Original Thoracic
Learning Thoracoscopic Lobectomy in Resident Training Chang-Lun Huang1 Chia-Chuan Liu2 Bing-Yen Wang1,2,3
Ching-Yuan Cheng1
1 Division of Thoracic Surgery, Department of Surgery, Changhua
Christian Hospital, Chung Shan Medical University, Taichung, Taiwan 2 Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan 3 Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
Ching-Hsiung Lin1
Yu-Chung Wu3
Address for correspondence Bing-Yen Wang, MD, Division of General Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, No. 135 Nanxiao St., Changhua City, Changhua County 500, Taiwan (e-mail: [email protected]).
Thorac Cardiovasc Surg 2014;62:690–695.
Abstract
Keywords
► thoracoscopic lobectomy ► resident training ► learning curve
Background Thoracoscopic lobectomy is a safe and effective procedure; however, the ways by which to incorporate this technically demanding procedure into residency training is still unknown. We reported on the outcomes of thoracoscopic lobectomies performed by a single thoracic resident, who was simultaneously undergoing training for both open and thoracoscopic lobectomies. Patients and Methods Between January 2010, and May 2011, data from 87 consecutive thoracoscopic lobectomies that were performed by a trainee surgeon (B.-Y.W.) were prospectively obtained. Data were grouped into the first 30 and subsequent 57 cases. Patient characteristics, operative data, complications, and surgical pathology were analyzed. Results The mean operating time in group 2 was significantly lower compared with group 1 (264.0 45.9 min in group 1 vs. 197.5 57.7 min in group 2; p < 0.001). There were no mortalities in both the groups and no significant differences in postoperative complications. Conclusions Thoracoscopic lobectomy can be taught to a nonexperienced thoracic resident during an open procedure without compromising the safety of patients. It appears that surgical performance reaches a plateau after the completion of 30 cases.
Introduction Thoracoscopic lobectomy had been introduced two decades ago.1 Since its initial introduction into practice, increasing evidence points to the advantages of this minimally invasive surgery compared with open techniques, such as less postoperative pain, shorter hospital stays, quicker recommencement of normal daily activities,2,3 reduced inflammatory response,4 and economical feasibility. In the management of early-stage lung cancer, thoracoscopic lobectomy has been
received September 28, 2013 accepted after revision November 22, 2013 published online March 3, 2014
proven to be safe based on its oncological outcome and improved survival rate5 compared with traditional open thoracotomy. With the increasing practice of thoracoscopic lobectomy, the best methods by which to incorporate this technically demanding procedure into training programs is an important issue. While previous studies reported on surgeons that were experienced in traditional open lobectomy and other minor thoracoscopic procedures, no studies have focused on evaluating a new thoracic resident in performing thoracoscopic lobectomies.
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1364203. ISSN 0171-6425.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
690
Theoretically, a surgeon must be initially familiar with traditional open lobectomy before learning thoracoscopic lobectomy. Thus, whether a supervised trainee could receive training for open and thoracoscopic lobectomies simultaneously without sacrificing the outcomes warrants further investigation. More than 200 lobectomies are performed annually at our institution, and the majority of them are thoracoscopic. We speculate that learning the thoracoscopic lobectomy procedure simultaneously with open lobectomy may be a feasible training program for thoracic surgical residents. We hypothesize that thoracic surgical residents without formal open lobectomy expertise can undertake thoracoscopic lobectomy training without compromising perioperative outcomes. We retrospectively reviewed the outcomes during the training program of a resident in open and thoracoscopic lobectomy procedures, and describe the learning process herein.
Patients and Methods Patients Between January 2010, and May 2011, data from 87 consecutive thoracoscopic lobectomies performed by a trainee surgeon at the Taipei Veterans General Hospital in Taiwan were obtained. In Taiwan, the total duration of the general and thoracic surgical residency programs is 5 years. This trainee surgeon (B.-Y.W.) had completed 2 years of the general surgery program followed by 3 years of thoracic surgery training. All operations were under the supervision of a consultant surgeon who was experienced in thoracoscopic lobectomy. The thoracic surgical resident was not experienced in open thoracic surgery, but had performed more than 100 minor thoracoscopic procedures under supervision, but not with the assistance of a consultant surgeon. The previously performed procedures included pleural biopsy, wedge resection, decortication, pleurodesis, resection of mediastinal tumor, pneumolysis, and mediastinal lymph node dissection. In addition, the resident assisted in more than 100 thoracoscopic lobectomies. The following patient parameters were determined: age, gender, preoperative pulmonary function, lobe removed, pathology, operative time, blood loss, harvested lymph node numbers, conversion rate, duration of chest tube drainage, length of hospital stay, and mortality and morbidity.
Anesthetic and Surgical Procedure After double-lumen endotracheal intubation for single-lung ventilation, the patient was positioned in the lateral decubitus position. The surgeon and an assistant (cameraman) stood anteriorly to the patient and another assistant, if available, stood posteriorly to the patient. The cameraman controlled the thoracoscope during the operation and was responsible for maintaining a clear and appropriate visual field. The other assistant manipulated one or more instruments to assist the procedure. A 4- to 5-cm utility incision via the fourth or fifth intercostal space and one or two additional thoracic ports via the seventh or eighth intercostal space were conducted. No rib spreading occurred. A thoracic port was first created, and a
Huang et al.
10-mm thoracoscopic camera with a 30-degree angle was inserted to evaluate the intrathoracic condition. Once the pulmonary ligament was lysed, the lobectomy was initiated with a hilar dissection, if feasible. Pulmonary artery branches, the pulmonary vein, and bronchus were isolated individually and ligated with endoscopic linear staplers. The fissures were divided after or during hilar ligation to facilitate the procedure. When converting to open thoracotomy, the utility incision was extended anterolaterally to the thoracotomy incision. A specimen was retrieved with a saline bag or commercialized endoscopic bag. Mediastinal lymph node dissection was performed (stations 2, 3, 4, 7, 8, and 9 for right side and stations 5, 6, 7, 8, and 9 for left side). One or two chest tubes were placed under direct vision through the 10-mm port sites. Extubation was performed at the postoperative theater, and the patient was transferred to intensive care unit for observation.
Statistical Analysis All consecutively performed thoracoscopic lobectomies were included and analyzed, even if the procedure was converted into an open thoracotomy. Sublobar resection, such as wedge resections and segmentectomies, pneumonectomies, bilobectomies, or sleeve resections, were excluded. The data were grouped into the first 30 (group 1) and subsequent 57 cases (group 2). Operative mortality was defined as death within 30 days after operation. Morbidity or postoperative complications were defined as any events that prolonged hospitalization or need for medical intervention. Statistical analysis was performed with SPSS 12.0 (SPSS, Chicago, Illinois, United States). Continuous variables were expressed as median standard deviation. Categorical values were analyzed by the Fischer exact test/continuity-adjusted χ2 analysis. The Student t-test or Mann–Whitney U test were used for continuous variables. A p value < 0.05 was considered statistically significant.
Results Between January 2010, and May 2011, the thoracic surgical resident had independently completed 87 consecutive thoracoscopic lobectomies under the supervision of a consultant thoracic surgeon. The characteristics of the patients that underwent a thoracoscopic lobectomy are summarized in ►Table 1. Patient age, gender, and preoperative pulmonary function were similar between the first 30 and subsequent 57 cases. In group 1 (i.e., first 30 cases), the majority of the patients were operated for primary lung cancer (n ¼ 27; 90%). There were no significant differences between groups 1 and 2 (i.e., subsequent 57 cases; n ¼ 47; 82.5%; p ¼ 0.312). There were no significant differences in the lobe removals between the two groups (p ¼ 0.380) or the proportion of the left or right lobe removals. The operative outcomes are summarized in ►Table 2. Operation time was defined as the time from the skin incision to wound closure. The duration of the operation time and amount of operative blood loss of every patient is illustrated in ►Fig. 1. The mean operation time in group 2 was Thoracic and Cardiovascular Surgeon
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Learning Thoracoscopic Lobectomy in Resident Training
Learning Thoracoscopic Lobectomy in Resident Training
Huang et al.
Table 1 Patient demographics
Age, mean SD
Group 1 (n ¼ 30)
Group 2 (n ¼ 57)
p value
61.4 12.1
60.3 11.6
0.689
Gender
0.306
Male
15
Female
22
15
35
FEV1 (L) , mean SD
2.45 0.67
2.37 0.67
0.595
FEV1 (%), mean SD
97.0 15.35
97.5 17.5
0.911
FVC (%), mean SD
97.0 11.7
95.0 15.8
0.561
DLCO (%), mean SD
72.9 14.8
71.5 16.4
0.693
Diagnosis
0.312
Lung cancer
27
47
Metastatic lung cancer
2
5
Bronchiectasis
0
3
Sequestration
1
1
Benign tumor
0
1
Lobe removed
0.380
RUL
10
14
RML
2
6
RLL
3
11
LUL
11
13
LLL
4
13
Abbreviations: DLCO, diffusing capacity of lungs for carbon monoxide; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; LUL, left upper lobe; LLL, left lower lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe; SD, standard deviation.
Table 2 Operative and postoperative data Group 1 (n ¼ 30)
Group 2 (n ¼ 57)
p value < 0.001
Operation time (min) Mean
264.0 45.9
197.5 57.7
Median
270 (180–390)
185 (110–370)
Blood loss (mL)
0.068
Mean
174.0 302.1
93.9 93.3
Median
50 (30–1,500)
50 (30–400)
Lymph nodes numbers, mean SD
16.2 7.4
17.8 7.4
0.328
Conversion rate (%)
6.7
1.8
0.272
Duration of chest tube drainage (d)
0.090
Mean SD
5.5 2.2
6.8 3.8
Median (range)
5 (2–13)
7 (3–30)
Duration of hospital stay (d)
0.221
Mean SD
7.2 3.0
8.25 3.9
Median (range)
6 (3–18)
8 (4–32)
Complication rates (%)
20
12.3
Surgical mortality (%)
0
0
Abbreviation: SD, standard deviation. Thoracic and Cardiovascular Surgeon
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0.337
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693
Prolong air leak > 7 d
Fig. 1 (A) Duration of operative time of thoraoscopic lobectomy in all 87 consecutive patients. (B) Amount of operative blood loss in all 87 consecutive patients
significantly lower compared with group 1 (264.0 45.9 min in group 1 vs. 197.5 57.7 min in group 2; p < 0.001). The mean blood loss was 174.0 302.1 mL in group 1 and 93.9 93.3 mL in group 2 (p ¼ 0.068). One patient in group 1 lost roughly 1,500 mL of blood due to a dislodgement of the Hem-o-lok (Weck Closure Systems, Research Triangle Park, North Carolina, United States) on a small branch of the pulmonary artery. This may have contributed to the larger blood loss volume in group 1. In regards to the harvested lymph node numbers, conversion rate, duration of chest tube drainage, duration of hospital stay, and complication rates, it was determined that there were no significant differences between the two groups. ►Table 3 presents information regarding the complications. There were no mortalities in both the groups. The pathological tumor, lymph node, and metastasis stages are listed in ►Table 4 for the patients with lung cancer in groups 1 (n ¼ 27) and 2 (n ¼ 47). Most patients had early stage lung cancer, that is, 85% in group 1 and 74.5% in group 2. During this training period, the surgical resident also performed nine traditional open lobectomies. The mean age of these nine patients was 62.3 12.0 years old, and the mean tumor size was 4.2 2.1 cm, which was the main reason for the patient exclusion from thoracoscopic lobectomy. The mean operation time and blood loss were 185.6 32.4 minutes and 145.6 126.3 mL, respectively. The nine cases were distributed randomly throughout the training period.
Discussion Since thoracoscopic lobectomy was first introduced about two decades ago, many experienced thoracic surgeons have demonstrated several advantages of this minimally invasive
Group 1 (n ¼ 30)
Group 2 (n ¼ 57)
1
4
Arrhythmia
2
0
Empyema
0
1
Subcutaneous emphysema
0
0
Gout attack
1
0
Pneumonia
1
0
Pleural effusion status post re-on chest tube
1
0
Hoarseness
0
1
Subcutaneous emphysema
0
2
technique that possesses similar postoperative survival outcomes to the open approach. In 2008, Whitson et al5 systemically reviewed 39 studies involving 3,256 thoracotomies and 3,114 thoracoscopic patients. It was found that patients with early-stage nonsmall cell lung cancer that underwent thoracoscopic lobectomy appeared to have lower morbidity and improved survival rates. On the basis of this evidence,
Table 4 Pathological staging for lung cancer Group 1 (n ¼ 27)
Group 2 (n ¼ 47)
2.42 1.15
2.48 1.21
Adenocarcinoma
26
43
SqCC
1
2
Others
0
2
Lymph node numbers, mean SD
16.8 7.4
19.2 6.5
Positive lymph node numbers, mean SD
0.15 0.53
0.64 1.92
Neoadjuvant therapy
3
3
T1aN0M0
10
8
T1bN0M0
0
5
T2aN0M0
13
22
Tumor size (cm) , mean SD Histology
Tumor stage
T3N0M0
0
3
T1bN1M0
0
1
T2aN1M0
1
3
T2bN1N0
0
1
T1aN2M0
1
0
T2aN2M0
0
3
T2aN0M1a
0
1
Abbreviations: SD, standard deviation; SqCC, squamous cell carcinoma. Thoracic and Cardiovascular Surgeon
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Table 3 Postoperative complications
Learning Thoracoscopic Lobectomy in Resident Training patients are more likely to request the most minimally invasive lobectomy not only because of the favorable oncologic outcomes and decreased morbidity, but also for cosmetic reasons. However, thoracoscopic lobectomy is still regarded to as a technically demanding procedure. Lack of tactile feedback and two-dimensional visualization may be some of the challenges. For surgeons experienced in performing posterolateral thoracotomies, changes in visualization and restricted tissue manipulation may further lengthen the learning process. During the earlier years of procedure adoption, thoracic surgeons performing thoracoscopic lobectomy were mostly self-taught and had developed some of the methods for transitioning from posterolateral thoracotomy to thoracoscopic lobectomy procedures. Ng and Ryder6 demonstrated a stepwise transition from open lobectomy to thoracoscopic lobectomy. When experience with posterolateral thoracotomy was obtained, resections through more limited lateral muscle-sparing incisions, and then, smaller utility thoracotomy incisions without rib spreading were applied. In their opinion, to document acceptable outcomes for open procedures before attempting transition to thoracoscopic lobectomy is important. Reed et al7 described a more detailed stepwise plan for introducing thoracoscopic lobectomy into a thoracic surgical training program. Wan et al8 agreed that thoracoscopic lobectomy could be taught to trainees that work under the supervision of experienced thoracoscopic surgeons and could be an integral part of the thoracic surgical training program. In published literature, all of the trainee surgeons described were experienced in open thoracotomy and minor thoracoscopic procedures,6–10 and no previous studies focused on surgical residents with respect to performing thoracoscopic lobectomy. Theoretically, a surgeon with no experience in conducting an open lobectomy would not have the ability to perform a thoracoscopic lobectomy. However, to date, thoracoscopic procedures are more likely to be performed instead of thoracotomies. Thus, surgical residents in minimal invasive centers must learn all thoracic surgical skills, that is, open and thoracoscopic approaches, simultaneously. For example, laparoscopic cholecystectomy has become the gold standard for the management of gall bladder diseases. More laparoscopic cholecystectomies are performed than open cholecystectomies. In fact, many surgical residents learn laparoscopic cholecystectomy before open cholecystectomy. For example, surgical residents can attend laparoscopic cholecystectomies and serve as an assistant or cameraman. After making progress in learning laparoscopic techniques, surgical residents may perform laparoscopic cholecystectomies under the supervision of an experienced surgeon. Even if surgical residents have never performed an open cholecystectomy, they may still learn to perform laparoscopic cholecystectomies proficiently. Furthermore, we speculate that a lobectomy may be taught from a thoracoscopy directly. However, whether a supervised resident is capable of receiving training in open and thoracoscopic lobectomies simultaneously without sacrificing the results has not yet been determined in previous studies. Thoracic and Cardiovascular Surgeon
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Huang et al. In our study, the surgical resident was not fully experienced in open lobectomy procedures, but had previously assisted in more than 100 thoracoscopic lobectomies and performed more than 100 minor thoracoscopic procedures. When the first 30 cases are compared with the subsequent 57 cases in our study, the mean operative time is significantly longer in the first 30 cases (264.0 45.9 min vs. 197.5 57.7 min; p < 0.001), indicating that the operative time decreases with experience and proficiency. Pleural adhesion was not a contraindication, with the exception of when adhesion was diffusely located and obliterated more than half of the pleural cavity, which may have lengthened the operative time. Incomplete or an absence of fissure was not a contraindication. Furthermore, one of the three conversion cases had contributed to a pleural adhesion or incomplete fissure. The consultant surgeon was available throughout the entire procedure to offer suggestions. The consultant surgeon solely monitored the entire procedure and stayed away from the surgical table. Some surgeons suggested that proficiency in thoracoscopic lobectomy techniques increases after performing approximately 50 cases, which is comparable to the number of cases required for proficiency with other advanced laparoscopic procedures.11 In our study, the operative time was significantly lower after performing 30 thoracoscopic lobectomies, whereas there were no statistically significant differences with respect to blood loss, harvested lymph node numbers, conversion rate, duration of chest tube drainage, length of hospital stay, or complication rates. In fact, it was very difficult to define the cutoff point for the learning curve. In our training programs, we believe that a stable surgical performance may occur after 30 cases. In our training program for thoracoscopic lobectomy, after completing 2 years of general surgery training, 3rd year residents are responsible for controlling the camera during thoracoscopic procedures, 4th year resident could perform minor thoracoscopic procedures and being an assistant during thoracoscopic lobectomies, and 5th year residents could be the operator under an experienced surgeon’s supervision. In our study, only 3 of 87 thoracoscopic lobectomies were converted into open thoracotomy, where the conversion rate was 6.7% in the first 30 cases and 1.8% in the subsequent 57 cases. Blood loss from the pulmonary artery remains one of the most important concerns and was the main reason for performing open thoracotomies in our study. Indeed, two of the three cases that converted into open thoracotomies were because of bleeding. To deal with bleeding from the pulmonary artery, experts suggest quickly applying a sponge stick to the site for temporary control of bleeding and extending the minithoracotomy wound. The other conversion was because of a difficult hilar dissection resulting from calcified lymph nodes. Some cognitively simulating programs were suggested in recent years and have the potential benefit of being incorporated into the training programs to overcome trainee deficiencies.12 However, its high cost may limit its wide acceptance.
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Learning Thoracoscopic Lobectomy in Resident Training
Conclusions We found that thoracoscopic lobectomies can be taught to surgical residents that are not fully experienced in the open procedure without compromising the perioperative outcomes. After performing roughly 30 cases, proficiency of the thoracoscopic lobectomy procedure and consistency in the surgical outcome was achieved in our study.
4 Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary
5
6
7
8
9
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 2 McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81(2):421–425, discussion 425–426 3 Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244(3):420–425
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10 11
12
function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72(2):362–365 Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg 2008;86(6): 2008–2016, discussion 2016–2018 Ng T, Ryder BA. Evolution to video-assisted thoracic surgery lobectomy after training: initial results of the first 30 patients. J Am Coll Surg 2006;203(4):551–557 Reed MF, Lucia MW, Starnes SL, Merrill WH, Howington JA. Thoracoscopic lobectomy: introduction of a new technique into a thoracic surgery training program. J Thorac Cardiovasc Surg 2008;136(2):376–381 Wan IY, Thung KH, Hsin MK, Underwood MJ, Yim AP. Videoassisted thoracic surgery major lung resection can be safely taught to trainees. Ann Thorac Surg 2008;85(2):416–419 Ferguson J, Walker W. Developing a VATS lobectomy programme— can VATS lobectomy be taught? Eur J Cardiothorac Surg 2006; 29(5):806–809 Petersen RH, Hansen HJ. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg 2010;37(3):516–520 Seder CW, Hanna K, Lucia V, et al. The safe transition from open to thoracoscopic lobectomy: a 5-year experience. Ann Thorac Surg 2009;88(1):216–225, discussion 225–226 Solomon B, Bizekis C, Dellis SL, et al. Simulating video-assisted thoracoscopic lobectomy: a virtual reality cognitive task simulation. J Thorac Cardiovasc Surg 2011;141(1):249–255
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There are some limitations in our study that need to be addressed. This was a retrospective study on a single resident that undertook training at a single medical center. While not all of the trainees at our institution undertake the same training path, this article highlights the most common training program available at our hospital.
Huang et al.
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Learning Thoracoscopic Lobectomy in Resident Training Chang-Lun Huang1 Chia-Chuan Liu2 Bing-Yen Wang1,2,3
Ching-Yuan Cheng1
1 Division of Thoracic Surgery, Department of Surgery, Changhua
Christian Hospital, Chung Shan Medical University, Taichung, Taiwan 2 Division of Thoracic Surgery, Department of Surgery, Koo Foundation Sun Yat-Sen Cancer Center, Taipei, Taiwan 3 Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital and School of Medicine, National Yang-Ming University, Taipei, Taiwan
Ching-Hsiung Lin1
Yu-Chung Wu3
Address for correspondence Bing-Yen Wang, MD, Division of General Thoracic Surgery, Department of Surgery, Changhua Christian Hospital, No. 135 Nanxiao St., Changhua City, Changhua County 500, Taiwan (e-mail: [email protected]).
Thorac Cardiovasc Surg 2014;62:690–695.
Abstract
Keywords
► thoracoscopic lobectomy ► resident training ► learning curve
Background Thoracoscopic lobectomy is a safe and effective procedure; however, the ways by which to incorporate this technically demanding procedure into residency training is still unknown. We reported on the outcomes of thoracoscopic lobectomies performed by a single thoracic resident, who was simultaneously undergoing training for both open and thoracoscopic lobectomies. Patients and Methods Between January 2010, and May 2011, data from 87 consecutive thoracoscopic lobectomies that were performed by a trainee surgeon (B.-Y.W.) were prospectively obtained. Data were grouped into the first 30 and subsequent 57 cases. Patient characteristics, operative data, complications, and surgical pathology were analyzed. Results The mean operating time in group 2 was significantly lower compared with group 1 (264.0 45.9 min in group 1 vs. 197.5 57.7 min in group 2; p < 0.001). There were no mortalities in both the groups and no significant differences in postoperative complications. Conclusions Thoracoscopic lobectomy can be taught to a nonexperienced thoracic resident during an open procedure without compromising the safety of patients. It appears that surgical performance reaches a plateau after the completion of 30 cases.
Introduction Thoracoscopic lobectomy had been introduced two decades ago.1 Since its initial introduction into practice, increasing evidence points to the advantages of this minimally invasive surgery compared with open techniques, such as less postoperative pain, shorter hospital stays, quicker recommencement of normal daily activities,2,3 reduced inflammatory response,4 and economical feasibility. In the management of early-stage lung cancer, thoracoscopic lobectomy has been
received September 28, 2013 accepted after revision November 22, 2013 published online March 3, 2014
proven to be safe based on its oncological outcome and improved survival rate5 compared with traditional open thoracotomy. With the increasing practice of thoracoscopic lobectomy, the best methods by which to incorporate this technically demanding procedure into training programs is an important issue. While previous studies reported on surgeons that were experienced in traditional open lobectomy and other minor thoracoscopic procedures, no studies have focused on evaluating a new thoracic resident in performing thoracoscopic lobectomies.
© 2014 Georg Thieme Verlag KG Stuttgart · New York
DOI http://dx.doi.org/ 10.1055/s-0033-1364203. ISSN 0171-6425.
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
690
Theoretically, a surgeon must be initially familiar with traditional open lobectomy before learning thoracoscopic lobectomy. Thus, whether a supervised trainee could receive training for open and thoracoscopic lobectomies simultaneously without sacrificing the outcomes warrants further investigation. More than 200 lobectomies are performed annually at our institution, and the majority of them are thoracoscopic. We speculate that learning the thoracoscopic lobectomy procedure simultaneously with open lobectomy may be a feasible training program for thoracic surgical residents. We hypothesize that thoracic surgical residents without formal open lobectomy expertise can undertake thoracoscopic lobectomy training without compromising perioperative outcomes. We retrospectively reviewed the outcomes during the training program of a resident in open and thoracoscopic lobectomy procedures, and describe the learning process herein.
Patients and Methods Patients Between January 2010, and May 2011, data from 87 consecutive thoracoscopic lobectomies performed by a trainee surgeon at the Taipei Veterans General Hospital in Taiwan were obtained. In Taiwan, the total duration of the general and thoracic surgical residency programs is 5 years. This trainee surgeon (B.-Y.W.) had completed 2 years of the general surgery program followed by 3 years of thoracic surgery training. All operations were under the supervision of a consultant surgeon who was experienced in thoracoscopic lobectomy. The thoracic surgical resident was not experienced in open thoracic surgery, but had performed more than 100 minor thoracoscopic procedures under supervision, but not with the assistance of a consultant surgeon. The previously performed procedures included pleural biopsy, wedge resection, decortication, pleurodesis, resection of mediastinal tumor, pneumolysis, and mediastinal lymph node dissection. In addition, the resident assisted in more than 100 thoracoscopic lobectomies. The following patient parameters were determined: age, gender, preoperative pulmonary function, lobe removed, pathology, operative time, blood loss, harvested lymph node numbers, conversion rate, duration of chest tube drainage, length of hospital stay, and mortality and morbidity.
Anesthetic and Surgical Procedure After double-lumen endotracheal intubation for single-lung ventilation, the patient was positioned in the lateral decubitus position. The surgeon and an assistant (cameraman) stood anteriorly to the patient and another assistant, if available, stood posteriorly to the patient. The cameraman controlled the thoracoscope during the operation and was responsible for maintaining a clear and appropriate visual field. The other assistant manipulated one or more instruments to assist the procedure. A 4- to 5-cm utility incision via the fourth or fifth intercostal space and one or two additional thoracic ports via the seventh or eighth intercostal space were conducted. No rib spreading occurred. A thoracic port was first created, and a
Huang et al.
10-mm thoracoscopic camera with a 30-degree angle was inserted to evaluate the intrathoracic condition. Once the pulmonary ligament was lysed, the lobectomy was initiated with a hilar dissection, if feasible. Pulmonary artery branches, the pulmonary vein, and bronchus were isolated individually and ligated with endoscopic linear staplers. The fissures were divided after or during hilar ligation to facilitate the procedure. When converting to open thoracotomy, the utility incision was extended anterolaterally to the thoracotomy incision. A specimen was retrieved with a saline bag or commercialized endoscopic bag. Mediastinal lymph node dissection was performed (stations 2, 3, 4, 7, 8, and 9 for right side and stations 5, 6, 7, 8, and 9 for left side). One or two chest tubes were placed under direct vision through the 10-mm port sites. Extubation was performed at the postoperative theater, and the patient was transferred to intensive care unit for observation.
Statistical Analysis All consecutively performed thoracoscopic lobectomies were included and analyzed, even if the procedure was converted into an open thoracotomy. Sublobar resection, such as wedge resections and segmentectomies, pneumonectomies, bilobectomies, or sleeve resections, were excluded. The data were grouped into the first 30 (group 1) and subsequent 57 cases (group 2). Operative mortality was defined as death within 30 days after operation. Morbidity or postoperative complications were defined as any events that prolonged hospitalization or need for medical intervention. Statistical analysis was performed with SPSS 12.0 (SPSS, Chicago, Illinois, United States). Continuous variables were expressed as median standard deviation. Categorical values were analyzed by the Fischer exact test/continuity-adjusted χ2 analysis. The Student t-test or Mann–Whitney U test were used for continuous variables. A p value < 0.05 was considered statistically significant.
Results Between January 2010, and May 2011, the thoracic surgical resident had independently completed 87 consecutive thoracoscopic lobectomies under the supervision of a consultant thoracic surgeon. The characteristics of the patients that underwent a thoracoscopic lobectomy are summarized in ►Table 1. Patient age, gender, and preoperative pulmonary function were similar between the first 30 and subsequent 57 cases. In group 1 (i.e., first 30 cases), the majority of the patients were operated for primary lung cancer (n ¼ 27; 90%). There were no significant differences between groups 1 and 2 (i.e., subsequent 57 cases; n ¼ 47; 82.5%; p ¼ 0.312). There were no significant differences in the lobe removals between the two groups (p ¼ 0.380) or the proportion of the left or right lobe removals. The operative outcomes are summarized in ►Table 2. Operation time was defined as the time from the skin incision to wound closure. The duration of the operation time and amount of operative blood loss of every patient is illustrated in ►Fig. 1. The mean operation time in group 2 was Thoracic and Cardiovascular Surgeon
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Learning Thoracoscopic Lobectomy in Resident Training
Learning Thoracoscopic Lobectomy in Resident Training
Huang et al.
Table 1 Patient demographics
Age, mean SD
Group 1 (n ¼ 30)
Group 2 (n ¼ 57)
p value
61.4 12.1
60.3 11.6
0.689
Gender
0.306
Male
15
Female
22
15
35
FEV1 (L) , mean SD
2.45 0.67
2.37 0.67
0.595
FEV1 (%), mean SD
97.0 15.35
97.5 17.5
0.911
FVC (%), mean SD
97.0 11.7
95.0 15.8
0.561
DLCO (%), mean SD
72.9 14.8
71.5 16.4
0.693
Diagnosis
0.312
Lung cancer
27
47
Metastatic lung cancer
2
5
Bronchiectasis
0
3
Sequestration
1
1
Benign tumor
0
1
Lobe removed
0.380
RUL
10
14
RML
2
6
RLL
3
11
LUL
11
13
LLL
4
13
Abbreviations: DLCO, diffusing capacity of lungs for carbon monoxide; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity; LUL, left upper lobe; LLL, left lower lobe; RLL, right lower lobe; RML, right middle lobe; RUL, right upper lobe; SD, standard deviation.
Table 2 Operative and postoperative data Group 1 (n ¼ 30)
Group 2 (n ¼ 57)
p value < 0.001
Operation time (min) Mean
264.0 45.9
197.5 57.7
Median
270 (180–390)
185 (110–370)
Blood loss (mL)
0.068
Mean
174.0 302.1
93.9 93.3
Median
50 (30–1,500)
50 (30–400)
Lymph nodes numbers, mean SD
16.2 7.4
17.8 7.4
0.328
Conversion rate (%)
6.7
1.8
0.272
Duration of chest tube drainage (d)
0.090
Mean SD
5.5 2.2
6.8 3.8
Median (range)
5 (2–13)
7 (3–30)
Duration of hospital stay (d)
0.221
Mean SD
7.2 3.0
8.25 3.9
Median (range)
6 (3–18)
8 (4–32)
Complication rates (%)
20
12.3
Surgical mortality (%)
0
0
Abbreviation: SD, standard deviation. Thoracic and Cardiovascular Surgeon
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0.337
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Learning Thoracoscopic Lobectomy in Resident Training
Huang et al.
693
Prolong air leak > 7 d
Fig. 1 (A) Duration of operative time of thoraoscopic lobectomy in all 87 consecutive patients. (B) Amount of operative blood loss in all 87 consecutive patients
significantly lower compared with group 1 (264.0 45.9 min in group 1 vs. 197.5 57.7 min in group 2; p < 0.001). The mean blood loss was 174.0 302.1 mL in group 1 and 93.9 93.3 mL in group 2 (p ¼ 0.068). One patient in group 1 lost roughly 1,500 mL of blood due to a dislodgement of the Hem-o-lok (Weck Closure Systems, Research Triangle Park, North Carolina, United States) on a small branch of the pulmonary artery. This may have contributed to the larger blood loss volume in group 1. In regards to the harvested lymph node numbers, conversion rate, duration of chest tube drainage, duration of hospital stay, and complication rates, it was determined that there were no significant differences between the two groups. ►Table 3 presents information regarding the complications. There were no mortalities in both the groups. The pathological tumor, lymph node, and metastasis stages are listed in ►Table 4 for the patients with lung cancer in groups 1 (n ¼ 27) and 2 (n ¼ 47). Most patients had early stage lung cancer, that is, 85% in group 1 and 74.5% in group 2. During this training period, the surgical resident also performed nine traditional open lobectomies. The mean age of these nine patients was 62.3 12.0 years old, and the mean tumor size was 4.2 2.1 cm, which was the main reason for the patient exclusion from thoracoscopic lobectomy. The mean operation time and blood loss were 185.6 32.4 minutes and 145.6 126.3 mL, respectively. The nine cases were distributed randomly throughout the training period.
Discussion Since thoracoscopic lobectomy was first introduced about two decades ago, many experienced thoracic surgeons have demonstrated several advantages of this minimally invasive
Group 1 (n ¼ 30)
Group 2 (n ¼ 57)
1
4
Arrhythmia
2
0
Empyema
0
1
Subcutaneous emphysema
0
0
Gout attack
1
0
Pneumonia
1
0
Pleural effusion status post re-on chest tube
1
0
Hoarseness
0
1
Subcutaneous emphysema
0
2
technique that possesses similar postoperative survival outcomes to the open approach. In 2008, Whitson et al5 systemically reviewed 39 studies involving 3,256 thoracotomies and 3,114 thoracoscopic patients. It was found that patients with early-stage nonsmall cell lung cancer that underwent thoracoscopic lobectomy appeared to have lower morbidity and improved survival rates. On the basis of this evidence,
Table 4 Pathological staging for lung cancer Group 1 (n ¼ 27)
Group 2 (n ¼ 47)
2.42 1.15
2.48 1.21
Adenocarcinoma
26
43
SqCC
1
2
Others
0
2
Lymph node numbers, mean SD
16.8 7.4
19.2 6.5
Positive lymph node numbers, mean SD
0.15 0.53
0.64 1.92
Neoadjuvant therapy
3
3
T1aN0M0
10
8
T1bN0M0
0
5
T2aN0M0
13
22
Tumor size (cm) , mean SD Histology
Tumor stage
T3N0M0
0
3
T1bN1M0
0
1
T2aN1M0
1
3
T2bN1N0
0
1
T1aN2M0
1
0
T2aN2M0
0
3
T2aN0M1a
0
1
Abbreviations: SD, standard deviation; SqCC, squamous cell carcinoma. Thoracic and Cardiovascular Surgeon
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Table 3 Postoperative complications
Learning Thoracoscopic Lobectomy in Resident Training patients are more likely to request the most minimally invasive lobectomy not only because of the favorable oncologic outcomes and decreased morbidity, but also for cosmetic reasons. However, thoracoscopic lobectomy is still regarded to as a technically demanding procedure. Lack of tactile feedback and two-dimensional visualization may be some of the challenges. For surgeons experienced in performing posterolateral thoracotomies, changes in visualization and restricted tissue manipulation may further lengthen the learning process. During the earlier years of procedure adoption, thoracic surgeons performing thoracoscopic lobectomy were mostly self-taught and had developed some of the methods for transitioning from posterolateral thoracotomy to thoracoscopic lobectomy procedures. Ng and Ryder6 demonstrated a stepwise transition from open lobectomy to thoracoscopic lobectomy. When experience with posterolateral thoracotomy was obtained, resections through more limited lateral muscle-sparing incisions, and then, smaller utility thoracotomy incisions without rib spreading were applied. In their opinion, to document acceptable outcomes for open procedures before attempting transition to thoracoscopic lobectomy is important. Reed et al7 described a more detailed stepwise plan for introducing thoracoscopic lobectomy into a thoracic surgical training program. Wan et al8 agreed that thoracoscopic lobectomy could be taught to trainees that work under the supervision of experienced thoracoscopic surgeons and could be an integral part of the thoracic surgical training program. In published literature, all of the trainee surgeons described were experienced in open thoracotomy and minor thoracoscopic procedures,6–10 and no previous studies focused on surgical residents with respect to performing thoracoscopic lobectomy. Theoretically, a surgeon with no experience in conducting an open lobectomy would not have the ability to perform a thoracoscopic lobectomy. However, to date, thoracoscopic procedures are more likely to be performed instead of thoracotomies. Thus, surgical residents in minimal invasive centers must learn all thoracic surgical skills, that is, open and thoracoscopic approaches, simultaneously. For example, laparoscopic cholecystectomy has become the gold standard for the management of gall bladder diseases. More laparoscopic cholecystectomies are performed than open cholecystectomies. In fact, many surgical residents learn laparoscopic cholecystectomy before open cholecystectomy. For example, surgical residents can attend laparoscopic cholecystectomies and serve as an assistant or cameraman. After making progress in learning laparoscopic techniques, surgical residents may perform laparoscopic cholecystectomies under the supervision of an experienced surgeon. Even if surgical residents have never performed an open cholecystectomy, they may still learn to perform laparoscopic cholecystectomies proficiently. Furthermore, we speculate that a lobectomy may be taught from a thoracoscopy directly. However, whether a supervised resident is capable of receiving training in open and thoracoscopic lobectomies simultaneously without sacrificing the results has not yet been determined in previous studies. Thoracic and Cardiovascular Surgeon
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Huang et al. In our study, the surgical resident was not fully experienced in open lobectomy procedures, but had previously assisted in more than 100 thoracoscopic lobectomies and performed more than 100 minor thoracoscopic procedures. When the first 30 cases are compared with the subsequent 57 cases in our study, the mean operative time is significantly longer in the first 30 cases (264.0 45.9 min vs. 197.5 57.7 min; p < 0.001), indicating that the operative time decreases with experience and proficiency. Pleural adhesion was not a contraindication, with the exception of when adhesion was diffusely located and obliterated more than half of the pleural cavity, which may have lengthened the operative time. Incomplete or an absence of fissure was not a contraindication. Furthermore, one of the three conversion cases had contributed to a pleural adhesion or incomplete fissure. The consultant surgeon was available throughout the entire procedure to offer suggestions. The consultant surgeon solely monitored the entire procedure and stayed away from the surgical table. Some surgeons suggested that proficiency in thoracoscopic lobectomy techniques increases after performing approximately 50 cases, which is comparable to the number of cases required for proficiency with other advanced laparoscopic procedures.11 In our study, the operative time was significantly lower after performing 30 thoracoscopic lobectomies, whereas there were no statistically significant differences with respect to blood loss, harvested lymph node numbers, conversion rate, duration of chest tube drainage, length of hospital stay, or complication rates. In fact, it was very difficult to define the cutoff point for the learning curve. In our training programs, we believe that a stable surgical performance may occur after 30 cases. In our training program for thoracoscopic lobectomy, after completing 2 years of general surgery training, 3rd year residents are responsible for controlling the camera during thoracoscopic procedures, 4th year resident could perform minor thoracoscopic procedures and being an assistant during thoracoscopic lobectomies, and 5th year residents could be the operator under an experienced surgeon’s supervision. In our study, only 3 of 87 thoracoscopic lobectomies were converted into open thoracotomy, where the conversion rate was 6.7% in the first 30 cases and 1.8% in the subsequent 57 cases. Blood loss from the pulmonary artery remains one of the most important concerns and was the main reason for performing open thoracotomies in our study. Indeed, two of the three cases that converted into open thoracotomies were because of bleeding. To deal with bleeding from the pulmonary artery, experts suggest quickly applying a sponge stick to the site for temporary control of bleeding and extending the minithoracotomy wound. The other conversion was because of a difficult hilar dissection resulting from calcified lymph nodes. Some cognitively simulating programs were suggested in recent years and have the potential benefit of being incorporated into the training programs to overcome trainee deficiencies.12 However, its high cost may limit its wide acceptance.
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Learning Thoracoscopic Lobectomy in Resident Training
Conclusions We found that thoracoscopic lobectomies can be taught to surgical residents that are not fully experienced in the open procedure without compromising the perioperative outcomes. After performing roughly 30 cases, proficiency of the thoracoscopic lobectomy procedure and consistency in the surgical outcome was achieved in our study.
4 Nagahiro I, Andou A, Aoe M, Sano Y, Date H, Shimizu N. Pulmonary
5
6
7
8
9
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 2 McKenna RJ Jr, Houck W, Fuller CB. Video-assisted thoracic surgery lobectomy: experience with 1,100 cases. Ann Thorac Surg 2006; 81(2):421–425, discussion 425–426 3 Onaitis MW, Petersen RP, Balderson SS, et al. Thoracoscopic lobectomy is a safe and versatile procedure: experience with 500 consecutive patients. Ann Surg 2006;244(3):420–425
695
10 11
12
function, postoperative pain, and serum cytokine level after lobectomy: a comparison of VATS and conventional procedure. Ann Thorac Surg 2001;72(2):362–365 Whitson BA, Groth SS, Duval SJ, Swanson SJ, Maddaus MA. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy. Ann Thorac Surg 2008;86(6): 2008–2016, discussion 2016–2018 Ng T, Ryder BA. Evolution to video-assisted thoracic surgery lobectomy after training: initial results of the first 30 patients. J Am Coll Surg 2006;203(4):551–557 Reed MF, Lucia MW, Starnes SL, Merrill WH, Howington JA. Thoracoscopic lobectomy: introduction of a new technique into a thoracic surgery training program. J Thorac Cardiovasc Surg 2008;136(2):376–381 Wan IY, Thung KH, Hsin MK, Underwood MJ, Yim AP. Videoassisted thoracic surgery major lung resection can be safely taught to trainees. Ann Thorac Surg 2008;85(2):416–419 Ferguson J, Walker W. Developing a VATS lobectomy programme— can VATS lobectomy be taught? Eur J Cardiothorac Surg 2006; 29(5):806–809 Petersen RH, Hansen HJ. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg 2010;37(3):516–520 Seder CW, Hanna K, Lucia V, et al. The safe transition from open to thoracoscopic lobectomy: a 5-year experience. Ann Thorac Surg 2009;88(1):216–225, discussion 225–226 Solomon B, Bizekis C, Dellis SL, et al. Simulating video-assisted thoracoscopic lobectomy: a virtual reality cognitive task simulation. J Thorac Cardiovasc Surg 2011;141(1):249–255
Thoracic and Cardiovascular Surgeon
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There are some limitations in our study that need to be addressed. This was a retrospective study on a single resident that undertook training at a single medical center. While not all of the trainees at our institution undertake the same training path, this article highlights the most common training program available at our hospital.
Huang et al.
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