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Eur J Cardiothorac Surg 2006;29:806-809
© 2006 Elsevier Science NL

Developing a VATS lobectomy programme — can VATS lobectomy be taught?

Royal Infirmary of Edinburgh, United Kingdom

Received 29 September 2005; received in revised form 2 February 2006; accepted 7 February 2006.

^_* Corresponding author. Address: 24 Beaulands Close, Cambridge CB4 1JA, United Kingdom. Tel.: +44 1223350952; fax: +44 1223350952. (Email: Drjiferguson{at}aol.com).

	Abstract

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

 
Objective: Although VATS lobectomy has been demonstrated to be safe and effective, the technique is not widely practiced. This may, in part, reflect difficulty in acquiring appropriate skills. We have evaluated the effect of experience and training on surgical outcomes during the development and establishment of a VATS lobectomy programme. Methods: Data were collected prospectively on 276 consecutive VATS lobectomies under the care of a single consultant as either the primary surgeon or supervising four trainees. The series was divided into cohorts of 46 patients. These comprised one trainee cohort and five sequential consultant cohorts. Statistical analysis utilised standard tests of significance. Results: Increasing experience with the VATS lobectomy programme was associated with a significant reduction in operating time but intraoperative blood loss and postoperative stay were not influenced by increasing consultant surgical experience. Training was associated with a mean increase of 22 min operative time (p = 0.0005) but no increase in intraoperative blood loss, morbidity, mortality or postoperative stay. The 46 trainee operative times were similar to the first 46 consultant cases. Conclusions: VATS lobectomy can be safely taught to trainee thoracic surgeons. However, in view of the limited number of centres undertaking VATS lobectomy, training should be coordinated at a national level to concentrate experience and improve uptake of this technique.

Key Words: VATS • Training • Lobectomy • Lung

	1. Introduction

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

 
The first video-assisted thoracoscopic lobectomy was performed in 1991[1]. Since that initial report, the literature has shown that VATS lobectomy is technically feasible [1], safe [2] and does not compromise the extent of the resection of the primary tumour or the management of regional lymph nodes [3]. Furthermore, VATS lobectomy for non-small cell lung cancer does not compromise the long-term survival of patients [2,4–6]. VATS lobectomy is acceptable to patients [7], provides reduced perioperative pain [8] and is an economically viable alternative to traditional open techniques [9] VATS lobectomy is now generally accepted as a safe, oncologically sound and valid alternative to open lobectomy in early-stage lung cancer.

Despite the apparent acceptability of this procedure in appropriate cases, few centres perform this form of surgery with more than 45% of VATS lobectomies in the UK, for example, performed by a single surgeon [10]. The question remains, therefore, can this technique be taught and widely disseminated or will it remain limited to a few thoracic surgeons in isolated centres?

This paper examines the effect of increasing experience on the performance of a self-taught surgeon and the impact of training of juniors on surgical outcomes during the development and establishment of a VATS lobectomy programme.

	2. Materials and methods

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

 
The study examines the results of the first 230 VATS lobectomies performed by a single surgeon who was self-trained and the first 46 VATS lobectomies performed by four trainee surgeons under the supervision of the same surgeon. The four trainee surgeons had each performed at least 50 anatomical pulmonary resections via thoracotomy and were well versed in less complex VATS surgery before starting the VATS lobectomy training programme.

All patients with malignant disease were staged preoperatively by contrast-enhanced CT, bronchoscopy and cervical mediastinoscopy at which ipsilateral stations 2 and 4 and station 7 were routinely biopsied. Where indicated, additional isotope, MR or ultrasound scans were utilised to elucidate problematic findings. Only patients with preoperative stage I or II disease were considered for surgery.

The resection were performed using a 4 cm anterior utility port and up to three (usually two) 10 mm ports. The resection technique was entirely video imaged using a 0° 10 mm videoscope. The hilar structures were managed by individual dissection, and isolation entirely analogous to open lobectomy. Vessels and bronchus were divided by endostaplers loaded with staples of appropriate size for the structure concerned. All hilar lobar nodes were excised. The specimen was removed via the anterior utility port using a plastic bag. The anterior port was not retracted, ipsilateral stations 2, 4, 8 and 9 (and 5 and 6 on the left side) were then explored and all visible nodes excised. Station 7 was re-biopsied in the presence of enlarged nodes.

All data were collected prospectively. All VATS lobectomies performed since the start of the programme either by the consultant or by trainee surgeons were included. Cases undertaken by senior surgeons under supervision were excluded. The consultant surgeon did not receive training in this technique before starting the programme.

The parameters of age, lobe removed, operating surgeon, operative time, blood loss, preoperative lung function, complications, morbidity, mortality, pathology and postoperative stay were recorded. Preoperative lung function was classified as abnormal if FEV1, FVC, Tco or Kco were more than two standard deviations away from their preoperative predicted value.

The data were grouped into the first 46 trainee cases and the first 230 consultant cases were divided into five sequential comparison groups of 46 cases.

Statistical analysis was performed using unpaired t-test and Fisher's PLSD test.

Fisher's PLSD calculates the ‘least significant difference’ between groups for a given significance level and then compares the actual mean difference to this. Fisher's PLSD method was used to adjust for multiple pairwise comparisons.

	3. Results

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

 
The data set was 100% complete.

The results are summarised in Tables 1–3 .

Table 2 shows that when the total consultant cases were compared to the total trainee cases there was no significant differences in age, pathology, preoperative lung function, postoperative stay, mean blood loss, conversion to thoracotomy postoperative bleeding or morbidity. Consultant group 1 shows a much higher rate of conversion to thoracotomy which reflects the initial learning curve of the consultant as he refined his surgical approach. The trainee group did not have a high conversion rate as they benefited from the consultant's supervision and expertise.

Table 3 compares operation time, blood loss and postoperative stay for each of the five consultant groups with the trainee cases. The consultant surgeon became significantly quicker as he became more experienced. The first 46 consultant cases took significantly longer than those in groups 2–5. Indeed, cases 47–92 (group 2) took significantly longer than the final cohort of consultant cases. The trainee cases took a similar amount of operation time to the first 46 consultant cases, however, the trainees took longer than those in consultant groups 2–5.

Table 3 also shows that the first 46 consultant cases had significantly more blood loss than the trainee cases and more than all subsequent consultant groups. The trainee group again benefited from the consultant's experience. The mean blood loss was less than 160 ml for all the groups. The differences between groups may be statistically significant, however, it is of little clinical significance.

	4. Discussion

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

 
This study set out to examine the effect of experience and of training on surgical outcomes during the development and establishment of a VATS lobectomy programme. The effect of experience and the effect of training will be discussed separately.

4.1 The effect of experience
When the first 46 consultant cases (group1) are compared to the other subsequent groups of consultant cases (see Table 3), the mean operative time is significantly greater in the first cohort of patients. The mean operative time in group 2 is also significantly greater than group 5. There are no other significant differences between the groups. Mean operative time decreases with experience and this decrease continues beyond the first set of 46 patients suggesting, as might be anticipated, continued improvement in performance with increasing experience.

The blood loss was significantly higher in consultant group 1 compared with any other consultant group. There were no significant differences in blood loss between consultant groups 2, 3, 4 and 5. Although blood loss throughout the series was always less than 160 ml and of no clinical significance, the reduction with experience, we believe, demonstrates that the processes of defining the optimal operative strategy had largely been accomplished within the first cohort of cases.

The mean postoperative stay was not affected by increasing experience reflecting the effect of social issues on patient discharge in the UK.

Pleural adhesions were not considered a contraindication except when there was obliteration of the entire pleural cavity. An incomplete or absent fissure was only a contraindication to VATS lobectomy during the consultant's own early learning phase. This is reflected in the high conversion to thoracotomy rate in consultant cases 1–46. The trainees were spared an early high conversion rate by consultant supervision and guidance.

4.2 The effect of training
The age of patients and the case mix of lower, upper and middle lobectomies were similar for trainees and consultants.

Training results in an increase in operative time when compared to consultant groups 2, 3, 4 and 5. The operative time of the first 46 consultant cases was similar to the first 46 trainee cases. Overall, the increase in time associated with training was approximately 22 min and it is possible that this increase in time would diminish with the increasing experience of individual trainees.

Blood loss in the trainee group was significantly less than in consultant group 1, reflecting that the optimal operative strategy had already been established and was utilised in the trainee cases.

Training in VATS lobectomy has no adverse effect on influence mortality, blood loss or postoperative stay. As with other cardiothoracic procedures VATS lobectomy can be safely and effectively taught to trainees [11].

The available literature and this study show that VATS lobectomy is a safe and valid operation that can be taught to trainees. Audit within the UK shows that only a few centres perform this technique and more than 45% of all UK VATS resections are performed/supervised by one consultant surgeon [10]. This situation would appear to be replicated across Europe.

We suggest that in view of the limited number of centres undertaking VATS lobectomy, training in this form of thoracic surgery should be coordinated at a national level in order to concentrate experience and improve uptake of this valuable technique.

	Appendix A

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

 
Conference discussion

Dr K. McManus (Belfast, Ireland): You would think that VATS lobectomy, being advanced thoracic surgery, should be one of the main topics at a meeting like this. This is the one paper on VATS lobectomy in adults in this whole meeting. That certainly reflects VATS lobectomy being done in the UK, and it looks as though it reflects what is being done in Europe. I don’t believe that you can teach this VATS technique. Your study says that it can be taught, but this is the only paper I’ve seen anywhere on teaching VATS lobectomy. All the other surgeons I know who are doing this surgery are self-taught. How do you expect that training will be organised so that surgeons can be taught how to do this operation, or are we going nowhere with this?

Dr Ferguson : I think we should take the approach, certainly within the UK, the same approach as was done with paediatric cardiac surgery, in that a national job centre in Birmingham for paediatric cardiac surgery is advertised nationally and applied for nationally and is out with the normal local training environment. So you establish national trainers, one-year scholarships are set up, and they are advertised nationally to the entire cohort of trainees within that country and beyond.

Dr D. Branscheid (Grosshansdorf, Germany): Is lymph node dissection included in your learning curve?

Dr Ferguson : The lymph node dissection performed in the unit is identical to that performed by the open technique. It is sampling of all visible stations, and we feel that because of the magnification and reduced blood loss from the endoscopic technique we get a better view and we take out more nodes. That is across the training, both of the consultant training and the trainees.

Dr W. Weder (Zurich, Switzerland): You, and especially Bill Walker, have to be congratulated for the pioneering work you have done in this field, and also that you are now studying how this technology can be taught. My question is, how much experience does a trainee need in open lobectomies before he can go into a training program for thoracoscopic lobectomy, or can thoracoscopic lobectomy be taught without a decent experience in open lobectomy?

Dr W. Walker (Edinburgh, UK): Perhaps I can answer that. I think the truth is that you should be an experienced surgeon with conventional surgery and know your way around the hilum. This is something to do in the late stages of training when someone is about to depart into their outside practice. And if I could just pick up on a point that Kieran made, I’d like to paraphrase what the Jesuits say: If you give me the senior trainee, I’ll give you the VATS surgeon.

	Footnotes

 
Presented at the joint 19th Annual Meeting of the European Association for Cardio-thoracic Surgery and the 13th Annual Meeting of the European Society of Thoracic Surgeons, Barcelona, Spain, September 25–28, 2005.

	References

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

 

1. Roviaro G, Rebuffat C, Varoli F, Vergani C, Mariani C, Maciocco M. Videoendoscopic pulmonary lobectomy for cancer. Surg Laparosc Endosc 1992;2(3):244-247.[Medline]
2. McKenna Jr. RJ, Wolf RK, Brenner M, Fischel RJ, Wurnig P. Is lobectomy by video-assisted thoracic surgery an adequate cancer operation?. Ann Thorac Surg 1998;66(6):1903-1908.[Abstract/Free Full Text]
3. Kondo T, Sagawa M, Tanita T, Satoh M, Ono S, Matsumura Y, Fujimura S. Assessment of systematic nodal dissection by VATS lobectomy for lung cancer. Kyobu Geka 2000;53(1):8-12.[Medline]
4. Roviaro G, Varoli F, Vergani C, Nucca O, Maciocco M, Grignani F. Long-term survival after videothoracoscopic lobectomy for stage I lung cancer. Chest 2004;126(3):725-732.[Abstract/Free Full Text]
5. Iwasaki A, Shirakusa T, Shiraishi T, Yamamoto S. Results of video-assisted thoracic surgery for stage I/II non-small cell lung cancer. Eur J Cardiothorac Surg 2004;26(1):158-164.[Abstract/Free Full Text]
6. Walker WS, Codispoti M, Soon SY, Stamenkovic S, Carnochan F, Pugh G. Long-term outcomes following VATS lobectomy for non-small cell bronchogenic carcinoma. Eur J Cardiothorac Surg 2003;23(3):397-402.[Abstract/Free Full Text]
7. Sugiura H, Morikawa T, Kaji M, Sasamura Y, Kondo S, Katoh H. Long-term benefits for the quality of life after video-assisted thoracoscopic lobectomy in patients with lung cancer. Surg Laparosc Endosc Percutan Tech 1999;9(6):403-408.[CrossRef][Medline]
8. Ohbuchi T, Morikawa T, Takeuchi E, Kato H. Lobectomy: video-assisted thoracic surgery versus posterolateral thoracotomy. Jpn J Thorac Cardiovasc Surg 1998;46(6):519-522.[Medline]
9. Nakajima J, Takamoto S, Kohno T, Ohtsuka T. Costs of videothoracoscopic surgery versus open resection for patients with of lung carcinoma. Cancer 2000;89(11 Suppl.):2497-2501.[CrossRef][Medline]
10. Thoracic surgical returns 2001–2002. Society of Cardiothoracic Surgeons of U.K. and Ireland. http://www.ctsnet.org/file/NationalSummary2001To2002.xls..
11. Goodwin AT, Birdi I, Ramesh TP, Taylor GJ, Nashef SA, Dunning JJ, Large SR. Effect of surgical training on outcome and hospital costs in coronary surgery. Heart 2001;85(4):454-457.[Abstract/Free Full Text]

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