Ann Thorac Surg 2008;85:416-419. doi:10.1016/j.athoracsur.2007.10.009
© 2008 The Society of Thoracic Surgeons
Original Articles: General Thoracic
Video-Assisted Thoracic Surgery Major Lung Resection Can Be Safely Taught to Trainees
Innes Y.P. Wan, FRCSEd,
Kin Hoi Thung, FRCSEd,
Michael K.Y. Hsin, FRCS,
Malcolm J. Underwood, MD, FRCS,
Anthony P.C. Yim, MD, FRCS*
Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
Accepted for publication October 2, 2007.
* Address correspondence to Dr Yim, Division of Cardiothoracic Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong, China (Email: yimap{at}cuhk.edu.hk).
 |
Abstract
|
|---|
Background: Video-assisted thoracoscopic surgery (VATS) major lung resection for lung cancer has been an important part of thoracic surgical training program in our institution. In this study, we compared the results of VATS major lung resection performed by surgical trainees with those performed by experienced thoracic surgeons with specialist interest in VATS.
Methods: From January 2002 to October 2006, the clinical data of 111 consecutive patients scheduled for VATS major lung resection were prospectively entered into the computerized clinical management system of the local health authority; these include patient demographics, comorbidity, operating time, postoperative complications, and outcome. We retrospectively compared the data of patients who were operated on by trainees with those who were operated on by experienced VATS surgeons.
Results: One hundred and eleven patients with clinical stage I and II lung cancer underwent VATS major lung resection. Fifty-one (46%) of the procedures were performed by consultant surgeons and 60 VATS lung resections (54%) were performed by supervised trainees. Patients’ demography and risk factors were comparable between the two groups. Trainees spent more time in performing the operation as compared with experienced VATS surgeons (mean operating time 162 minutes, p = 0.01). There was no significant difference in intraoperative or postoperative complications and outcomes between the two groups.
Conclusions: Video-assisted thoracic surgery major lung resection for early stage nonsmall-cell lung cancer can be taught to residents who work under the supervision of experienced VATS surgeons. Video-assisted thoracic surgery major lung resection for lung cancer should be an integral part of thoracic surgical training program.
|
Introduction
|
|---|
Video-assisted thoracic surgery (VATS) in the management of lung cancer was described more than a decade ago [1], but the practice of VATS major lung resection for lung cancer has not been widely adopted. Recent studies have shown that major lung resection by VATS has low perioperative morbidity and mortality. It is an adequate procedure for achieving good local control. It has been shown to be associated with good prognosis in patient with stage I nonsmall-cell lung cancer (NSCLC) [2]. However, this newly developed procedure was generally performed by self-taught senior surgeons, with the junior surgeons having little involvement in it. With the ever-increasing accountability and demand for surgical excellence across the world, the pressure on the surgical team to minimize mistakes has been enormous. To strike a balance between attaining surgical excellence while maintaining our training commitment, we examined the results of VATS major lung resection performed by supervised trainees as compared with the results of those performed by experienced VATS thoracic surgeons. We would like to know whether VATS major lung resection can be safely taught without compromising surgical outcome in the management of lung cancer.
|
Patients and Methods
|
|---|
Patients
From January 2002 to October 2006, the data of 111 consecutive patients scheduled for VATS major lung resection were recorded and prospectively entered into the computerized clinical management system of the local health authority. All patients were under the care of the public hospital system funded by the government. This study was approved by the Hospital Ethics Committee, and all patients had written informed consent before surgery.
Patients who received wedge or other nonanatomical resections were excluded. All patients had preoperative computed tomography (CT) scan of the thorax, bronchoscopy, and pulmonary function tests. Mediastinoscopy was performed if there was radiologic evidence of mediastinal lymphadenopathy (>1 cm) on preoperative CT scan of the thorax. Positron emission tomography (PET) was performed only when indicated. Patients with clinical stage I or II disease were considered for VATS lung resection. Patients with tumor size more than 4 cm and bronchoscopic findings of endobronchial lesions were excluded. All VATS major lung resections were performed by trainees who had completed 2 years of thoracic surgical training and were competent in performing open major lung resection under supervision. The consultants supervised the trainees throughout the whole procedure. There were three trainees involved in this study.
Anesthetic and Surgical Technique
The anesthetic management was standardized with selective one-lung ventilation using a double-lumen endotracheal tube. The patient was placed in a full lateral decubitus position with flexion of the operating table at the level of the nipple. We routinely used a 10-mm thoracoscope and a three-chip camera (Stryker, Kalamazoo, Michigan) and a 30-degree lens [3]. The VATS exploration was routinely performed before any attempt of surgical resection, to exclude pleural metastases [4]. A utility thoracotomy of 6 cm was made usually over the fourth intercostals space without rib spreading to facilitate the use of conventional instruments as in conventional thoracotomy. Division of pulmonary vessels and bronchus was accomplished with mechanical endostaplers (EndoGIA 30; Autosuture USSC, Norwalk, Connecticut). Routine systematic mediastinal lymph node sampling over four stations was performed for all patients, and a standardized postoperative protocol was adopted [3].
Statistical Analysis
Statistical analysis was performed with SPSS 11.0 (SPSS, Chicago, Illinois). Continuous variables were expressed as mean values ± SD. Categorical variables were analyzed by either Fisher’s exact test or 
2 test. Student’s t test or the Mann-Whitney U test was used for comparison of continuous variables.
For the postoperative outcomes, hospital stay, blood loss, and duration of chest drainage were presented as mean with standard deviation. Thirty-day mortality rates and complications were recorded by the clinical management system of the health authority. Major postoperative complications consisted of pneumonia, air leak, empyema, cardiac disorders, and renal failure.
|
Results
|
|---|
From January 2002 to October 2006, 111 patients with clinical stage I and II lung cancer were scheduled for VATS major lung resection. Fifty-one (46%) of the procedures were performed by consultant surgeons who were self-trained and 60 VATS lung resection (54%) were performed by supervised trainee. Patients’ characteristics and risk factors were comparable between the two groups. The pulmonary function results were comparable, and no significant difference was observed with respect to the presence of adhesion noted during the procedure (Table 1).
The different lobes being removed by the trainees and consultants are shown in Table 2, and more VATS pneumonectomies were performed by the consultant group. The final pathologic staging of the two groups of patients were comparable, as shown in Table 3. One patient in the consultant group and 3 patients in the trainee group required conversion to thoracotomy for control of bleeding from the pulmonary artery, which was statistically insignificant (p = 0.39; Table 4). The trainees spent more time in performing the operation, with a mean operating time of 162 minutes (p = 0.01). However, there was no difference in intraoperative blood loss (Table 4). All patients were extubated in the operating theater, and there is no in-hospital mortality for the two groups.
The duration of postoperative chest drainage was comparable between the two groups (Table 4). Seven patients in the consultant group and 8 patients in the trainee group had postoperative complications, which included cardiac arrhythmia, pneumonia, prolonged air leak longer than 6 days, and renal impairment; but there was no significant statistical difference between the two groups (p = 0.95; Table 4).The duration of hospital stay was similar, with a mean of 6.23 days for the consultant group and 7.32 days for the trainee group (p = 0.38; Table 4).
|
Comment
|
|---|
Despite the concerns regarding the safety and efficacy of VATS major lung resection, excellent outcome has been demonstrated for patients with early lung cancer [5]. Even though the technique has yet to gain wide acceptance, there is accumulating evidence to show that the VATS approach may contribute to better preservation of human immune function [6, 7]. Surgical trauma induced by the conventional surgery is believed to be associated with a certain degree of immunosuppression, which theoretically can lead to promotion of tumor growth and, thus, tumor recurrence [6, 7]. Furthermore, we are treating an increasingly aging population, who often present with multiple comorbidities, and a minimally invasive approach may result in early mobilization and restoration of body function [8], factors of utmost importance during the early postoperative period for this group of patients [9].
On the other hand, there has been increasing public awareness of surgeons’ performance and outcomes. This outcome-oriented mentality may have a negative impact on surgical training as a whole, but in particular with the VATS approach, which is perceived to be a technically more challenging operation. It has been shown that VATS lobectomy can be taught safely to surgical trainees without compromising outcome [10], but in that series, only 16.7% of the cases were performed by trainees. In our study, 54% of the VATS major lung resections were performed by supervised trainees, which is a much higher percentage as compared with previous studies [10]. In our series, the case mix and patients’ characteristics were comparable between the trainees’ and consultants’ groups. The operation time was longer in the trainees’ group, as shown by the previous study, but that did not translate into any compromise of the short-term outcome.
Within our institute, cardiothoracic surgical training consists of 2 years of general surgical training and 5 years of higher training. All consultants or trainers are experienced VATS surgeons with at least 3 years of experience with VATS major lung resection. All trainees involved in this study had at least 2 years of thoracic surgical training with experience in simple VATS procedures and open major lung resection.
We propose that the VATS approach has an additional advantage as a training tool as the intraoperative image was magnified and monitored closely by the supervisor throughout the entire procedure, training could take place in a stepwise manner under strict supervision. The trainees can develop the psychomotor proficiency while making progress through their learning curve and have the comfort of knowing that backup from the consultants is readily available in this particular setting. Furthermore, the VATS approach could be extended to monitor the development of established surgeons, or even for surgical auditing, as the entire procedure could be recorded and be reviewed and discussed at a later stage. A video library of various procedures could be established, and with the recent advances in computer engineering and virtual reality, these image collections would easily be converted into surgical stimulation. Junior trainees could get familiarized with the procedure, and these virtual procedures can also serve as a mean for lay public education, although much of this is left for future development.
One limitation of our analysis was the impossibility of trying to determine the exact degree of intervention by an individual supervisor involved, in a retrospective manner. The degree of involvement may vary greatly among different surgeons, ranging from "talk through the procedure" to "do the crux of the procedure on your behalf." No matter what method was adopted, the trainees had the firsthand experience of the surgical technique, which would be essential for their future development. We would suggest the trainee to begin with lower lobe resection and then progress to right middle, then to the upper lobe. The left upper lobe will be reserved for experienced trainees. We routinely divide the vein first, then the artery and bronchus, leaving the completion of fissure at the end. We do not think that fused fissure is an contraindication for VATS resection or training of residents. The most difficult part of the training will be the dissection of the pulmonary artery and the passage of the jaws of the endoscopic staplers around the vessels under videoscopic guidance. Maintenance of adequate traction during dissection is of utmost importance. All trainees were able to perform VATS major lung resection independently upon graduation from our program.
In conclusion, we have demonstrated that the VATS major lung resection for early stage NSCLC can be taught to trainees who work under the supervision of experienced VATS surgeons. We believe that in the modern era of general thoracic surgery, it is essential to expose trainees to both conventional thoracotomy as well as to the VATS approach for lung resection early in their career, given that VATS lung resection is likely to become an integral part of the thoracic surgeon’s armamentarium.
|
References
|
|---|
- Roviaro G, Rebuffat C, Varoli F, Vergani C, Maciocco M. Videoendoscopic pulmonary lobectomy for cancer Surg Laparosc Endosc 1992;2:244-247.[Medline]
- Kondo T, Sagawa M, Tanita T, et al. Assessment of systematic nodal dissection by VATS lobectomy for lung cancer Kyobu Geka 2000;53:8-12.[Medline]
- Yim AP. VATS major pulmonary resection revisited—controversies, techniques, and results Ann Thorac Surg 2002;74:615-623.[Abstract/Free Full Text]
- Yim APC. Routine video-assisted thoracoscopy prior to thoracotomy Chest 1996;109:1099-1100.[Medline]
- 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;126:725-732.[Medline]
- Yim AP, Wan S, Lee A, Arifi TW. VATS lobectomy reduces cytokine responses compared with conventional surgery Ann Thorac Surg 2000;70:243-247.[Abstract/Free Full Text]
- Ng CS, Whealan RL, Lacy AM, Yim AP. Is minimal access surgery for cancer associated with immunologic benefits? World J Surg 2005;29:975-981.[Medline]
- Li WW, Lee TW, Yim AP. Shoulder function after thoracic surgery Thorac Surg Clin 2004;14:331-343.[Medline]
- Nakata M, Saeki H, Yokoyama N, Kurita A, Takiyama W, Takashima S. Pulmonary function after lobectomy: video-assisted thoracic surgery versus thoracotomy Ann Thorac Surg 2000;70:938-941.[Abstract/Free Full Text]
- Ferguson J, Walker W. Development a VATS lobectomy programme—can VATS lobectomy be taught Eur J Cardiothorac Surg 2006;29:806-809.[Abstract/Free Full Text]
This article has been cited by other articles:
|
|
|
|
 
C. W. Seder, K. Hanna, V. Lucia, J. Boura, S. W. Kim, R. J. Welsh, and G. W. Chmielewski
The safe transition from open to thoracoscopic lobectomy: a 5-year experience.
Ann. Thorac. Surg.,
July 1, 2009;
88(1):
216 - 226.
[Abstract]
[Full Text]
[PDF]
|
|
|
Top
Abstract
Introduction
