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Background: The past two decades have seen increasingly rapid advances in new surgical techniques and procedures in thoracic surgery. One of the greatest challenges is to educate and train thoracic surgeons in a safe and patient-free environment. The content of surgical training and education differs significantly among European countries. A common European training and certification structure might provide better opportunities to educate competent thoracic surgeons in the future. The objective of this article is to summarize the current state of educational programs and certification within thoracic surgery in Europe. Methods: A comprehensive search of the literature was performed, using PubMed Database, Medline, Cochrane and Google Scholar from May 2000 until June 2023, focusing on thoracic surgery education and training, thoracic surgery education and certification in Europe, certification, and training of general thoracic surgeons in Europe, and Canadian and American training and certification in thoracic surgery. Results: A total of 560 articles were retrieved from PubMed/Medline, Google Scholar, and Cochrane. After removing the duplicates, 365 articles were scanned based on their title and abstract. Three hundred and twelve articles did not meet the inclusion criteria for this study. Fifty-three full text articles were assessed for eligibility and a total of 25 articles were selected for this study. In addition, we must accept the adopt advances in thoracic surgery and evolve the modern training program in thoracic surgery. There is a need for revision and refining of thoracic surgeon’s curricula across Europe. By harmonizing the training programs and certification in Thoracic Surgery across Europe, we provide competent thoracic surgeons with an equalized and better patient outcome. Conclusions: There is a need for a structured and evidence-based surgical curriculum, which includes simulation training to provide competent surgeons in Eu

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., 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.

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 < 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.

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.