Learning curve of uniportal video-assisted lobectomy: analysis of 15-month experience in a single center

Uniportal video-assisted thoracoscopic surgery for lobectomy: the learning curve

OBJECTIVES

Prior reported learning curves for uniportal video-assisted thoracoscopic lobectomy were predominantly based on surgery duration, while reports on complications are limited. Therefore, our study assessed the learning curve based on both technique-related complications and surgery duration.

METHODS

We retrospectively collected data from patients who had undergone uniportal video-assisted thoracoscopic lobectomy between 2015 and 2020. Exclusion criteria were concomitant procedures other than ipsilateral wedge resection, discontinued procedures, or lost to follow-up (less than 30 days). Learning curves were constructed per surgeon who performed over 20 procedures using non-risk adjusted cumulative sum (CUSUM) analysis for technique-related complications and cumulative sum analysis for surgery duration. Based on the literature, an acceptable complication rate was set at 30%, an unacceptable complication rate at 45%, and a mean surgery duration of 145 min.

RESULTS

Learning curves were constructed for three thoracic surgeons and one fellow who performed 324 uniportal video-assisted thoracoscopic lobectomies in total. Each surgeon was experienced in multiportal video-assisted thoracoscopic lobectomy, the fellow was familiar with basic multiportal video-assisted thoracoscopic procedures. Cumulative sum charts of three surgeons reached a statistically significant technique-related complication rate below 30% between 50 and 96 procedures. Regarding surgery duration, typical learning curves were observed for three surgeons with a transition point between 14 and 26 procedures.

CONCLUSIONS

Learning of uniportal video-assisted thoracoscopic surgery for lobectomy is safe without unacceptable complication rates and has a declining surgery duration over time for thoracic surgeons with experience in multiportal video-assisted thoracoscopic lobectomies. However, it remains unknown when the different stages of mastery are completed.

Supervision by an experienced surgeon can reduce the learning curve of uniportal thoracoscopic lobectomy

Background

This retrospective study was performed to investigate the learning curve of uniportal thoracoscopic lobectomy with ND2a-1 or greater lymphadenectomy for two senior surgeons, and to evaluate how supervision affected the learning curve.

Methods

Between February 2019 and January 2022, 140 patients with primary lung cancer underwent uniportal thoracoscopic lobectomy with ND2a-1 or greater lymphadenectomy in our department. Two senior surgeons (HI and NM) performed most of the operations, with junior surgeons performing the rest. HI initiated this surgical method in our department and supervised all operations performed by other surgeons. Patient characteristics and perioperative outcomes were reviewed, and the learning curve was evaluated based on operative time and the cumulative sum method (CUSUM_OT).

Results

No significant differences were observed in patient characteristics or perioperative outcomes between groups. Three distinct learning curve phases were identified for each senior surgeon: HI, cases 1-21, cases 22-40, cases 41-71; NM cases 1-16, cases 17-30, cases 31-49. For HI, the rate of conversion to thoracotomy was significantly higher in the initial phase (14.3%, P=0.04) although other perioperative outcomes were equivalent between phases. For NM, while the duration of postoperative drainage was significantly shorter in phase 2 and phase 3 (P=0.026), other perioperative outcomes, including conversion rate (5.3-7.1%), were equivalent between phases.

Conclusions

Supervision by an experienced surgeon was important for avoiding conversion to thoracotomy during the initial period, and facilitated the surgeon rapidly gaining proficiency with the surgical method.

CT-guided percutaneous transthoracic needle biopsy (PTNB): A thoracic surgeon's learning curve and experience summary

BACKGROUND

Few studies have investigated the learning process of percutaneous transthoracic needle biopsy (PTNB). Here, we aimed to evaluate the number of cases required to achieve proficiency by plotting the learning curve of PTNB.

METHODS

Data were collected from 94 consecutive patients who underwent computed tomography-guided PTNB by a thoracic surgeon at the Affiliated Hospital of Xuzhou Medical University between May 2021 and February 2022. The data collected included patient information, relevant examination results, intraoperative parameters, postoperative complications, and diagnostic results.

RESULTS

The inflection points of the cumulative sum curve were around cases 13 and 24, according to which three phases were identified, including phase I, phase II, and phase III. A significant downtrend was observed regarding operative time (phase I, 26.53 ± 9.13 min vs. phase III, 18.42 ± 4.29 min, p < 0.05), rate of false-negative (phase I, 15.4% vs. phase III, 5.7%; p < 0.05), rate of pneumothorax (phase I, 30.8% vs. phase III, 12.9%; p < 0.05), and rate of hemoptysis (phase I, 15.4% vs. phase III, 2.9%; p < 0.05).

CONCLUSIONS

Thirteen cases were accumulated to lay the technical foundation, and 24 cases were required to achieve proficiency. In this study we summarize our own experience and provide specific guidance for young doctors with no experience in biopsy.

Extensive open lobectomy experience is not a prerequisite for learning uniportal video-assisted thoracic surgery lobectomy

BACKGROUND AND OBJECTIVES

Uniportal video-assisted thoracoscopic surgery (U-VATS) lobectomy has been increasingly adopted to manage early stage lung cancer. However, little information is available on whether this technique can be taught to surgeons inexperienced in open lobectomy. This study aimed to investigate the learning curve for U-VATS lobectomy performed by a single surgeon with limited open lobectomy experience.

METHODS

From July 2018 to September 2020, 103 patients received U-VATS lobectomy for lung cancer by a single surgeon. The learning curve was assessed using three statistical methods: the moving average analysis, cumulative sum (CUSUM) analysis, and risk-adjusted CUSUM (RA-CUSUM) analysis.

RESULTS

The moving average analysis showed a continuous decrease in operative time throughout the study period. The CUSUM analysis demonstrated three well-differentiated learning phases: Phase 1 (the initial 34 cases) representing the initial learning, Phase 2 (the middle 33 cases) representing the improvement of competence, and Phase 3 (the final 36 cases) representing technical proficiency. RA-CUSUM analysis revealed that the maximized cumulative surgical failure, defined as the maximum cumulative difference between the observed and predicted surgical failures, was found in the 61st case.

CONCLUSIONS

U-VATS lobectomy is feasible for surgeons with limited open lobectomy experience. Multidimensional statistical analyses suggested that 61-67 cases were required to gain technical proficiency and ensure acceptable surgical outcomes.

Learning curve of uniportal video-assisted thoracoscopic lobectomy: an analysis of the proficiency of 538 cases from a single centre

OBJECTIVES

Uniportal video-assisted thoracoscopic surgery (UniVATS) is widely used as a minimally invasive thoracic operation. The goal of our study was to analyse the effect of long-term experience with the UniVATS lobectomy on the learning curve.

METHODS

The learning curves were quantitatively evaluated by the unadjusted cumulative sum, and they were segmented using joinpoint linear regression analysis. The variables were compared between subgroups using trend analysis, and linear regression analysis was applied to correlate clinical characteristics at different stages of the learning curve with the duration of the operation.

RESULTS

The learning curve for the UniVATS lobectomy can be divided into 3 phases of proficiency at ∼200-300 procedures, with a fourth phase as the number of procedures increases. The 1st-52nd, 52nd-156th, 156th-244th and 244th-538th procedures comprised the preliminary learning stage, preliminary proficiency stage, proficiency stage and advanced proficiency stage, respectively. Surgical outcomes and their variability between stages improved with increasing case numbers, with the most significant addition of an auxiliary operating port and conversions. In multivariable analysis, as stages progressed, influences other than surgical experience increased the operative time, with male and extensive pleural adhesions in the preliminary proficiency stage; male and incomplete pulmonary fissures in the proficiency stage; and male, extensive pleural adhesions and incomplete pulmonary fissures in the advanced proficiency stage.

CONCLUSIONS

As the number of procedures increases, there may be 4 different proficiency stages in the UniVATS lobectomy learning curve. The surgeon enters the fourth stage at approximately the 244th procedure. Moreover, at stage 4, the perioperative indicators tend to stabilize, and influences other than surgical experience become more significant.

Surgical Effectiveness of Uniportal-VATS Lobectomy Compared to Open Surgery in Early-Stage Lung Cancer

Background

Although the feasibility and safety of Uniportal-Video-Assisted thoracic surgery (U-VATS) has been proven, its surgical effectiveness is still debated. The aim of this study is to assess the equivalence of the U-VATS approach compared with an open technique in terms of surgical (nodal-upstaging, complications, and post-operative results) and short-term survival outcomes.

Methods

The clinical data of patients undergoing lobectomy for NSCLC at our center, from January 2014 to December 2019, were analyzed retrospectively. All patients undergoing open or U-VATS lobectomy with lymphadenectomy for early-stage lung cancer (cT1-T3N0, stages IA-IIB) were included in the study. Only 230 patients satisfied the inclusion criteria. Group bias was reduced through 1:1 propensity score matching, which resulted in 46 patients in each group (open surgery and U-VATS).

Results

The intra- and post-operative mortality were null in both groups. There was no difference in the post-operative complications (p: 1.00) between U-VATS and open lobectomy. There was also no recorded difference in the pathological nodal up-staging [11 (23.9%) after thoracotomy vs. 8 (17.4%) after U-VATS, p: 0.440). The chest tube duration was longer in the open group (p: 0.025), with a higher post-operative pain (p: 0.001). Additionally, the 3-year overall survival (OS) was 78% after U-VATS lobectomy vs. 74% after open lobectomy (p: 0.204), while 3-year disease-specific survival (DSS) was 97 vs. 89% (p: 0.371), respectively. The 3-year disease-free survival (DFS) was 62% in the U-VATS group and 66% in the thoracotomy group, respectively (p: 0.917).

Conclusions

Uniportal-VATS lobectomy for the treatment of early-stage lung cancer seems to be a safe and effective technique with similar surgical and short-term survival outcomes as open surgery, but with lower post-operative pain and shorter in-hospital stay.

The learning curve of thoracoscopic surgery in a single surgeon and successful implementation of uniportal approach

Background

In some institutions, a recently introduced uniportal approach has replaced the multiportal approach for thoracoscopic major pulmonary resection. This study investigated the effect of this change on the surgical learning curve by examining the perioperative results of a single surgeon.

Methods

Between April 2012 and August 2020, 376 patients with primary lung cancer underwent thoracoscopic lobectomy with ND2a-1/2 lymphadenectomy in the authors’ hospital. Surgery was performed by one of the authors in 189 of these patients, who were thus enrolled in this retrospective study. The surgeries were classified chronologically into five phases and the operative time, rate of intraoperative massive bleeding, and rate of postoperative prolonged air leak (PAL) were then compared. The learning curve (i.e., operative time) was assessed by Spearman’s rank correlation test. The perioperative results achieved with the uniportal and multiportal approaches were also compared before and after the patients were matched for their characteristics based on the propensity score.

Results

The five phases differed significantly with respect to the operative time and rate of postoperative PAL (P<0.0001, P=0.0061). The correlation between operative time and number of consecutive cases was also significant (r=−0.579, P<0.0001). Superior results in terms of operative time (P<0.0001), duration of postoperative drainage (P<0.0001), and rate of postoperative PAL (P=0.0034) were obtained using a uniportal rather than multiportal approach.

Conclusions

The transition from a multiportal to a uniportal approach did not cause a decline in the learning curve of thoracoscopic lobectomy with ND2a-1/2 lymphadenectomy.

The feasibility and advantages of immediate removal of urinary catheter after lobectomy: A prospective randomized trial

Aim

This study aims to evaluate the feasibility and advantages of immediate urinary catheter removal compared with prolonged indwelling catheterization in lung cancer lobectomy.

Design

This study was designed as a prospective, single‐centre, randomized and open‐label clinical study.

Methods

People with lung cancer undergoing lobectomy/pneumonectomy were recruited and randomly allocated to two groups. One group had their urinary catheter removed immediately while the other group had it removed 48 hr after surgery.

Results

No significant difference in the incidence of postoperative urinary retention (POUR) was observed between the two groups. However, the incidence of postoperative catheter‐associated urinary tract infection (CAUTI) in the immediate removal group (6.7%) was lower than the control group (17.2%) (p = .030). Furthermore, the incidence of catheter‐associated emergence agitation (CAEA) in the control group (25.3%) was higher than the immediate removal group (8.9%) (p = .007). The average length of hospital stay of the immediate removal group [6.51(4–11) days] was shorter than the control group [7.20(5–12) days] (p = .002). Immediate removal of urinary catheter appeared to have fewer complications and shorter hospital stay than delayed removal.

Clock dial integrated positioning combined with single utility port video-assisted thoracoscopic surgery: a new localization method for lung tumors

Background

Preoperative localization of lung tumor mainly consisted of two methods: CT-guided percutaneous localization and electromagnetic navigation bronchoscopy-guided localization. However, these invasive methods could result in serious complications. In order to avoid the adverse effects of preoperative invasive localization, we propose a method of intraoperative noninvasive localization for lung tumors: clock dial integrated positioning (CDIP).

Methods

To retrospectively analyze the clinic data about the application of CDIP for 127 lung tumour patients in single utility port video-assisted thoracoscopic surgery (SUPVATS) between June 2017 and October 2017.

Results

One hundred and twenty-four cases (97.64%) underwent thoracoscopic surgery, which including 14 lobectomy, 107 partial resection, 2 lobectomy plus partial resection and 1 left pneumonectomy. Three cases (2.36%) underwent thoracoscopic biopsy. The mean operation time and intraoperative bleeding were 47.9±22.1 min and 70.1±40.3 mL, respectively. The mean postoperative hospital stay and chest drain duration were 3.9±2.2 and 3.6±1.8 days, respectively. There were 118 cases of malignant tumors, including adenocarcinoma (n=101), squamous cell carcinoma (n=9), large cell carcinoma (n=2), small cell lung carcinoma (n=3), and metastatic lung carcinoma (n=3). The remaining nine cases were benign tumors, including granuloma (n=3), intrapulmonary lymph node (n=2), sclerosing hemangioma (n=2), and hamartoma (n=2). The incidence of postoperative complications was 10.2%. There was no mortality, secondary operation, or conversion to open procedure due to massive intraoperative bleeding.

Conclusions

CDIP combined with SUPVATS is a safe, feasible, and effective method for the localization of lung tumors. This novel method can provide a reliable alternative technique when the marker is dislocated.

Uniportal video-assisted thoracic surgery for the treatment of lung cancer: a consensus report from Chinese Society for Thoracic and Cardiovascular Surgery (CSTCVS) and Chinese Association of Thoracic Surgeons (CATS)

Uniportal video-assisted thoracoscopic surgery (UniVATS) has been widely adopted in China, where several ultra-high volume thoracic surgical and training centers are located. The objective of this consensus from Chinese experts was to summarize the current application and give reference for the future development of UniVATS in the treatment of lung cancer. A panel of 41 experts from 21 Chinese hospitals was invited to join this project. The Delphi method was used in this consensus consisting of two rounds of voting. The questionnaire was based on the current clinical evidence. Forty (97.6%) experts completed the 2 rounds of questionnaires. The experts’ experience was relatively similar. We defined the UniVATS as monitor-dependent surgery, no use of rib-spreading and single incision less than 4 cm. Tumor with stage of T1–T3 and N0–N2 is considered amenable to UniVATS. Other consensus was reached on several points outlining the safety and feasibility, surgical skills, learning curve, short-term and long-term outcomes for lung cancer, and current application of subxiphoid and nonintubated UniVATS approach. This consensus statement represents a collective agreement among Chinese experts to suggest that UniVATS is an effective alternative to multi-portal approach, although high-level evidence is expected in the future. Some agreements can be referred in the training of young surgeons.

Subxiphoid uniportal video-assisted thoracoscopic pulmonary segmentectomy: effect of learning curve and future perspectives

OBJECTIVES

Subxiphoid uniportal video-assisted thoracoscopic segmentectomy (SU-VATs) has been widely adopted because it is associated with better postoperative pain scores. Nevertheless, it also has had some limitations that have gradually been decreasing. Therefore, our goal was to evaluate the change in perioperative results with SU-VATs as the learning curve developed to outline the current status and the points that should be of future concern.

METHODS

Three hundred patients who underwent SU-VATs from September 2014 to May 2018 were divided chronologically into 2 groups; group 1 comprised the first 150 cases and group 2 comprised the last 150 cases. Different perioperative variables were analysed and compared between the 2 groups. In addition, the cumulative sum analysis and multivariable logistic regression were conducted to identify the cut-off point and predictors of significant improvement in operative time.

RESULTS

The cumulative sum analysis showed significant improvement in the operative time after the 148th case. Group 2 showed a statistically significant decrease in operative time (104.3 ± 36.7 vs 132 ± 43.1 min; P < 0.001), amount of operative blood loss [50 (80 ml) vs 100 (50 ml); P < 0.001], chest drain duration (2.6 ± 1.6 vs 3.2 ± 1.4 days; P = 0.004) and hospital stay (3.7 ± 1.7 vs 4.2 ± 1.7 days; P = 0.008). The number of dissected lymph nodes was significantly higher in the second group [11 (4) vs 9 (4); P < 0.001].

CONCLUSIONS

Limitations of SU-VATs are being overcome by the improvement in the learning curve and in the expertise of the surgeons. Our future concerns should focus on examining the long-term survival rate, the oncological efficacy and the effect on quality of life.

[Comparison of the Clinical Effect of Uniportal Video-assisted Thoracoscopic Lobectomy and Biportal Video-assisted Thoracoscopic Lobectomy in the Treatment of Lung Cancer]

背景与目的

近年来单孔胸腔镜肺癌根治术逐渐兴起，作为一种新的手术方式，其可行性及安全性尚未得到普遍认可。本研究拟探讨单孔胸腔镜肺癌根治术在治疗Ⅰ期至部分Ⅲa期肺癌病例中的可行性及安全性。

方法

回顾性分析苏州大学附属第一医院胸外科同一治疗组在2018年5月-2019年3月连续进行的胸腔镜肺癌根治术患者的临床资料。排除部分不符合要求的病例后，根据手术方式分为单孔组（55例）和单操作孔组（87例），共142例。分析两组患者的临床数据，进行统计学分析。

结果

142例患者均行肺叶切除+淋巴结清扫术，术后顺利出院，未有围手术期死亡。单孔组和单操作孔组比较，年龄、肿瘤位置、术后病理类型、肿瘤大小、肿瘤的病理性原发灶-淋巴结-转移（pathological tumor-node-metastasis, pTNM）分期的差异均无统计学意义（P > 0.05）。单孔组手术时间更短[(167.65±43.85) min vs (181.71±51.28) min]，术中出血量更少[(57.45±50.19) mL vs (87.47±132.54) mL]，术后引流管留置时间[(4.82±2.82) d vs (5.84±3.43) d]及术后住院天数[(6.91±3.88) d vs (7.74±3.87) d]更短，但差异无统计学意义（P > 0.05）。单孔组的术后总引流量显著低于单操作孔组[(1, 064.82±776.38) mL vs (1, 658.71±1, 722.38) mL]，术后24 h及72 h视觉疼痛评分明显更低[（4.73±0.73）分vs（5.25±0.74）分；（2.16±0.71）分vs（2.55±0.86）分]，差异有统计学意义（P < 0.05）。

结论

在Ⅰ期至部分Ⅲa期肺癌病例中，单孔胸腔镜肺癌根治术安全可行。

Uniportal VATS approach to sub-lobar anatomic resections: literature review and personal experience

Surgical scientific literature contains relatively little information regarding the surgical outcomes of anatomic sublobar resections performed with the uniportal video-assisted thoracoscopic surgery (U-VATS) technique. This paper attempts to evaluate the role of U-VATS segmentectomies in the landscape of a minimally invasive approach to the treatment of early stage non small cell lung cancer (NSCLC).

Preoperative 3D-CT bronchography and angiography facilitates single-direction uniportal thoracoscopic anatomic lobectomy

Background

Competency in video-assisted thoracoscopic surgery (VATS) lobectomy is estimated to be reached after 50 cases. Preoperative identification of individualized pulmonary vascular drainage is essential for the safe and fluent performance of single-direction uniportal VATS (UVATS) anatomic lobectomy. Digital anatomy models established by three-dimensional computed tomography bronchography and angiography (3D-CTBA) is therefore utilized to accumulate variations of the right upper lobe (RUL) veins, as right upper lobectomy is considered to be the most complicated and challenging procedure. This study aims to investigate the perioperative outcomes and learning curve of single-direction UVATS RUL lobectomy assisted with 3D-CTBA.

Methods

The patients who underwent single-direction intercostal UVATS anatomic RUL lobectomy after 3D-CTBA simulation by the same surgeon at Xuzhou Central Hospital between January 2017 and April 2019 were retrospectively reviewed (3D-CTBA group), and consisted of 99 males and 54 females, with a mean age of 61.6 years, with the variations of the RUL vein being assessed preoperatively. They were further divided into group A (30 cases), B (30 cases), C (30 cases), and D (63 cases), in accordance with the order of surgery. Meanwhile, the first 35 cases of single-direction UVATS RUL lobectomy by another experienced surgeon (after the learning curve of this procedure) who did not use 3D-CTBA was enrolled as a control group. The operation time, intraoperative blood loss, stations and numbers of harvested lymph nodes, the incidence of conversion to multiport VATS or thoracotomy, thoracic tube retention for drainage, complications defined under the Clavien-Dindo system, pain score, and postoperative hospital stay were analyzed. The previous surgical experience of the two surgeons was also evaluated.

Results

A significant difference was evident among the 5 groups in terms of age, smoking history, the proportion of neoadjuvant chemotherapy, and T staging of the tumors (P<0.05, respectively). As for the 3D-CTBA group, a total of 29 cases (19.0%) of anomalous RUL posterior segmental pulmonary vein (PV) (V²) drainage were recorded, while the other 124 patients indicated the central type (V2a. Cent.). Of the uncommon RUL V², they could be further classified into 4 types [V2a. Post. (5/153, 3.3%), VX2a. Ant. (17/153, 11.1%), VXX2a. Ant. (3/153, 2.0%), and nonspecific complicated (4/153, 2.6%)]. Single-direction UVATS lobectomy was performed in every patient successfully. No perioperative mortality, major bleeding, conversion to thoracotomy, the addition of incisions, or 30-day unplanned readmission was recorded. One patient in group B reported an injury of a bronchial artery. All cases had an R0 resection. The operation time of group A (109.8±25.4 min) was significantly longer than that of group B (79.7±11.1 min), C (77.0±12.1 min), D (69.3±16.0 min), and the control (86.1±17.9 min, P<0.001 respectively). Moreover, the operation time of the patients in group B, C, and D was slightly shorter than the control, although without significance (P>0.05, respectively). Furthermore, the duration of chest tube drainage in group A (3.7±2.2 days) was noticeably longer than that in group B (3.0±0.9 days), C (2.7±1.6 days), D (2.6±0.8 days), and the control (2.7±1.6 days, P=0.004 among the groups). Similarly, postoperative hospital stay in group A (3.9±2.3 days) was noticeably longer than that in group B (3.0±1.0 days), C (2.8±1.8 days), D (2.6±0.8 days), and the control (2.8±1.8 days, P=0.002 among the groups). The 5 groups indicated comparable stations and numbers of the harvested lymph nodes, intraoperative blood loss, postoperative total chest drainage volume, incidence of complications, and pain scale on the 14^th day after surgery (P>0.05, respectively).

Conclusions

Preoperative 3D-CTBA digital anatomy facilitates the safe and fluent performance of single-direction UVATS anatomic right upper lobectomy, with a learning curve of 30 cases. High-quality trials for better evidence are called for to verify these findings.

Descriptive review of patent ductus arteriosus ligation by video-assisted thoracoscopy in pediatric population: 7-year experience

Background

Less invasive procedures such as video-assisted thoracoscopic surgery (VATS) are desirable for patent ductal artery (PDA) ligation when pharmacologic or conservative approaches fail. Studies done on VATS-PDA ligation showed better outcomes when compared to open thoracotomies, however, complication rates remain conflicting. Learning curve can be a postulated reason which may also precludes the acceptability. We therefore sought to report our single centered 7-year experience of PDA closure with VATS.

Methods

Single centered retrospective study of 127 patients who underwent PDA ligature with VATS from February 2012 to October 2018. The cohort was divided into two groups, i.e., 2012-2014 (early phase) and 2015-2018 (late phase) and were further compared. Early and late outcomes, including mortality and morbidity, were analyzed.

Results

The included patients had a mean age of 1.7 years. Among them, preterm infants accounted for 38.6%, there was no operative mortality. Six deaths (4.7%) occurred during in-hospital stay, predominantly in the neonatal intensive care unit (NICU) due to massive cerebral bleeding and cardiopulmonary failure. Overall conversion rate to thoracotomy was 16.5%. It decreased from 20% in early phase to less than 5% in late phase. Fifty patients (39.4%) required transfer to the NICU. The mean in-hospital stay for the remainders was only 2.2±1.6 days. All but two patients discharged home survived follow-up period without any adverse events and nobody among non-converted cases expressed concerns regarding chest deformity. A 5-year probability of survival estimated according to the Kaplan-Meier curve was 93.6%.

Conclusions

VATS is a safe as well as efficient method for closure of PDA that ensures satisfactory late cosmetic results. Postoperative mortality and extended hospital stay may be attributed to prematurity. Although learning curve exists it does not affect the safety and late outcomes.