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Introduction: The use of routine postoperative chest drains after video-assisted thoracoscopic surgery (VATS) of the lung is a practice based on tradition with the aim of draining fluid and air. However, new evidence suggests that chest drains can be avoided in selected cases. With this randomised controlled trial, we wish to establish the efficacy and safety of avoiding postoperative chest drains compared with routine postoperative chest drains., Methods and Analysis: This is a two-centre randomised controlled trial without allocation concealment, but where randomisation occurs after the end of procedure leaving operative personnel blinded during surgery. The sample size is calculated to show a difference in pain measurements using the Numeric Rating Scale under different circumstances and at different time points to show superiority of the intervention. The trial is pragmatic by design to reflect the daily clinical scenario and with the aim of increasing the external validity of the results., Ethics and Dissemination: Approval by the local ethics committees has been obtained for both sites. The study was registered with ClinicalTrials.gov (NCT05358158) prior to inclusion. The results of the trial will be disseminated by publication in an international journal and presentation at major international thoracic surgical meetings., Article Summary: This is a randomised controlled trial estimating the effects of avoiding a chest drain after VATS wedge resection of the lung on pain, total morphine use, quality of life and complications., Trial Registration Number: NCT05358158., Competing Interests: Competing interests: BLH has received a speaker’s fee from Medela Healthcare. HJH has received a speaker’s fee from Medtronic and BD. TDC has been on the speaker bureaus for AstraZeneca, Boehringer-Ingelheim, Pfizer, Roche Diagnostics, Takeda, Merck Sharp & Dohme (MSD) and Bristol-Myers Squibb and has been in an Advisory Board for Bayer and Merck Sharp & Dohme (MSD). RHP has received a speaker’s fee from Medtronic, AMU, AstraZeneca, Medela and is an advisory board member for AstraZeneca, Roche, MSD, BMS. LH, MB and HK have no conflicts of interest to report. This is an investigator-initiated trial with no ties to private industries., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Although video-assisted thoracoscopic surgery (VATS) lobectomy has become the gold standard for pulmonary resections of non-small-cell lung cancer (NSCLC), lobectomy is still performed via thoracotomy in many European and North American centres. VATS lobectomy was implemented overnight from thoracotomy in our low-volume centre in early 2019, after 1 senior surgeon undertook observership VATS-training overseas, and immediately became the mainstay of surgical treatment for NSCLC in Iceland. We aimed to investigate our short-term outcomes of VATS lobectomy., Methods: This was a retrospective study on all pulmonary resections for NSCLC in Iceland 2019-2022, especially focusing on VATS lobectomies, all at cTNM stage I or II. Data were retrieved from hospital charts, including information on perioperative complications, mortality, length of stay and operation time., Results: Out of 204 pulmonary resections, mostly performed by a single senior cardiothoracic surgeon, 169 were lobectomies (82.9%) with 147 out of 169 (87.0%) being VATS lobectomies. Anterolateral thoracotomy was used in 34 cases (16.7%), including 22 lobectomies (64.7%), and 5 (3.4%) conversions from VATS lobectomy. The median postoperative stay for VATS lobectomy was 4 days and the average operating time decreased from 155 to 124 min between the first and last year of the study (P < 0.001). The rate of major and minor complications was 2.7% and 15.6% respectively. One year survival was 95.6% and all patients survived 30 days postoperatively., Conclusions: The implementation of VATS lobectomy has been successful in our small geographically isolated centre, serving a population of 390 000. Although technically challenging, VATS lobectomy was implemented fast for most NSCLC cases, with short-term outcomes that are comparable to larger high-volume centres., (© The Author(s) 2024. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery.)

Objectives: Lung volume reduction surgery (LVRS) has proven an effective treatment for emphysema, by decreasing hyperinflation and improving lung function, activity level and reducing dyspnoea. However, postoperative air leak is an important complication, often leading to reoperation. Our aim was to analyse reoperations after LVRS and identify potential predictors., Methods: Consecutive single-centre unilateral VATS LVRS performed from 2017 to 2022 were included. Typically, 3-5 minor resections were made using vascular magazines without buttressing. Data were obtained from an institutional database and analysed. Multivariable logistic regression was used to identify predictors of reoperation. Number and location of injuries were registered., Results: In total, 191 patients were included, 25 were reoperated (13%). In 21 patients, the indication for reoperation was substantial air leak, 3 patients bleeding and 1 patient empyema. Length of stay (LOS) was 21 (11-33) vs. 5 days (3-11), respectively. Only 3 injuries were in the stapler line, 13 within < 2cm and 15 injuries were in another site. Multivariable logistic regression analysis showed that decreasing DLCO increased risk of reoperation, OR 1.1 (1.03, 1.18, P = 0.005). Resections in only one lobe, compared to resections in multiple lobes, were also a risk factor OR 3.10 (1.17, 9.32, P = 0.03). Patients undergoing reoperation had significantly increased 30-day mortality, OR 5.52 (1.03, 26.69, P = 0.02)., Conclusions: Our incidence of reoperation after LVRS was 13% leading to prolonged LOS and increased 30-day mortality. Low DLCO and resections in a single lobe were significant predictors of reoperation. The air leak was usually not localized in the stapler line., (© 2023. The Author(s).)

Objectives: To identify and prioritize technical procedures for simulation-based training to be integrated into the thoracic surgical curriculum., Methods: A 3-round Delphi survey was conducted from February 2022 to June 2022 among 34 key opinion leaders in thoracic surgery from 14 countries worldwide. The 1st round was a brainstorming phase to identify technical procedures that a newly qualified thoracic surgeon should be able to perform. All the suggested procedures were categorized, qualitatively analysed and sent to the 2nd round. The second round investigated: the frequency of the identified procedure at each institution, the number of thoracic surgeons that should be able to perform these procedures, the degree of risk to the patient if the procedure is performed by a non-competent thoracic surgeon and the feasibility of simulation-based education. In the 3rd round, elimination and re-ranking of the procedures from the 2nd round were performed., Results: Response rates in the 3 iterative rounds were 80% (28 out of 34), 89% (25 out of 28) and 100% (25 out of 25) in the 1st, 2nd and 3rd round, respectively. Seventeen technical procedures were included for simulation-based training in the final prioritized list. The top 5 procedures were Video-Assisted Thoracoscopic Surgery (VATS) lobectomy, VATS segmentectomy, VATS mediastinal lymph node dissection, diagnostic flexible bronchoscopy and robotic-assisted thoracic surgery port placement, robotic-assisted thoracic surgery docking and undocking., Conclusions: The prioritized list of procedures represents a consensus of key thoracic surgeons worldwide. These procedures are suitable for simulation-based training and should be integrated in the thoracic surgical curriculum., (© The Author(s) 2023. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Aim: The aim of this study is to develop a reliable composite score based on simulator metrics to assess competency in virtual reality video-assisted thoracoscopic surgery lobectomy and explore the benefits of combining it with expert rater assessments., Methods: Standardized objective assessments (time, bleeding, economy of movement) and subjective expert rater assessments from 2 previous studies were combined. A linear mixed model including experience level, lobe and the number of previous simulated procedures was applied for the repeated measurements. Reliability for each of the 4 assessments was calculated using Cronbach's alpha. The Nelder-Mead numerical optimization algorithm was used for optimal weighting of scores. A pass-fail standard for the composite score was determined using the contrasting groups' method., Results: In total, 123 virtual reality video-assisted thoracoscopic surgery lobectomies were included. Across the 4 different assessments, there were significant effects (P &lt; 0.01) of experience, lobe, and simulator experience, but not for simulator attempts on bleeding (P = 0.98). The left upper lobe was significantly more difficult compared to other lobes (P = 0.02). A maximum reliability of 0.92 could be achieved by combining the standardized simulator metrics with standardized expert rater scores. The pass/fail level for the composite score when including 1 expert rater was 0.33., Conclusions: Combining simulator metrics with 1 or 2 raters increases reliability and can serve as a more objective method for assessing surgical trainees. The composite score may be used to implement a standardized and feasible simulation-based mastery training program in video-assisted thoracoscopic surgery lobectomy., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To determine the number of procedures and expert raters necessary to provide a reliable assessment of competence in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy., Methods: Three randomly selected VATS lobectomies were performed on a virtual reality simulator by participants with varying experience in VATS. Video recordings of the procedures were independently rated by three blinded VATS experts using a modified VATS lobectomy assessment tool (VATSAT). The unitary framework of validity was used to describe validity evidence, and generalizability theory was used to explore the reliability of different assessment options., Results: Forty-one participants (22 novices, 10 intermediates, and 9 experienced) performed a total of 123 lobectomies. Internal consistency reliability, inter-rater reliability, and test-retest reliability were 0.94, 0.85, and 0.90, respectively. Generalizability theory found that a minimum of two procedures and four raters or three procedures and three raters were needed to ensure the overall reliability of 0.8. ANOVA showed significant differences in test scores between the three groups (P < 0.001). A pass/fail level of 19 out of 25 points was established using the contrasting groups' standard setting method, leaving one false positive (one novice passed) and zero false negatives (all experienced passed)., Conclusion: We demonstrated validity evidence for a VR simulator test with different lung lobes, and a credible pass/fail level was identified. Our results can be used to implement a standardized mastery learning training program for trainees in VATS lobectomies that ensures that everyone reaches basic competency before performing supervised operations on patients., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Video-Assisted Thoracoscopic Surgery (VATS) lobectomy is an advanced procedure and to maximize patient safety it is important to ensure the competency of thoracic surgeons before performing the procedure. The objective of this study was to investigate validity evidence for a virtual reality simulator-based test including multiple lobes of the lungs., Method: VATS experts from the department of Cardiothoracic Surgery at Rigshospitalet, Copenhagen, Denmark, worked with Surgical Science (Gothenburg, Sweden) to develop VATS lobectomy modules for the LapSim ® virtual reality simulator covering all five lobes of the lungs. Participants with varying experience in VATS were recruited and classified as either novice, intermediate, or experienced surgeons. Each participant performed VATS lobectomy on the simulator for three different randomly chosen lobes. Nine predefined simulator metrics were automatically recorded on the simulator., Results: Twenty-two novice, ten intermediate, and nine experienced surgeons performed the test resulting in a total of 123 lobectomies. Analysis of Variances (ANOVA) found significant differences between the three groups for parameters: blood loss (p < 0.001), procedure time (p < 0.001), and total instrument path length (p = 0.03). These three metrics demonstrated high internal consistency and significant test-retest reliability was found between each of them. Relevant pass/fail levels were established for each of the three metrics, 541 ml, 30 min, and 71 m, respectively., Conclusion: This study provides validity evidence for a simulator-based test of VATS lobectomy competence including multiple lobes of the lungs. The test can be used to ensure basic competence at the end of a simulation-based training program for thoracic surgery trainees., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC part of Springer Nature.)

Objectives: Lung volume reduction (LVR) is an efficient and approved treatment for selected emphysema patients. There is some evidence that repeated LVR surgery (LVRS) might be beneficial, but there are no current data on LVRS after unsuccessful bronchoscopic LVR (BLVR) with endobronchial valves (EBVs). We hypothesize good outcome of LVRS after BLVR with valves., Methods: In this study, we retrospectively investigated all patients who underwent LVRS between 2015 and 2019 at 2 centres after previous unsuccessful EBV treatment. They were further divided into subgroups with patients who never achieved the intended improvement after BLVR (primary failure) and patients whose benefit was fading over time due to the natural development of emphysema (secondary failure). Patients with severe air leak after BLVR and immediate concomitant LVRS and fistula closure thereafter were analysed separately., Results: A total of 38 patients were included. Of these, 19 patients had primary failure, 15 secondary failure and 4 were treated as an emergency due to severe air leak. At 3 months after LVRS, forced expiratory volume in 1 s had improved significantly by 12.5% (P = 0.011) and there was no 90-day mortality. Considering subgroups, patients with primary failure after BLVR seem to profit more than those with secondary failure. Patients with severe air leak after BLVR did not profit from fistula closure with concomitant LVRS., Conclusions: LVRS after previous BLVR with EBVs can provide significant clinical improvement with low morbidity, although results might not be as good as after primary LVRS., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Competency-based training has gained ground in surgical training and with it assessment tools to ensure that training objectives are met. Very few assessment tools are available for evaluating performance in thoracoscopic procedures. Video recordings would provide the possibility of blinded assessment and limited rater bias. This study aimed to provide validity evidence for a newly developed and dedicated tool for assessing competency in Video-Assisted Thoracoscopic Surgery (VATS) lobectomy., Methods: Participants with varying experience with VATS lobectomy were included from different countries. Video recordings from participants' performance of a VATS right upper lobe lobectomy on a virtual reality simulator were rated by three raters using a modified version of a newly developed VATS lobectomy assessment tool (the VATSAT) and analyzed in relation to the unitary framework (content, response process, internal structure, relation to other variables, and consequences of testing)., Results: Fifty-three participants performed two consecutive simulated VATS lobectomies on the virtual reality simulator, leaving a total of 106 videos. Content established in previously published studies. Response process Standardized data collection was ensured by using an instructional element, uniform data collection, a special rating program, and automatic generation of the results to a database. Raters were carefully instructed in using the VATSAT, and tryout ratings were carried out. Internal structure Inter-rater reliability was calculated as intra-class correlation coefficients, to 0.91 for average measures (p < 0.001). Test/re-test reliability was calculated as Pearson's r of 0.70 (p < 0.001). G-coefficient was calculated to be 0.79 with two procedures and three raters. By performing D-theory was found that either three procedures rated by two raters or five procedures rated by one rater were enough to reach an acceptable G-coefficient of ≥ 0.8. Relation to other variables Significant differences between groups were found (p < 0.001). The participants' VATS lobectomy experience correlated significantly to their VATSAT score (p = 0.016). Consequences of testing The pass/fail score was found to be 14.9 points by the contrasting groups' method, leaving five false positive (29%) and six false negatives (43%)., Conclusion: Validity evidence was provided for the VATSAT according to the unitary framework. The VATSAT provides supervisors and assessors with a procedure-specific assessment tool for evaluating VATS lobectomy performance and aids with the decision of when the trainee is ready for unsupervised performance.

Objectives: The optimal level of suction on digital chest drainage devices after lobectomy using video-assisted thoracoscopic surgery (VATS) is unknown and varies between thoracic centres. In this randomized controlled trial, we assessed the potential benefits of low suction of -2 cmH2O compared to -10 cmH2O, using a digital drainage device., Methods: Two hundred and twenty-eight patients were randomized into 2 groups after VATS lobectomy for suspected or confirmed lung cancer. Primary outcome was time to chest drain removal. Drain data were obtained from the digital drainage devices, and patient data were obtained from medical records during admission, with a follow-up until postoperative day 30., Results: For the -2 cmH2O and -10 cmH2O groups, median (interquartile range) drainage duration was 27.4 h (23.3-71.2) and 47.5 h (24.5-117.8) (P = 0.047), and the incidence of prolonged air leak >5 days was 14.4% and 24.3% (P = 0.089), respectively. Median total fluid production was 566 h (329-1155) ml and 795 h (454-1605) ml (P = 0.007). Median time to consistent air leak cessation (<20 ml/min) was 5.2 h (0.3-34.2) and 23.7 h (0.8-90.8) (P < 0.001). There were no differences in the proportion or the size of the pneumothorax or subcutaneous emphysema after drain removal, and no differences were observed in postoperative morbidity. Median length of in-hospital stay was 2.0 days (2.0-5.8) and 3.0 days (2.0-9.0) (P = 0.18)., Conclusions: A low suction level significantly shortened drainage duration, time to air leak cessation and total fluid production, without increasing morbidity., Clinical Trial Registration Number: NCT02911259., (© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Lung volume reduction surgery (LVRS) is a treatment option for patients with severe emphysema. A multicentre randomised trial (NETT) found, that LVRS reduced symptoms from emphysema, and in selected patients with heterogen-ous emphysema it improved survival. Since NETT was performed, other studies have demonstrated positive outcomes, both symptomatic and for survival in previously classified high-risk patients. Post-operative mortality after LVRS is now negligible, which is often credited to minimally invasive techniques, greater experience with the patient group and improved operative equipment.

This review is about the initial diagnostic workup and the surgical treatment of patients with lung cancer in Denmark. Due to the development of international and national clinical guidelines for diagnosis and treatment of lung cancer, survival has increased. Data from 2005-2016 in the National Danish Lung Cancer Registry show an increase in: 1) the number of women being diagnosed, 2) the part of surgical candidates being thoracoscopically treated, 3) the number of patients being referred to surgery and 4) the survival rate.

Background: Specific assessment tools can accelerate trainees' learning through structured feedback and ensure that trainees attain the knowledge and skills required to practice as competent, independent surgeons (competency-based surgical education). The objective was to develop an assessment tool for video-assisted thoracoscopic surgery (VATS) lobectomy by achieving consensus within an international group of VATS experts., Method: The Delphi method was used as a structured process for collecting and distilling knowledge from a group of internationally recognized VATS experts. Opinions were obtained in an iterative process involving answering repeated rounds of questionnaires. Responses to one round were summarized and integrated into the next round of questionnaires until consensus was reached., Results: Thirty-one VATS experts were included and four Delphi rounds were conducted. The response rate for each round were 68.9% (31/45), 100% (31/31), 96.8% (30/31), and 93.3% (28/30) for the final round where consensus was reached. The first Delphi round contained 44 items and the final VATS lobectomy Assessment Tool (VATSAT) comprised eight items with rating anchors: (1) localization of tumor and other pathological tissue, (2) dissection of the hilum and veins, (3) dissection of the arteries, (4) dissection of the bronchus, (5) dissection of lymph nodes, (6) retrieval of lobe in bag, (7) respect for tissue and structures, and (8) technical skills in general., Conclusion: A novel and dedicated assessment tool for VATS lobectomy was developed based on VATS experts' consensus. The VATSAT can support the learning of VATS lobectomy by providing structured feedback and help supervisors make the important decision of when trainees have acquired VATS lobectomy competencies for independent performance.

Background: Competence in video-assisted thoracoscopic surgery lobectomy has previously been established on the basis of numbers of procedures performed, but this approach does not ensure competence. Specific assessment tools, such as the newly developed video-assisted thoracoscopic surgery lobectomy assessment tool, allow for structured and objective assessment of competence. Our aim was to provide validity evidence for the video-assisted thoracoscopic surgery lobectomy assessment tool., Methods: Video recordings of 60 video-assisted thoracoscopic surgery lobectomies performed by 18 thoracic surgeons were rated using the video-assisted thoracoscopic surgery lobectomy assessment tool. All 4 centers of thoracic surgery in Denmark participated in the study. Two video-assisted thoracoscopic surgery experts rated the videos. They were blinded to surgeon and center., Results: The total internal consistency reliability Cronbach's alpha was 0.93. Inter-rater reliability between the 2 raters was Pearson's r = 0.71 (P < .001). The mean video-assisted thoracoscopic surgery lobectomy assessment tool scores for the 10 procedures performed by beginners were 22.1 (standard deviation [SD], 8.6) for the 28 procedures performed by the intermediate surgeons, 31.2 (SD, 4.4), and for the 20 procedures performed by experts 35.9 (SD, 2.9) (P < .001). Bonferroni post hoc tests showed that experts were significantly better than intermediates (P < .008) and beginners (P < .001). Intermediates' mean scores were significantly better than beginners (P < .001). The pass/fail standard calculated using the contrasting group's method was 31 points. One of the beginners passed, and 2 experts failed the test., Conclusions: Validity evidence was provided for a newly developed assessment tool for video-assisted thoracoscopic surgery lobectomy (video-assisted thoracoscopic surgery lobectomy assessment tool) in a clinical setting. The discriminatory ability among expert surgeons, intermediate surgeons, and beginners proved highly significant. The video-assisted thoracoscopic surgery lobectomy assessment tool could be an important aid in the future training and certification of thoracic surgeons., (Copyright © 2018 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objectives: Large retrospective series have indicated lower rates of cN0 to pN1 nodal upstaging after video-assisted thoracic surgery (VATS) compared with open resections for Stage I non-small-cell lung cancer (NSCLC). The objective of our multicentre study was to investigate whether the presumed lower rate of N1 upstaging after VATS disappears after correction for central tumour location in a multivariable analysis., Methods: Consecutive patients operated for PET-CT based clinical Stage I NSCLC were selected from prospectively managed surgical databases in 11 European centres. Central tumour location was defined as contact with bronchovascular structures on computer tomography and/or visibility on standard bronchoscopy., Results: Eight hundred and ninety-five patients underwent pulmonary resection by VATS (n = 699, 9% conversions) or an open technique (n = 196) in 2014. Incidence of nodal pN1 and pN2 upstaging was 8% and 7% after VATS and 15% and 6% after open surgery, respectively. pN1 was found in 27% of patients with central tumours. Less central tumours were operated on by VATS compared with the open technique (12% vs 28%, P < 0.001). Logistic regression analysis showed that only tumour location had a significant impact on N1 upstaging (OR 6.2, confidence interval 3.6-10.8; P < 0.001) and that the effect of surgical technique (VATS versus open surgery) was no longer significant when accounting for tumour location., Conclusions: A quarter of patients with central clinical Stage I NSCLC was upstaged to pN1 at resection. Central tumour location was the only independent factor associated with N1 upstaging, undermining the evidence for lower N1 upstaging after VATS resections. Studies investigating N1 upstaging after VATS compared with open surgery should be interpreted with caution due to possible selection bias, i.e. relatively more central tumours in the open group with a higher chance of N1 upstaging., (© The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

The Society for Translational Medicine and The Chinese Society for Thoracic and Cardiovascular Surgery conducted a systematic review of the literature in an attempt to improve our understanding in the postoperative management of chest tubes of patients undergoing pulmonary lobectomy. Recommendations were produced and classified based on an internationally accepted GRADE system. The following recommendations were extracted in the present review: (I) chest tubes can be removed safely with daily pleural fluid of up to 450 mL (non-chylous and non-sanguinous), which may reduce chest tube duration and hospital length of stay (2B); (II) in rare instances, e.g., persistent abundant fluid production, the use of PrR P/B <0.5 when evaluating fluid output to determine chest tube removal might be beneficial (2B); (III) it is recommended that one chest tube is adequate following pulmonary lobectomy, except for hemorrhage and space problems (2A); (IV) chest tube clearance by milking and stripping is not recommended after lung resection (2B); (V) chest tube suction is not necessary for patients undergoing lobectomy after first postoperative day (2A); (VI) regulated chest tube suction [-11 (-1.08 kPa) to -20 (1.96 kPa) cmH 2 O depending upon the type of lobectomy] is not superior to regulated seal [-2 (0.196 kPa) cmH 2 O] when electronic drainage systems are used after lobectomy by thoracotomy (2B); (VII) chest tube removal recommended at the end of expiration and may be slightly superior to removal at the end of inspiration (2A); (VIII) electronic drainage systems are recommended in the management of chest tube in patients undergoing lobectomy (2B)., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

The objective of this study was to evaluate the potential of predicting the pleural fluid output in patients after video-assisted thoracoscopic lobectomy of the lung. Detailed measurements of continuous fluid output were obtained prospectively using an electronic thoracic drainage device (Thopaz+™, Medela AG, Switzerland). Patients were divided into high (≥500 mL) and low (<500 mL) 24-hour fluid output, and detailed flow curves were plotted graphically to identify arithmetic patterns predicting fluid output in the early (≤24 hours) and later (24-48 hours) post-operative phase. Furthermore, multiple logistic regression analysis was used to predict high 24-hour fluid output using baseline data. Data were obtained from 50 patients, where 52% had a fluid output of <500 mL/24 hours. From visual assessment of flow curves, patients were grouped according to fluid output 6 hours postoperatively. An output ≥200 mL/6 hours was predictive of 'high 24-hour fluid output' (P<0.0001). However, 33% of patients with <200 mL/6 hours ended with a 'high 24-hour fluid output'. Baseline data showed no predictive value of fluid production, and 24-hour fluid output had no predictive value of fluid output between 24 and 48 hours. Assessment of initial fluid production may predict high 24-hour fluid output (≥500 mL) but seems to lack clinical value in drain removal criteria., Competing Interests: Conflicts of Interest: Henrik Jessen Hansen reports personal fees from Medtronic, Medela, and Bard outside the submitted work. René Horsleben Petersen reports personal fees from Medtronic and Medela outside the submitted work. Professor Henrik Kehlet and Bo Laksáfoss Holbek have no conflict of interest.

Objective: To compare the incidence of major adverse cardiac events (MACE) and mortality following video-assisted thoracoscopic surgery (VATS) lobectomy in patients with and without coronary artery disease (CAD)., Methods: Multicentre retrospective analysis of 1699 patients undergoing VATS lobectomy (January 2012-March 2015). CAD definition: previous acute myocardial infarct (AMI), angina, percutaneous coronary intervention (PCI) or coronary artery bypass graft (CABG). MACE definition: postoperative acute myocardial ischemia, cardiac arrest or any cardiac death. Propensity score analysis was performed to match patients with and without CAD. Outcomes of the 2 matched groups were compared., Results: The incidence of MACE and mortality for the entire population was 0.4% (7 patients) and 1.7% (29 patients); 218 patients (13%) had a history of CAD: 106 previous AMI, 55 angina, 32 CABG, and 81 PCI. The propensity score yielded 2 well-balanced groups of 218 pairs with and without CAD. MACE (CAD 2 [0.9%] vs no-CAD 1 [0.5%]; P = 1), cardiovascular and pulmonary complications (CAD 61 [28%] vs no-CAD 51 [23%]; P = .3) and postoperative stay (CAD 7.3 days vs no-CAD 6.2 days; P = .3) were not different between the groups. The incidence of atrial fibrillation (CAD 31 [14%] vs no-CAD 18 [8.2%]; P = .07), 30-day mortality (CAD: 11 [5%] vs no-CAD 2 [0.9%]; P = .02) and death among complicated patients (CAD 18% vs no-CAD 3.9%; P = .009) were higher in the CAD group., Conclusions: The incidence of MACE following VATS lobectomy in patients with CAD is low and similar to patients without CAD. However, their risk of postoperative mortality is fivefold higher compared with non-CAD patients, warranting refined preoperative functional evaluation and more intense postoperative monitoring., (Copyright © 2017 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Microlobectomy is a novel form of videoscopic-assisted thoracic surgery lobectomy. Strict inclusion criteria consist of the following: no intercostal incisions greater than 5 mm, 12 mm subxiphoid port, subxiphoid removal of the specimen, total endoscopic technique with CO2 insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices., Methods: The combined early experiences of six hospitals from three countries were combined from September 2014 to May 2016. During that time, the study represents a consecutive cohort study of this technique., Results: Seventy-two patients underwent microlobectomy. The median (range) age was 66 (27-82). Half of the patients were female. There were 48 right-sided resections and 24 on the left. There were four segmental resections and there was one right pneumonectomy. Four operations were performed robotically (with 8-mm intercostal incisions). The median (range) operative time was 180 (94-285) minutes and the blood loss was 118 (5-800) mL. There were three conversions to thoracotomy and two conversions to videoscopic-assisted thoracic surgery by means of an intercostal utility incision to complete the operation. The median (range) length of stay was 3 (1-44) days and 30 patients (42%) when home by day 2 and 16 patients (22%) were discharged on day 1. There were no deaths. Five patients (7%) had a prolonged airleak. There were no wound infections and there was one incisional hernia., Conclusions: We believe that microlobectomy is an interesting novel form of videoscopic-assisted thoracic surgery lobectomy and has several theoretical advantages. We have presented our early results and hope that this will stimulate others to investigate this type of videoscopic-assisted thoracic surgery lobectomy further.

Background: The societies of thoracic surgery are working to incorporate simulation and competency-based assessment into specialty training. One challenge is the development of a simulation-based test, which can be used as an assessment tool. The study objective was to establish validity evidence for a virtual reality simulator test of a video-assisted thoracoscopic surgery (VATS) lobectomy of a right upper lobe., Methods: Participants with varying experience in VATS lobectomy were included. They were familiarized with a virtual reality simulator (LapSim ® ) and introduced to the steps of the procedure for a VATS right upper lobe lobectomy. The participants performed two VATS lobectomies on the simulator with a 5-min break between attempts. Nineteen pre-defined simulator metrics were recorded., Results: Fifty-three participants from nine different countries were included. High internal consistency was found for the metrics with Cronbach's alpha coefficient for standardized items of 0.91. Significant test-retest reliability was found for 15 of the metrics (p-values <0.05). Significant correlations between the metrics and the participants VATS lobectomy experience were identified for seven metrics (p-values <0.001), and 10 metrics showed significant differences between novices (0 VATS lobectomies performed) and experienced surgeons (>50 VATS lobectomies performed). A pass/fail level defined as approximately one standard deviation from the mean metric scores for experienced surgeons passed none of the novices (0 % false positives) and failed four of the experienced surgeons (29 % false negatives)., Conclusion: This study is the first to establish validity evidence for a VATS right upper lobe lobectomy virtual reality simulator test. Several simulator metrics demonstrated significant differences between novices and experienced surgeons and pass/fail criteria for the test were set with acceptable consequences. This test can be used as a first step in assessing thoracic surgery trainees' VATS lobectomy competency.

Objective: Chest drains are used routinely after wedge resection by video-assisted thoracoscopic surgery (VATS), although this practice is based largely on tradition rather than evidence. Chest drains may furthermore cause pain, infections, and prolonged length of stay. The aim of this prospective observational study was to assess the feasibility of avoiding chest drains following VATS wedge resection for pulmonary nodules., Methods: Between 1 February and 25 August 2015 166 consecutive patients planned for VATS wedge resection of pulmonary nodules were screened for inclusion using the following criteria: Forced expiratory volume in 1 s (FEV1) ≥60 % of expected, FEV1/forced vital capacity ≥70 %, tumour diameter ≤2 cm, distance from tumour to visceral pleura ≤3 cm, ≤2 separate wedges, no air leak on an intraoperative air leakage test and absence of severe adhesions, bullous/emphysematous disease, pleural effusion and coagulopathy. Chest X-rays were done twice on the day of surgery. 30-day complications were compiled from patient records., Results: 49 patients underwent 51 unilateral VATS wedge resections without using a post-operative chest drain. No patient required reinsertion of a chest drain. 30 (59 %) patients had a pneumothorax of mean size 12 ± 12 mm on supine 8-h post-operative X-ray for which the majority resolved spontaneously within 2-week control. There were no complications on 30-day follow-up. Median length of stay was 1 day., Conclusions: The results support that VATS wedge resection for pulmonary nodules without a post-operative chest drain may be safe in a selected group of patients.

Objectives: The objective of this study was to assess the safety of video-assisted thoracoscopic surgery (VATS) completion lobectomy (CL) for non-small cell lung cancer (NSCLC) after diagnostic wedge resection by comparing with standard VATS lobectomy (SL)., Methods: Data were retrieved from an institutional database of consecutive VATS lobectomies between January 1st 2007 and December 31st 2013. Patients were grouped into CL or SL. Patient characteristics, operative data, converted procedures, complications, and mortality was compared using Pearson Chi square, Fisher's exact test, or Mann-Whitney U test., Results: In total 80 CL and 958 SLs were performed. There were no significant differences in median operating time, median chest drain duration or median length of stay. Median operative bleeding was 100 mL (IQR 50-238) in the CL group compared to 75 mL (IQR 25-200) in the SL group (p = 0.01). There were no differences between groups in major or minor complications. Median time from VATS wedge resection to CL was 33 days (IQR 27-41). Conversion rate was 1.3% in the CL group and 2.6% in the SL group (p = 0.72). 30-day mortality was 0 vs. 1.1 % for the CL group and the SL group accordingly (p > 0.99)., Conclusions: This study comparing short-term surgical outcome and complications after surgical treatment of NSCLC indicates that VATS completion lobectomy after diagnostic wedge resection seems safe when looking at a relatively short time interval between the two procedures.

Objectives: Lung cancer is the most common cause of cancer-related deaths worldwide. Survival is highly dependent on surgery. Video-assisted thoracoscopic surgery (VATS) is increasingly chosen over open thoracotomy (OT) because of the possible benefits of the minimally invasive approach. Consequently, our aim was to compare the 30-day morbidity and mortality for lung cancer patients operated by VATS lobectomy or lobectomy by OT., Method: Data were obtained from prospective national and regional databases, including patients who underwent lobectomy for lung cancer in the eastern part of Denmark from 1 January 2005 to 31 December 2011. All patients operated before 2009 were re-staged according to the latest International Association for the Study of Lung Cancer lung cancer classification. Patient characteristics, comorbidities, pathology and operative data were assessed using an independent samples t-test, Pearson's χ(2), Fisher's exact test and Mann-Whitney test. Morbidity was assessed using multinomial logistic regression adjusted for gender, age, cancer stage, forced expiratory volume in 1 s (FEV1), year of surgery and Charlson comorbidity score., Results: In total, 1379 patients underwent lobectomy, 785 patients via VATS and 594 patients via thoracotomy. The two groups were similar in gender and FEV1. The patients operated by VATS were older (P < 0.001), and had a lower Charlson comorbidity score (P = 0.034), higher frequency of adenocarcinomas (P < 0.001) and lower cancer stage (P < 0.001). Among the VATS patients, 285 (36.3%) and among the thoracotomy patients, 288 (48.5%) had minor complications (P < 0.001); and 157 (20.0%) VATS patients and 212 (35.7%) thoracotomy patients had major complications (P < 0.001). The 30-day mortality rate was 1% in the VATS group and 1.5% in the thoracotomy group (P = 0.47). Multinomial logistic regression analysis showed that the prevalence of both minor [odds ratio (OR) = 1.51; 95% confidence interval (Cl) = 1.18-1.96] and major complications (OR = 1.91, 95% Cl = 1.44-2.53) was significantly higher for patients who underwent lobectomy via thoracotomy compared with VATS., Conclusion: Patients undergoing lobectomy via VATS were less likely to have at least one minor complication within the first 30 postoperative days and less likely to have at least one major complication, compared with patients operated by thoracotomy. These findings remained after adjusting for gender, age, FEV1, cancer stage, year of surgery and Charlson comorbidity score., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Objectives: To provide a short overview of fast-track video-assisted thoracoscopic surgery (VATS) and to identify areas requiring further research., Design: A literature search was made using key words including: fast-track, enhanced recovery, video-assisted thoracoscopic surgery, robot-assisted thoracoscopic surgery (RATS), robotic, thoracotomy, single-incision, uniportal, natural orifice transluminal endoscopic surgery (NOTES), chest tube, air-leak, digital drainage, pain management, analgesia, perioperative management, anaesthesia and non-intubated. References from articles were screened for further articles. Using abstracts, areas of interest for developing a fast-track protocol were selected., Results: The minimally invasive approach can be divided into several surgical methods that need further research to establish superiority. The role of intubation has to be further examined as well as the role of chest drains. Multimodal analgesic treatment including preoperative methylprednisolone seems promising and requires further research., Conclusions: The fast-track data from other procedures may support future development and improvement of fast-track VATS.

Objectives: The aims of this study were to develop virtual reality simulation software for video-assisted thoracic surgery (VATS) lobectomy, to explore the opinions of thoracic surgeons concerning the VATS lobectomy simulator and to test the validity of the simulator metrics., Methods: Experienced VATS surgeons worked with computer specialists to develop a VATS lobectomy software for a virtual reality simulator. Thoracic surgeons with different degrees of experience in VATS were enrolled at the 22nd meeting of the European Society of Thoracic Surgeons (ESTS) held in Copenhagen in June 2014. The surgeons were divided according to the number of performed VATS lobectomies: novices (0 VATS lobectomies), intermediates (1-49 VATS lobectomies) and experienced (>50 VATS lobectomies). The participants all performed a lobectomy of a right upper lobe on the simulator and answered a questionnaire regarding content validity. Metrics were compared between the three groups., Results: We succeeded in developing the first version of a virtual reality VATS lobectomy simulator. A total of 103 thoracic surgeons completed the simulated lobectomy and were distributed as follows: novices n = 32, intermediates n = 45 and experienced n = 26. All groups rated the overall user realism of the VATS lobectomy scenario to a median of 5 on a scale 1-7, with 7 being the best score. The experienced surgeons found the graphics and movements realistic and rated the scenario high in terms of usefulness as a training tool for novice and intermediate experienced thoracic surgeons, but not very useful as a training tool for experienced surgeons. The metric scores were not statistically significant between groups., Conclusions: This is the first study to describe a commercially available virtual reality simulator for a VATS lobectomy. More than 100 thoracic surgeons found the simulator realistic, and hence it showed good content validity. However, none of the built-in simulator metrics could significantly distinguish between novice, intermediate experienced and experienced surgeons, and further development of the simulator software is necessary to develop valid metrics., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Testing stimulates learning, improves long-term retention, and promotes technical performance. No purpose-orientated test of competence in the theoretical aspects of VATS lobectomy has previously been presented. The purpose of this study was, therefore, to develop and gather validity evidence for a theoretical test on VATS lobectomy consisting of multiple-choice questions., Methods: Four European VATS lobectomy experts were interviewed to explore their views on important theoretical VATS lobectomy knowledge (step 1). This information was used to construct the test items in compliance with existing guidelines for multiple-choice questions (step 2). The experts rated the relevance of the items to confirm content validity in a modified Delphi approach (step 3). Finally, the test was administered to physicians, who were categorised into different experience levels based on their experience in VATS procedures overall and in VATS lobectomies specifically. Their answers were used to achieve construct validity (step 4)., Results: Initially, 81 items were constructed and two Delphi iterations reduced the test to 50 items. Item analysis led to the exclusion of 19 items and the mean discrimination index of the 31 final items was 0.26. Cronbach's alpha for internal consistency was 0.75. The mean item difficulty was calculated to 0.63. According to performed VATS procedures, significantly different test performances were detected when comparing the group performances (p = 0.002) and the experts performed significantly better than the novices (p < 0.001) and intermediates (p = 0.01). In the category of performed VATS lobectomies, significant group performances were also found. In this category, the experts were also significantly better than the novices (p < 0.001), the trainees (p = 0.002), and the intermediates (p = 0.01)., Conclusions: This study led to the development of a theoretical test on VATS lobectomy consisting of multiple-choice questions. Both content and construct validity evidence were established.

Objective: To investigate whether the use of routinely obtained chest X-rays is necessary after elective VATS., Methods: We retrospectively reviewed 1097 chest X-rays obtained routinely after elective VATS, performed in patients aged over 15 years during an 18-month period. VATS procedures were divided into three groups according to the degree of pulmonary resection. The chest X-rays (obtained anterior-posterior in one plane with the patient in the supine position) were categorized as abnormal if showing pneumothorax >5 cm, possible intra-thoracic bleeding and/or a displaced chest tube. Medical charts were reviewed for all patients with abnormal chest X-rays to see if an intervention was made based on the X-ray. In case of an intervention, detailed clinical data were collected., Results: 44 of 1097 chest X-rays (4.0 %) were abnormal and 10 of these X-rays (0.9 %) led to a clinical intervention. Proportions of abnormal chest X-rays were unequally distributed between groups (p < 0.001), whereas the number of interventions was not (p = 0.43). Of the ten chests X-rays that led to an intervention, three showed possible intra-thoracic bleeding, six showed pneumothorax >5 cm and one showed a kinked chest tube. All the patients with possible intra-thoracic bleeding were re-explored in the operating theatre the same day., Conclusions: Only 10 of 1097 chest X-rays (0.9 %) obtained routinely after elective VATS procedures led to a clinical intervention, supporting the abandon of routine chest X rays in favour of a more individualised approach, based on clinical observations.

Video-assisted thoracic surgery (VATS) is emerging as the standard surgical procedure for both minor and major oncological lung surgery. Thoracic epidural analgesia (TEA) and paravertebral block (PVB) are established analgesic golden standards for open surgery such as thoracotomy; however, there is no gold standard for regional analgesia for VATS. This systematic review aimed to assess different regional techniques with regard to effect on acute postoperative pain following VATS, with emphasis on VATS lobectomy. The systematic review of PubMed, The Cochrane Library and Embase databases yielded 1542 unique abstracts; 17 articles were included for qualitative assessment, of which three were studies on VATS lobectomy. The analgesic techniques included TEA, multilevel and single PVB, paravertebral catheter, intercostal catheter, interpleural infusion and long thoracic nerve block. Overall, the studies were heterogeneous with small numbers of participants. In comparative studies, TEA and especially PVB showed some effect on pain scores, but were often compared with an inferior analgesic treatment. Other techniques showed no unequivocal results. No clear gold standard for regional analgesia for VATS could be demonstrated, but a guide of factors to include in future studies on regional analgesia for VATS is presented., (© The Author 2013. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background: Video-assisted thoracic surgery is gradually replacing conventional open thoracotomy as the method of choice for the treatment of early-stage non-small cell lung cancers, and thoracic surgical trainees must learn and master this technique. Simulation-based training could help trainees overcome the first part of the learning curve, but no virtual-reality simulators for thoracoscopy are commercially available. This study aimed to investigate whether training on a laparoscopic simulator enables trainees to perform a thoracoscopic lobectomy., Methods: Twenty-eight surgical residents were randomized to either virtual-reality training on a nephrectomy module or traditional black-box simulator training. After a retention period they performed a thoracoscopic lobectomy on a porcine model and their performance was scored using a previously validated assessment tool., Results: The groups did not differ in age or gender. All participants were able to complete the lobectomy. The performance of the black-box group was significantly faster during the test scenario than the virtual-reality group: 26.6 min (SD 6.7 min) versus 32.7 min (SD 7.5 min). No difference existed between the two groups when comparing bleeding and anatomical and non-anatomical errors., Conclusion: Simulation-based training and targeted instructions enabled the trainees to perform a simulated thoracoscopic lobectomy. Traditional black-box training was more effective than virtual-reality laparoscopy training. Thus, a dedicated simulator for thoracoscopy should be available before establishing systematic virtual-reality training programs for trainees in thoracic surgery.

Video-assisted thoracoscopic surgery (VATS) has undergone significant evolution over several decades. Although endoscopic instruments continued to improve, it was not until 1992 that the first VATS lobectomy for lung cancer was performed. Despite significant seeding of such procedure in several thoracic units globally, the uptake was slow and frustrating. Many surgeons considered it complex and unsafe being skeptic about its oncological validity. The last decade has witnessed significant change of practice in many thoracic units with a new generation of VATS thoracic surgeons. Additionally the technique has been refined, standardized and proved its validity and superiority in lung cancer treatment.

Objectives: In fast-track pulmonary resections, we removed chest tubes after video-assisted thoracic surgery (VATS) lobectomy with serous fluid production up to 500 ml/day. Subsequently, we evaluated the frequency of recurrent pleural effusions requiring reintervention., Methods: Data from 622 consecutive patients undergoing VATS lobectomy from January 2009 to December 2011 were registered prospectively in an institutional database. Data included age, gender, lobe(s) resected, bleeding and duration of surgery. Follow-up was 30 days from discharge. All complications requiring pleurocentesis or reinsertion of a chest tube, and all readmissions were registered. Twenty-three patients were excluded due to missing data, in-hospital mortality and loss to follow-up, leaving 599 for final analysis. Our primary outcome was the number of patients requiring reintervention due to recurrent pleural effusion. Secondary outcomes included time of chest tube removal and time to discharge. The incidence of recurrent pleural effusions requiring reintervention was compared between three groups according to the postoperative day (POD) of chest tube removal (Day 0-1, 2-3 and ≥4, respectively) using Fisher's exact test., Results: Pleural effusion after chest tube removal required reintervention in 17 patients (2.8%). Of these, 7 needed readmission. Median time from surgery to chest tube removal was 2 days, and median time from surgery to discharge was 4 days. No statistically significant association was found between the incidence of reinterventions due to recurrent pleural effusion and the POD of chest tube removal (P=0.50). The median time from chest tube removal to discharge was 1 day in all groups. Of the patients who needed reintervention, none had complications regarding this, except one who developed pneumothorax after pleurocentesis., Conclusions: Our findings suggest that chest tube removal after VATS lobectomy is safe despite volumes of serous fluid production up to 500 ml/day. The proportion of patients who developed pleural effusion necessitating reintervention was low (2.8%), and a complication of the reintervention was seen in only 1 patient.

Introduction: An increasing proportion of thoracic procedures are performed using video-assisted thoracic surgery. This minimally invasive technique places special demands on the surgeons. Using simulation-based training on artificial models or animals has been proposed to overcome the initial part of the learning curve. This study aimed to investigate the effect of simulation-based training and to compare self-guided and educator-guided training., Methods: The study included a surgeon group (n = 10) and 30 randomized novices in 3 groups. A control group (n = 10) and the group of surgeons (n = 10) were tested with no previous simulator training. A self-guided training group (n = 10) and an educator-guided training group (n = 10) trained for 3 hours on 3 scenarios of increasing fidelity and difficulty before taking a standardized test consisting of performing a wedge resection on a porcine lung, which was recorded and assessed blindly and independently by 2 thoracoscopic experts using a modified version of a validated assessment tool., Results: Interrater reliability was acceptable (Spearman ρ = 0.73, P < 0.001). The control group and the self-guided training group performed significantly worse than the experienced surgeons (P = 0.012 and P = 0.010, respectively). There was no significant difference between the educator-guided training group and the experienced surgeons (P = 0.271)., Conclusions: This randomized study concerning simulation-based training for thoracoscopy showed that 3 hours of intensive simulator training with a dedicated educator enables novices to perform an acceptable wedge resection in a simple, simulated model. Although not significant, it seemed that having an educator present during training had a beneficiary effect. Transfer studies are required for further conclusions.

Objectives: Lobectomies done by video-assisted thoracic surgery (VATS) result in fewer complications and less pain and save total costs compared with the traditional approach. However, the majority of procedures are still performed via open thoracotomies, because VATS lobectomy is considered difficult to learn, requiring experience in open surgery, and causing complications in the initial phase of the learning curve. The aim of this study was to describe a training model appreciating patient safety during training and to explore the initial learning curve for a trainee rather inexperienced in open surgery., Methods: A trainee who had performed 14 lobectomies by thoracotomy was enrolled in a training programme at a high-volume VATS centre. The training model included courses and simulations followed by the selection of suitable patients operated on during close expert supervision. Data regarding time, a variety of quality indicators and complications were collected prospectively and compared with experts' performance., Results: Over 12 months, 29 of 214 VATS lobectomies were performed by the trainee. Twice, the supervisor had to finish the procedure due to technical difficulties. None of the operations were converted to open thoracotomy. Compared with experts, the trainee operated significantly slower [median 120 (range 74-160) vs 100 (range 42-255) min, P = 0.04]; had similar perioperative bleeding [median 100 (range 10-500) vs 50 (range 5-2500) ml, P = 0.79]; had earlier chest tube removal [median 1 (range 1-6) vs 2 (range 1-32) postoperative days, P < 0.001]; and reduced hospital stay [median 3 (range 1-10) vs 4 (range 1-41) days, P < 0.001]. Twenty-three (79%) patients had no complications, while 2 had atrial fibrillation. Pneumothorax after chest tube removal, incisional infection, prolonged pain and need for pleuracentesis were each seen once., Conclusions: With thorough preparation of trainees and training on selected patients under close supervision, the learning curve can be overcome with good results even if the trainee has limited prior experience in open surgery.

Introduction: The objective of this study is to report the impact of computed tomography (CT) screening on the use of Video-Assisted Thoracic Surgery (VATS) in a randomized screening trial., Methods: The Danish Lung Cancer Screening Trial is a randomized clinically controlled trial of 4104 smokers and previous smokers who were randomized to either screening with five annual low-dose CT scans or no screening in Copenhagen from 2004 to 2006. The major end point is the effect of CT screening on lung cancer mortality and treatment options. All diagnostic and treatment interventions in both groups were monitored prospectively until 1 to 3 years after the last screening round., Results: By February 1, 2011 68 cases of lung cancer were detected in the screening group. Furthermore, seven patients with a benign nodule underwent surgical treatment because of suspicion of malignancy (12%). Fifty-one of the 68 lung cancer patients were eligible for surgical treatment. Eight patients had open thoracotomy. Of the operations for lung cancer, 84% were performed by VATS in the CT-screened arm, significantly higher than the control arm (p < 0.05). Thirty-six patients had a VATS lobectomy. One patient had a VATS segmentectomy, and four patients had a VATS wedge resection. The seven benign nodules were all treated with VATS., Conclusions: CT screening seems to facilitate the use of VATS in the treatment of lung cancer with an 84% rate in our data. Furthermore, all benign nodules could be removed by VATS. In our view, a basic requirement for a surgical institution to be involved in lung cancer CT screening is a dedicated VATS program.

Background: As we move toward competency-based education in medicine, we have lagged in developing competency-based evaluation methods. In the era of minimally invasive surgery, there is a need for a reliable and valid tool dedicated to measure competence in video-assisted thoracoscopic surgery. The purpose of this study is to create such an assessment tool, and to explore its reliability and validity., Methods: An expert group of physicians created an assessment tool consisting of 10 items rated on a five-point rating scale. The following factors were included: economy and confidence of movement, respect for tissue, precision of operative technique, creation and placement of ports, localization of pathologic tissue, use of staplers, retrieval of tissue in bag and placement of chest tube. Fifty consecutive thoracoscopic wedge resections were recorded and assessed blindly and independently by two experts using the tool., Results: Four residents, four fellows and five consultants performed 1-10 (median 4) operations each. The fellows performed significantly better than the residents (P = 0.03; effect size, ES = 0.72). The consultants scored 11% higher than the fellows, but this difference was not significant (P = 0.10, ES = 0.64). The inter-rater reliability was acceptable (Cronbach's alpha 0.71)., Conclusions: This tool for assessing performance in thoracoscopy is reliable and valid. It can provide unbiased feedback to trainees, and can be used to evaluate new teaching curricula, i.e. simulation-based training. Furthermore, it has potential to aid in certification of new thoracic surgeons.

Background: Lobectomy using video-assisted thoracoscopic surgery (VATS) still is a controversial operation despite its many observed benefits. The controversy may be due to difficulties performing the procedure. This study addresses a standardized anterior approach facilitating the operation., Methods: This report describes 156 VATS lobectomies performed with a uniform anterior three-port technique. The surgeon and the assistant stand on the abdominal side of the patient, and the setup is independent of the lobe to be resected., Results: From 2005 to 2007, 156 VATS lobectomies and 13 conversions (7.7%) were performed with an anterior three-port technique. No mortality occurred among the VATS lobectomies during a 30-day period. The major comorbidity rate was 78%. The comorbidities included former thoracic surgery (9%) or a history of another cancer (22%), indicating potentially difficult surgery and a nonselected population. The majority (92%) of the patients had lung cancer. The major postoperative problem was air leakage, which usually prolongs the tube time and the in-hospital stay, but a "no-touch fissure" technique significantly reduced the median tube time to 4 days and the postoperative hospital stay to 5 days., Conclusions: This study shows that VATS lobectomies can be performed using a standardized anterior approach with low rates of conversion and morbidity. A "no-touch fissure" technique lowers the postoperative tube time, the in-hospital stay, and the number of patients with prolonged air leakage. A uniform anterior approach facilitates VATS lobectomy and makes this advanced procedure more easily adaptable by many surgeons familiar with an open anterior approach. The findings show that VATS lobectomy can be performed safely for a large proportion of lung cancer patients.

Objective: Thoracoscopic (video-assisted thoracoscopic surgery (VATS)) lobectomy is a safe and effective method for treating early-stage lung cancer. Despite this, it is still not widely practised, which could be due to a shallow learning curve. We have evaluated the surgical outcome in a training programme at an institution with an established VATS lobectomy programme. We present the surgical data and outcome of the first 50 intended VATS lobectomies performed by a consultant in training as the primary surgeon., Methods: Data were obtained from a prospectively registered surgical database consisting of 262 consecutively intended VATS lobectomies. A single consultant performed 212 intended VATS lobectomies. His first 50 intended VATS lobectomies were excluded, as they were considered to be his learning curve, leaving 162 intended VATS lobectomies, of which 12 were converted to open lobectomy, performed from January 2005 to April 2008. Fifty intended VATS lobectomies were performed by a consultant in a training programme for VATS lobectomies, of which three were converted to open lobectomy from April 2007 to April 2008. The training consultant was experienced in open thoracic surgery and had performed more than 200 minor VATS procedures prior to the training programme. The surgical data and outcome between the 47 VATS lobectomies were compared with the 150 VATS lobectomies performed by the experienced consultant using statistical analysis., Results: There were significantly better results for the training consultant regarding prolonged air leak, chest tube duration and length of stay, which probably reflects the careful selection of the patients favouring the training consultant. The operation time was significant longer for the consultant in training (p<0.0001)., Conclusions: With careful selection of patients, VATS lobectomy can be taught safely in a surgical institution experienced in VATS lobectomies. Using statistical analysis, the surgical outcome for the training consultant was acceptable in comparison to the outcome of the experienced consultant. The consultant in training did spend more time in the operating theatre (p<0.0001) and we recommend taking that into account when planning future training programmes in VATS lobectomy., (Copyright (c) 2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.)

Introduction: Esophageal perforation can within hours result in seriously-ill patients with a high risk of complications. The array of treatment options is many and minimal invasive methods are emerging., Materials and Methods: Six patients with esophageal perforations, who were managed successfully by thoracoscopic debridement, irrigation and drainage. The causes of the lesions and the importance of early diagnosis are described. The different treatment schemes are outlined, and the specifics of this thoracoscopic approach are described. The importance of port placement is underlined and illustrated in Figure 1., Results: The six patients with a median age of 70.5 years (29-80) were successfully treated with videothoracoscopic debridement, irrigation with saline and drainage. Median time in surgery was 91.5 min. and the in-hospital time was 17.5 days. There were no complications except for one patient with continuous bacterial contamination of the pleural cavity, necessitating chest tube treatment for weeks after discharge. No patient was re-operated nor had a fatal course., Discussion: The potential applications of thoracoscopic surgery as a minimal invasive treatment for esophageal perforations are discussed, as well as the advantages of a combination of videothorascopic drainage and placement of a covered expandable stent. This combination must be evaluated in future studies.

Introduction: This article reports the introduction of VATS (video-assisted thoracic surgery) lobectomy in lung cancer patients in our department., Methods: From 22 October 1999 to 15 December 2000, ten patients with peripheral primary lung cancer with no signs of spreading underwent VATS lobectomy. In an additional four patients, the resection started as VATS, but had to be converted to an open procedure., Results: No 30 day mortality or late complications were seen. One patient who developed empyema underwent surgery and one had a stroke, but with total remission., Discussion: We have shown that it is possible to introduce VATS lobectomy with acceptable results. A literature overview demonstrates that thoracoscopic lobectomies offer similar survival data to that of conventional surgery.