundaries. Moreover, UniVATS has proven its feasibility for numerous and more complex procedures for lung cancer diagnosis and treatment, which are reviewed in this document as well as its current and future development.

Factors during training which predict future use of minimally invasive thoracic surgery

Background

While minimally invasive thoracic surgery (MIS) has increased nationwide over the years, most patients undergoing lung and esophageal resections still undergo an open approach. We performed a national survey to analyze factors associated with a propensity to perform MIS after completing a cardiothoracic training program.

Materials and methods

Cardiothoracic surgery trainees in 2 or 3-year programs from 2010 to 2016 were sent an online survey regarding the numbers and types of cases performed during training and current practice patterns as attending surgeons. Comfort level with MIS was also assessed. Responses were recorded and analyzed using SPSS.

Results

One hundred thirty-six trainees responded, with a mean of 121 lobectomies (30-250) and 40 esophagectomies (8-110) performed during training. Mean minimally invasive lobectomy and esophagectomy rates during training were 53% and 30% respectively. A greater ratio of MIS procedures performed during training correlated with a higher rate performed as an attending (lobectomies, p = 0.04; esophagectomies, p = 0.01) and a greater comfort level with performing these procedures (lobectomies, p = 0.01 and esophagectomies, p < 0.01).

Conclusions

Based on these results, performing a greater ratio of minimally invasive lobectomies and esophagectomies during fellowship training increases the likelihood of performing them as an attending.

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Trainees who perform more minimally invasive procedures as trainees are more likely to do so as attendings.

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Trainees who perform many open lobectomies do not necessarily convert to minimally invasive approaches as attendings.

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Trainees who perform many esophagectomies are less likely to convert as attendings.

[Thinking on the Training of Uniportal Video-assisted Thoracic Surgery]

近年来，单孔胸腔镜技术迅速发展，已成为全球外科发展方向。单孔胸腔镜外科医师的针对性，规范化、系统化培训已成为重要的课题，技术培训是保证手术安全性的必不可少的重要环节。单孔电视胸腔镜技术培训应包括：由临床大中心经验丰富的专家直接面对面的教授手术技巧，或聘请专家导师前往学员所在单位进行针对性现场指导，这是一个代表性的、不可缺少的重要环节。网络视频通常也可以作为培训的方式。目前的技术提供了很多模拟训练，诸如：体外模拟器，人工合成胸腔、肺模型，动物实验，3D和VR技术能够为学习者提供各种层面的培训需求。对于大样本量的培训中心，短期的集中培训和中长期的系统性培训目前越来越受关注。根据学员的分级评估，采用多元化的培训模式，因材施教的针对性训练，有助于提高培训效果。我科在单孔胸腔镜外科医师培训方面做了一些工作，积累了一些培训经验，我们认为这样的培训是可行且完全有必要的。

Uniportal lobectomy and segmentectomy-is it for all?

Technological advances have markedly transformed the philosophy of thoracic surgery in the current era, with notable improvements in patient outcomes with video-assisted thoracoscopic surgery (VATS). More recently, innovations in uniportal VATS approaches have been promising, although robust data on their efficacy is limited. Nonetheless, the lessons learned from experience with the 2-port and 3-port VATS lobectomy and segmentectomy can be applied to further improve the efficacy of uniportal approaches, in terms of achieving oncologic efficacy and improving patient outcomes. This perspective reviews contemporary outcomes of uniportal lobectomy and segmentectomy, highlights our institutional experience, and examines future directions and challenges pertaining to widespread adoption of this innovative technique.