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Ann Thorac Surg 1997;64:211-215
© 1997 The Society of Thoracic Surgeons

Original Articles: General Thoracic

Video-Assisted Thoracic Surgery: Has Technology Found its Place?

Michael J. Mack, MD, Granger R. Scruggs, Kevin M. Kelly, PhD, Hani Shennib, MD, Rodney J. Landreneau, MD

Columbia Hospital at Medical City Dallas, Dallas, Texas, The Montreal General Hospital, Montreal, Canada, and Allegheny General Hospital,Pittsburgh, Pennsylvania

Accepted for publication January 17, 1997.


   Abstract
Top
 Footnotes
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background. Since the introduction of minimally invasive surgical techniques in thoracic surgery in 1990, video-assisted thoracic surgery (VATS) has become the approach for many thoracic operations. The role of VATS has slowly evolved but has not been clearly defined. To better understand the role of VATS, we undertook a survey of practicing thoracic surgeons.

Methods. A questionnaire was sent to members of the General Thoracic Surgery Club asking the role of VATS in their practice and their opinions regarding appropriate applications, advantages, and limitations of the approach.

Results. Two hundred of the 229 members (87.3%) responded to the questionnaire. In this largely academic (66.3%) group of thoracic surgeons, 72% of whom had more than 10 years experience in general thoracic surgery, VATS was the preferred approach (>50% response) for the management of pleural disease, lung biopsy, recurrent pneumothorax, and sympathectomy. A majority of respondents thought that VATS was an acceptable approach for the diagnosis of the indeterminate pulmonary nodule and of anterior and posterior mediastinal masses, and for the management of early empyema, clotted hemothoraces, secondary pneumothorax, limited lung cancer treatment, and benign esophageal disease. Video-assisted thoracic surgery was thought to be unacceptable or investigational by a majority for thymectomy, lobectomy, and lung volume reduction operations. Video- assisted thoracic surgery still represents only a small portion of the thoracic procedures performed, but there is a gradual increase in its rate of use, although 38.1% expressed concern regarding overuse. The main limitation was thought to be in the management of oncologic disease.

Conclusions. It appears that VATS is a valuable addition to the practice of thoracic surgery, but significant limitations exist. Although there appear to be many specific indications defined, there is still a significant evolutionary component.


   Introduction
Top
 Footnotes
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Video-assisted thoracic surgery (VATS) was introduced in 1990 and was quickly used as an approach strategy for many thoracic diseases [1–3]. Although many benefits were immediately apparent including decreased pain and shortened hospital stay [4], significant concern arose regarding increased cost, overuse, and compromise of surgical principles, especially in oncologic disease [5–7]. Only a few controlled studies have been performed comparing the efficacy of VATS with that of conventional thoracic surgical procedures [8, 9]. To gain an assessment of the impact of VATS on the practice of thoracic surgery and attempt to define a current role for the procedure, we performed a survey of a group of thoracic surgeons whose practice is mainly devoted to noncardiac thoracic surgery.


   Material and Methods
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
In November 1995, a questionnaire was sent to members of the General Thoracic Surgery Club. The club is an organization of thoracic surgeons who devote more than 50% of their practice to noncardiac thoracic surgery. The questionnaire contained 15 questions regarding demographics and opinions of thoracic surgeons about VATS including frequency of use, the role in their practice, the limitations of the procedure, and their opinions regarding which procedures were appropriate for VATS.

The questionnaire was mailed to all 229 members of the General Thoracic Surgery Club in November 1995. A second mailing was sent to those members who did not respond to the first mailed questionnaire. Responses were then entered on a spreadsheet format. Statistical analysis of responses was performed on an IBM compatible computer using Statistical Analysis Software (SAS), Version 6.06.


   Results
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Of the 229 questionnaires mailed, 200 were returned, of which 189 were completed in full. The results were presented in an oral format at a breakfast session at the Annual Meeting of The Society of Thoracic Surgeons in January 1996 and the Annual Meeting of the General Thoracic Surgery Club in March 1996. Demographics of the surveyed population of general thoracic surgeons are shown in Figures 1and 2GoGo. One hundred thirty (66.3%) of the surgeons surveyed practice in an academic or government institution, whereas 66 (33.7%) categorized themselves as working in a largely private practice setting. The surveyed population was quite experienced in thoracic surgery, with 51.5% having practiced thoracic surgery for 15 or more years and more than 90% having at least 5 years of practice experience.



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  		Fig 1. . Type of practice of the General Thoracic Surgery Club respondents (n = 196).

 


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  		Fig 2. . Years in practice of the General Thoracic Surgery Club respondents (n = 196).

 
The majority of thoracic surgeons (60.2%) used VATS in 20% or less of all the general thoracic surgical cases (Fig 3Go). Fifty-four percent of surgeons believed that the frequency of VATS in their practice had remained the same within the past year, whereas one third believed they were using VATS more and 12.4% believed they were using VATS less (Fig 4Go).



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  		Fig 3. . Percentage of general thoracic surgical procedures performed by video-assisted thoracic surgery (VATS) (n = 196).

 


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  		Fig 4. . Change in the frequency of video-assisted thoracic surgery in the respondents' practice in the past year (n = 196).

 
Figure 5Go shows responses to the question of whether thoracic surgeons believed the frequency of VATS would increase, decrease, or remain the same in their practice. Although the majority (62.6%) believed that the role of VATS had stabilized, approximately one third anticipated using VATS more in the future.



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  		Fig 5. . Percentage of respondents who anticipate the frequency of video-assisted thoracic surgery in their practice to increase, stay the same, or decrease (n = 196).

 
Regarding appropriate use of VATS in the practice of thoracic surgery, the majority (51.9%) believed that the rate of use was about right. However, a substantial proportion (38.1%) believed that significant overuse existed (Fig 6Go). Surveyed surgeons were then given 18 diseases or conditions for which thoracic surgical procedures are frequently used and then asked their opinion of whether VATS was the preferred approach for management, an acceptable approach, investigational, or unacceptable for the specific procedure. Those results are listed in Table 1Go.



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  		Fig 6. . Percentage of respondents who believe video-assisted thoracic surgery is overused, properly used, or underused in thoracic surgery (n = 196).

 

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  		Table 1. . Role of Video-Assisted Thoracic Surgery in the Management of Thoracic Surgical Problems
 
Regarding specific procedures, VATS was believed to be the preferred approach for a number of relatively simple thoracic procedures. Determination of whether a VATS approach is the preferred or an acceptable, investigational, or unacceptable one was done as follows: if more than 50% of the respondents chose that category, determination of the role of the procedure was made. Video-assisted thoracic surgery was believed to be the preferable approach for diagnosis of indeterminate pleural effusions, the diagnosis of indeterminate pleural masses, and lung biopsy for diffuse disease in non–ventilator-dependent patients (see Table 1Go). Video-assisted thoracic surgery was also believed to be the preferred approach by the majority of respondents for treatment of spontaneous pneumothorax, performance of a sympathectomy, and the therapeutic management of malignant pleural effusions. Video-assisted thoracic surgery was believed to be an acceptable approach, but not necessarily the preferred approach, by a majority of thoracic surgeons for the diagnosis of indeterminate solitary pulmonary nodules, the management of early empyemas, the diagnosis of posterior mediastinal masses, and the management of effusive pericardial disease. It also was believed to be an acceptable approach for the diagnosis of anterior mediastinal masses.

The majority of thoracic surgeons believed that it was either the preferable or acceptable approach for the management of clotted hemothoraces, treatment of secondary pneumothorax, and performance of a wedge resection for lung cancer in patients with limited pulmonary reserve. The majority also believed that it was acceptable or preferable for the management of benign esophageal disease.

In the more complex procedures, VATS was still thought to be investigational or unacceptable. The performance of lung volume reduction operations, VATS lobectomy, and thymectomy for myasthenia gravis still fell into either an unacceptable or investigational category according to a majority of the respondents.

Additional questions in the survey addressed the views of surgeons regarding the limitation of VATS and what factors precluded wider use of the video-assisted approach. The overwhelming majority of surgeons (78%) expressed concern about the ability to maintain surgical oncologic principles while performing VATS procedures (Fig 7Go). A slight majority (51%) believed existing instrumentation was still a limiting factor, and operating time, age, experience, and bias were other factors mentioned.



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  		Fig 7. . Answers to the question: What are the limitations of video-assisted thoracic surgery? (n = 200). (Oncol. = oncologic;OR=operating room.)

 
The majority of thoracic surgeons (74.6%) believed that VATS was a valuable addition to thoracic surgery (Fig 8Go).



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  		Fig 8. . Respondents' opinions about the role of video-assisted thoracic surgery in thoracic surgery (n = 197). (Add. = addition.)

 
It was also a consensus of the surveyed surgeons that VATS was still a procedure in the domain of thoracic surgery and that the performance of even simple diagnostic procedures by nonsurgeons was not appropriate (Fig 9Go).



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  		Fig 9. . Percentage of respondents who think it is appropriate for a pulmonologist to perform simple diagnostic thoracoscopic procedures (n = 193).

 

   Comment
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Five years ago a joint committee of The Society of Thoracic Surgeons and The American Association for Thoracic Surgery believed a new designation for thoracoscopy was necessary to portray adequately the wide spectrum of procedures that were now being performed by the thoracoscopic approach [10]. Hence, the name video-assisted thoracic surgery (VATS) was born in an attempt to better convey the wide spectrum of procedures now performed thoracoscopically. It has now been 5 years since the wide introduction of video thoracoscopic procedures; therefore, it is appropriate to make an assessment of this approach for performing thoracic surgical procedures.

Although any survey of a population is of course subjective, we believed we could obtain an accurate assessment of the current role of VATS from survey from a group of surgeons whose primary interest was in the practice of thoracic surgery. The surveyed group was largely academically based and very experienced in the practice of thoracic surgery. Therefore, we believed that a survey of this group would represent at least a conservative viewpoint as to the current role of VATS procedures.

Based on the frequency of VATS procedures performed (see Fig 4Go), it appears that the evolutionary nature of the approach has attenuated to some degree, although the frequency of performing VATS in practice was either increasing (see Fig 4Go) or was anticipated to increase (see Fig 5Go) by approximately one third of the respondents. The majority of surgeons believed that VATS was a mature procedure that had defined its role in the practice of thoracic surgery (see Fig 6Go).

The main limitations of the VATS procedure were clearly believed by the majority of respondents to revolve around concerns about the ability to maintain strict adherence to surgical oncologic principles. Case reports of tumor spread through trocar sites have been well documented in the literature [5, 6]. Not only the spread of cancer, but the ability to perform a "complete" oncologic operation without compromise (eg, adequate regional lymph node dissection) was a significant concern).

There also was clearly a concern by the majority of thoracic surgeons who felt encumbered by the lack of adequate instrumentation and development of surgical techniques. A significant number (46%) still believed that the time required to perform a VATS procedure took longer than an open procedure. In addition, a significant number of thoracic surgeons still felt very inexperienced in VATS techniques.

Despite the limitations and concerns, three quarters of the respondents believed that VATS was a valuable addition to the practice of thoracic surgery, whereas only 6% of the surveyed population did not feel positive regarding the role of VATS.

Despite this, it is clear that only a minority of thoracic surgical procedures are now being performed by the VATS approach. The survey appears to indicate that this will increase somewhat over the next few years as surgeons gain more experience and as newer thoracic surgeons who have developed experience in VATS techniques from their training in general surgery now embrace the VATS approach. In addition, as more studies are performed examining the more complex procedures, it is anticipated that there will be a slow increase in the use of VATS in these advanced procedures.

As any new procedure or technological advancement occurs, there is initial enthusiasm regarding the procedure and widespread application is quickly apparent. The "envelope" is pushed and the appropriateness and utility of the development are studied in broad application. The limitations of the procedure are defined and a "definition of technological usefulness" is arrived at. However, as the variables change including surgeon experience, surgical technique, development of better instrumentation, or the publication of broader experience with the techniques, this definition of technological usefulness changes. From a review of the number of articles on thoracoscopy and VATS published over the past 5 years in The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery, it appears that VATS is following this trend (Fig 10Go). As the procedure was being introduced (1992, 1993), there was a dramatic increase in the number of articles published on the procedure. As the procedure matured, a plateau effect seemed to occur in the number of articles published. More recently, however, there appears to have been a renewed interest and slight increase in the number of publications regarding VATS procedures.



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  		Fig 10. . Articles published in The Annals of Thoracic Surgery andThe Journal of Thoracic and Cardiovascular Surgeryon video-assisted thoracic surgery and minimally invasive thoracic surgery.

 
Despite the technically simple nature of many of the VATS procedures, the majority of thoracic surgeons believed that VATS remains in the realm of thoracic surgery. Because VATS is an "approach" and not an "operation" and the potential for significant intraoperative and postoperative complications exists, the majority of surgeons believed that VATS should still be performed only by thoracic surgeons who would be capable of conversion to an open approach.

The results of the survey were also examined to see whether different attitudes existed among different subgroups of thoracic surgeons (eg, young versus old, academic versus private practice). In none of the questions asked did a significant difference in the responses exist between private practice or academic surgeons, nor was there a difference based on the years in practice. The percentage of general thoracic procedures performed and the frequency with which the procedure was increasing or anticipated to increase also were uniform throughout the surveyed population.

As minimally invasive surgical concepts are introduced into cardiac surgery, it appears that a renewed interest is now again developing in VATS procedures. As this occurs, we anticipate that the relatively mature and defined role for VATS in general thoracic surgery will continue to slowly evolve.


   Footnotes
Top
 Footnotes
Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 
Address reprint requests to Dr Mack, 7777 Forest Ln, Suite A-323, Dallas TX 75230.


   References
Top
 Footnotes
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

  1. Mack MJ, Aronoff RJ, Acuff TE, Douthit MB, Bowman RT, Ryan WH. The present role of thoracoscopy in the diagnosis and treatment of diseases of the chest. Ann Thorac Surg 1992;54:403–9.
  2. Roviaro G. Major pulmonary resections: pneumonectomies and lobectomies. Ann Thorac Surg 1993;56:779–83.[Abstract]
  3. Naunheim KS, Mack MJ, Hazelrigg SR, et al. Safety and efficacy of VATS techniques for the treatment of spontaneous pneumothorax. J Thorac Cardiovasc Surg 1995;109:1198–204.
  4. Landreneau RJ, Hazelrigg SR, Mack MJ, et al. Postoperative pain-related morbidity: video assisted thoracic surgery versus thoracotomy. Ann Thorac Surg 1993;56:1285–9.[Abstract]
  5. Walsh GL, Nesbitt JC. Tumor implants after thoracoscopic resections of metastatic sarcoma. Ann Thorac Surg 1995;59:215–6.
  6. Fry WA, Siddiqui A, Pensler JM, et al. Thoracoscopic implantation of cancer with a fatal outcome. Ann Thorac Surg 1995;59:42–5.
  7. Miller JI, Jr. Therapeutic thoracoscopy: new horizons for an established procedure. Ann Thorac Surg 1991;52:1036–7.[Medline]
  8. Kirby TJ, Mack MJ, Landreneau RJ, Rice TR. Lobectomy: video assisted thoracic surgery vs. thoracotomy. A randomized trial. J Thorac Cardiovasc Surg 1995:109:997–1002.[Abstract]
  9. Kadokura M, Colby TV, Myers JL, et al. Pathologic comparison of video-assisted thoracic surgical lung biopsy with traditional open lung biopsy. J Thorac Cardiovasc Surg 1995;109:494–8.[Abstract/Free Full Text]
  10. Maziak DE, McKneally MF. Video-assisted thoracic surgery. Ann Thorac Surg 1995;59:780–1.[Free Full Text]



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