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Eur J Cardiothorac Surg 2004;26:393-395
© 2004 Elsevier Science NL

A prospective audit evaluating the role of video-assisted cervical mediastinoscopy (VAM) as a training tool

A.E. Martin-Ucara,b, G.K. Chettya, R. Vaughanb, D.A. Wallera*

a Department of Thoracic Surgery, Glenfield Hospital, Groby Road, Leicester LE3 9QP, UK
b The Price-Thomas Thoracic Surgical Unit, Northern General Hospital, Sheffield, UK

Received 20 January 2004; received in revised form 11 March 2004; accepted 15 March 2004.

* Corresponding author. Tel.: +44-116-256-3959; fax: +44-116-236-7768
e-mail: david.waller{at}uhl-tr.nhs.uk


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 
Objective: Cervical mediastinoscopy is an important diagnostic and staging technique. Limited operative field and visibility have traditionally made it a difficult procedure to learn and supervise. Video-assisted techniques can aid training in the procedure. We designed a prospective study to assess the usefulness of video-assisted mediastinoscopy (VAM) as a training tool. Methods: 43 patients were operated upon by two trainees during their initial formation in general thoracic surgery (25 patients in 15 months, and 18 patients in 9 months, respectively). Indications: staging (n=23), diagnosis of enlarged mediastinal nodes (n=14), and diagnosis/staging (n=6). End-points of the study: operative time, need of consultant assistance during procedures, and ability of the trainee to identify all nodal stations independently. Results: There were no complications. The mean operative time was 29 (range 18–51) min. Valid histological samples were obtained in all cases. There were no false negative results in the 13 patients who underwent subsequent lung resection (sensitivity 100%). Operative time (R2=0.83 and 0.77), need for consultant assistance (R2=0.98 and 0.94), and failure to independently reach all nodal stations (R2=0.95 and 0.94) significantly decreased with experience in both trainees' cases (cubic curve fit; P<0.001 throughout). Discussion: VAM permits a rapid learning and adequate supervision of the technique without compromising safety, operative time or completeness of the procedure. The main advantages are: increased visual field, image magnification, adequate light source and the ability to use two instruments simultaneously. VAM should be the technique of choice in thoracic surgical teaching units.

Key Words: Learning curve • Teaching • Cervical mediastinoscopy


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Results
 4. Discussion
 References
 
Cervical mediastinoscopy is an important diagnosis and staging technique [1,2]. In the United Kingdom over 2000 mediastinoscopies are performed per year [3]. The procedure carries a low incidence of major complications, estimated at around 0.5% in the largest series [4,5]. However, when they occur, can be of serious consequences. The more common major complication reported is iatrogenic injury to the major vessels, which can even require repair under cardiopulmonary bypass circuit [4,5]. Other reported complications include damage to recurrent laryngeal nerve on the left side [4], oesophagus [6] and even the tracheo-bronchial tree [5,7].

With increasing demands for outcomes and decreasing opportunities for training, management of the surgical learning curve is vital to ensure adequate training without adverse results. Technical developments can aid minimizing the learning curve effect. The advent of video-assisted techniques has enabled the procedure to be performed under a magnified visual field, allowing supervision during initial training [8].

We aimed to assess the effect of video-assisted mediastinoscopy (VAM) on the training of two general thoracic surgical trainees during their initial experience.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Results
 4. Discussion
 References
 
Two first-year general thoracic surgical trainees performed VAM on 43 patients. A total of 25 patients [19 males and 6 females, mean age 59 (range 29–82) years] over a 15-month period (January 2001–April 2002) by trainee A attached to two different teaching units; and 18 patients [12 males and 6 females, mean age 64 (range 31–80) years] over a 9-month period (May 2002–January 2003) by trainee B. Indications for surgery were: staging of lung cancer (n=23), diagnosis of enlarged mediastinal nodes (n=14), and both diagnosis/staging (n=6). Median FEV1 was 2.2 (range 1.05–5.20) l.

The procedures were performed as a day-case in a dedicated thoracic surgical operating room with the patients under general anaesthesia in a supine position with neck extension. During the procedures the consultant thoracic surgeon remained in the operating theatre supervising the operations on the video monitors. When required, he would provide direct operative assistance if difficulties were encountered. The patients were routinely extubated in the operating theatre at the end of the procedure.

Selected end-points of the study were: operative time, need of consultant assistance during the procedures, and the ability of the trainee to reach and identify all nodal stations independently [pretracheal (station 3), high (stations 2R and 2L) and low (stations 4R and 4L) paratracheal and subcarinal (station 7) regions]. There was no attempt of performing extended mediastinoscopy [9], but we aimed to identify all nodal stations independently of the indications for the procedure. Other end-points included complications and false negative results on patients subsequently undergoing pulmonary resection with systematic mediastinal nodes dissection for malignancy. The results were prospectively recorded and analyzed with the use of regression curves.


   3. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
4. Discussion
 References
 
There was no hospital mortality or morbidity in the group. Valid histological samples were obtained in all cases.

3.1. Patholology findings
Positive pathological diagnoses were found in 23 cases. These included: 8 cases of metastatic nodal deposits, 3 of lymphoma and benign disease in 12 cases (5 sarcoidosis, 5 tuberculosis and 2 benign hyperplastic lymphatic tissue). In the remaining 20 cases no positive diagnosis was made (19 in patients staged for non-small cell lung cancer and 1 with malignant mesotheloma). There were no false negative results in those patients who proceeded to resection. Diagnostic and staging procedures were distributed evenly during the experience.

3.2. Learning process
The mean operative time was 29 (range 18–51) min and rapidly reduced as experience increased (R2=0.83 and 0.77 in both trainees) (Fig. 1) . Need for direct senior surgeon's assistance (R2=0.98 and 0.94) (Fig. 2) , and failure to independently reach all nodal stations (R2=0.95 and 0.94) (Fig. 3) significantly decreased with experience (cubic curve fit; P<0.001 in all cases). After a short initial learning period, the trainees were able to identify all stations, obtain adequate histological samples, and perform the procedure without direct assistance in 30 (86%)of the last 35 cases.



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  		Fig. 1. Operating time rapidly decreased in both trainees as their experience increased (R2=0.83 trainee A; and R2=0.77 trainee B; P<0.001 in both cases).

 


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  		Fig. 2. After an initial learning period, the need for direct senior assistance significantly reduced (R2=0.98 trainee A; and R2=0.94 trainee B; P<0.001 in both cases).

 


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  		Fig. 3. Failure for the trainee to independently reach all nodal stations (R2=0.95 trainee A; and R2=0.94 trainee B; P<0.001 in both cases) also declined after the initial experience.

 

   4. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
References
 
Cervical mediastinoscopy remains the standard for mediastinal staging of lung cancer and is also effective for the diagnosis of mediastinal lymphadenopathy [1,2,10,11]. Traditionally cervical mediastinoscopy has been a technique difficult to learn and supervise due to the restricted visual field and the considerable distance between visual point and operative target. Training in any surgical procedure carries a learning curve, as demonstrated in different thoracic surgical procedures. This learning curve has been analysed in techniques adopting new technologies such as video-assisted thoracic surgery (VATS) for pneumothorax [12], and laparoscopic anti-reflux procedures [13]. Most surgeons would agree that the effects of this learning curve could be enhanced if a technique is difficult to supervise.

Following an initial report in the use of VAM [14], Venissac and co-workers have recently reported a series of 240 operations performed with this technique, deeming the procedure safe and effective [8]. Another recent report explored the feasibility of VAM following chemotherapy regimes with good results [15]. In addition to the advantages in supervision, one of the advantages described in the use of VAM is the facilitation of simultaneous visualization and bimanual dissection that has enabled two groups of authors to report their experience performing formal lymph node dissection via this approach [16,17].

The important role of VAM as an aid for learning has not been fully explored. We aimed to assess how this technique could impact the learning curve of two general thoracic surgical trainees on his initial year of training. After a very short learning process (of around five cases in our experience) VAM permits a rapid learning and adequate supervision of the technique without compromising safety, operative time or completeness of the procedure. Although only a small number of cases in this series underwent pulmonary resection after a negative VAM, there were no false negatives when the resected specimens from the routine lymphadenectomy at time of surgery were analyzed. The main advantages we encountered are: increased visual field, image magnification, adequate light source and the ability to use two instruments simultaneously. We recommend VAM as the technique of choice in teaching units responsible for training.


   Footnotes
 
Presented at the 10th Annual Meeting of the European Society of Thoracic Surgeons, Istanbul, Turkey, October 26–28, 2002.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Results
 4. Discussion
 References
 

  1. Carlens E. Mediastinoscopy: a method for inspection and tissue biopsy of the superior mediastinum. Dis Chest 1959;36:343-352.[Medline]
  2. Pearson F.G. Mediastinoscopy: a method of biopsy in the superior mediastinum. J Thorac Cardiovasc Surg 1965;49:11-21.[Medline]
  3. UK Thoracic Surgical Registry. Society of Cardiothoracic Surgeons of Great Britain and Ireland. Annual returns; 1991–2000.
  4. Bacsa S., Czako Z., Vezendi S. The complications of mediastinoscopy. Panminerva Med 1974;16(11–12):402-406.[Medline]
  5. Puhakka H.J. Complications of mediastinoscopy. J Laryngol Otol 1989;103(3):312-315.[Medline]
  6. Dernevik L., Larsson S., Pettersson G. Esophageal perforation during mediastinoscopy—the successful management of 2 complicated cases. Thorac Cardiovasc Surg 1985;33(3):179-180.[Medline]
  7. Schubach S.L., Landreneau R.J. Mediastinoscopic injury to the bronchus: use of in-continuity bronchial flap repair. Ann Thorac Surg 1992;53(6):1100-1103.[Abstract]
  8. Venissac N., Alifano M., Mouroux J. Video-assisted mediastinoscopy: experience from 240 consecutive cases. Ann Thorac Surg 2003;76(1):208-212.[Abstract/Free Full Text]
  9. Ginsberg R.J., Rice T.W., Goldberg M., Waters P.F., Schmocker B.J. Extended cervical mediastinoscopy. A single staging procedure for bronchogenic carcinoma of the left upper lobe. J Thorac Cardiovasc Surg 1987;94(5):673-678.[Abstract]
  10. Venuta F., Rendina E.A., Pescarmona E.O., de Giacomo T., Flaishman I., Guarino E., Ricci C. Ambulatory mediastinal biopsy for hematologic malignancies. Eur J Cardiothorac Surg 1997;11(2):218-221.[Abstract]
  11. Hujala K.T., Sipila J.I., Grenman R. Mediastinoscopy—its role and value today in the differential diagnosis of mediastinal pathology. Acta Oncol 2001;40(1):79-82.[CrossRef][Medline]
  12. Waller D.A. Video-assisted thoracoscopic surgery for spontaneous pneumothorax—a 7-year learning experience. Ann R Coll Surg Engl 1999;81(6):387-392.[Medline]
  13. Deschamps C., Allen M.S., Trastek V.F., Johnson J.O., Pairolero P.C. Early experience and learning curve associated with laparoscopic Nissen fundoplication. J Thorac Cardiovasc Surg 1998;115(2):281-284.[Abstract/Free Full Text]
  14. Venissac N., Alifano M., Karimdjee B.S., Guillot F., Rabary O., Mouroux J. Video-mediastinoscopy in management of patients with lung cancer: a preliminary study. Surg Laparosc Endosc Percutan Tech 2000;10(2):71-75.[CrossRef][Medline]
  15. Lardinois D., Schallberger A., Betticher D., Ris H.B. Postinduction video-mediastinoscopy is as accurate and safe as video-mediastinoscopy in patients without pretreatment for potentially operable non-small cell lung cancer. Ann Thorac Surg 2003;75(4):1102-1106.[Abstract/Free Full Text]
  16. Hurtgen M., Friedel G., Toomes H., Fritz P. Radical video-assisted mediastinoscopic lymphadenectomy (VAMLA)—technique and first results. Eur J Cardiothorac Surg 2002;21(2):348-351.[Abstract/Free Full Text]
  17. Leschber G., Holinka G., Linder A. Video-assisted mediastinoscopic lymphadenectomy (VAMLA)—a method for systematic mediastinal lymphnode dissection. Eur J Cardiothorac Surg 2003;24(2):192-195.[Abstract/Free Full Text]



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