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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 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.

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 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.

This report presents the case of a woman successfully treated with thoracoscopic detorsion of the right lung after she was diagnosed with a 180-degree torsion, 6 months after a video-assisted thoracoscopic right upper lobectomy for a stage 1 adenocarcinoma.

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. 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. 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

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

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 (

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.

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.

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). 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. 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). 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.

To provide a short overview of fast-track video-assisted thoracoscopic surgery (VATS) and to identify areas requiring further research.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.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.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.

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. 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. 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. 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.

ObjectiveMicrolobectomy 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 CO2insufflation, vision through a 5-mm camera, stapling via the subxiphoid port, or with 5-mm stapling devices.MethodsThe 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.ResultsSeventy-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.ConclusionsWe 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.

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.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).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).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.

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. 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. 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. 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.

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.

OBJECTIVES The optimal postoperative analgesic strategy after video-assisted thoracoscopic surgery lobectomy remains undetermined. We hypothesized that high-dose preoperative methylprednisolone (MP) would improve analgesia compared to placebo. METHODS A total of 120 adult patients were randomized equally to 125 mg MP or placebo before the start of their elective video-assisted thoracoscopic surgery lobectomy. Group allocation was blinded to patients, investigators and caregivers, and all patients received standardized multimodal, opioid-sparing analgesia. Our primary outcome was area under the curve on a numeric rating scale from 0 to 10, for pain scores on the day of surgery and on postoperative days 1 and 2. Clinical follow-up was 2-3 weeks, and telephone follow-up was 12 weeks after surgery. RESULTS Ninety-six patients were included in the primary analysis. Methylprednisolone significantly decreased median pain scores on the day of surgery: at rest (numeric rating scale 1.6 vs 2.0, P = 0.019) and after mobilization to a sitting position (numeric rating scale 1.7 vs 2.5, P = 0.004) but not during arm abduction and coughing (P = 0.052 and P = 0.083, respectively). Nausea and fatigue were reduced on the day of surgery (P = 0.04 and 0.03), whereas no outcome was improved on postoperative Days 1 and 2. Methylprednisolone did not increase the risk of complications but increased blood glucose levels on the day of surgery (P

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 PrRP/B

Background Safety in the operating room is dependent on the team's non-technical skills. The importance of non-technical skills appears to be different for minimally invasive surgery as compared with open surgery. The aim of this study was to identify which non-technical skills are perceived by team members to be most important for patient safety, in the setting of video-assisted thoracoscopic surgery (VATS) lobectomy. Methods This was an explorative, semistructured interview-based study with 21 participants from all four thoracic surgery centers in Denmark that perform VATS lobectomy. Data analysis was deductive, and directed content analysis was used to code the text into the Oxford Non-Technical Skills system for evaluating operating teams' non-technical skills. Results The most important non-technical skills described by the VATS teams were planning and preparation, situation awareness, problem solving, leadership, risk assessment, and teamwork. These non-technical skills enabled the team to achieve shared mental models, which in turn facilitated their efforts to anticipate next steps. This was viewed as important by the participants as they saw VATS lobectomy as a high-risk procedure with complementary and overlapping scopes of practice between surgical and anesthesia subteams. Conclusions This study identified six non-technical skills that serve as the foundation for shared mental models of the patient, the current situation, and team resources. These findings contribute three important additions to the shared mental model construct: planning and preparation, risk assessment, and leadership. Shared mental models are crucial for patient safety because they enable VATS teams to anticipate problems through adaptive patterns of both implicit and explicit coordination.

The main goal for any doctor should be to give the patients the best possible treatment for their medical condition, whatever it is. The decision regarding treatment should be based on scientific evidence, ideally via clinical trials. This can often be quite straight forward in pharmaceutical medicine, where you can design randomized and double blinded studies in order to identify evidence for the superior treatment. In surgery, however, the preferred technique quite often is more eminence than evidence based. It is difficult to design adequately large studies and very difficult to do so in a double blinded fashion. Senior peer pressure and difficulty with constructing effective clinical surgical trials (often interlinked phenomena) leads to conservatism and resistance to radical new ideas.

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.

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. 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. 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. 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.

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.Participants with varying experience in VATS lobectomy were included. They were familiarized with a virtual reality simulator (LapSimFifty-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-values0.05). Significant correlations between the metrics and the participants VATS lobectomy experience were identified for seven metrics (p-values0.001), 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).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.

No golden standard for analgesia in video-assisted thoracic surgery (VATS) lobectomy exists. A simple multimodal approach using an intercostal catheter (ICC) may be of benefit since acute post-operative pain following VATS lobectomy primarily originates from the chest drain area.Prospective observational cohort. Forty-eight consecutive patients received a standardized regimen consisting of paracetamol, non-steroidal anti-inflammatory drug and gabapentin. Further, surgeons performed a single-shot paravertebral block (PVB) at five levels (15 ml of 0.5% bupivacaine) and inserted an ICC at the drain site level for continuous delivery of 6 ml of 0.25% bupivacaine h(-1). Pain scores at rest, mobilization and with the extended arms were followed until discharge or for 4 days.Forty-eight patients, mean age 64 years (CI: 61-68), were included. The mean time for the PVB and ICC placement was 5 min (CI: 4.7-5.9). The mean pain score at rest using a numerical rating scale (NRS, 0-10) was3 for 1-16 h and decreased from 4.7 to 1.7 (NRS day 1-4, getting out of bed). The ICC was removed with the drain in 48/73/92% on day 1/2/3 after surgery. The median day of discharge was 3 (interquartile range 2-4) with85% of patients reporting satisfactory or very satisfactory pain treatment all days.Acute pain after VATS lobectomy may be adequately controlled using a multimodal non-opioid regime including PVB and an ICC. The low pain scores and reduced time used inserting the ICC may present an alternative to continuous epidural analgesia or conventional PVB.

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.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.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.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.

Background The risk of persistent postsurgical pain (PPP) and subsequent pain-related functional impairment may potentially be reduced by video-assisted thoracic surgery (VATS) compared to thoracotomy. The aim of the study was therefore to assess in detail the incidence and consequences on activities of daily living of PPP after VATS. Methods Using a prospective observational design, 47 patients undergoing VATS completed both preoperative, early postoperative and 3 months follow-up. Preoperative pain, pain characteristics, psychological factors, pain-related functional impairment and quantitative sensory testing (QST) including nociceptive thresholds were compared with postoperative data. Results Only five (11%) patients developed PPP with NRS > 3 originating from the surgical area. However, about 30% of patients still reported some pain-related functional impairment from the surgical area within four well-defined domains of everyday activities. Psychological and sensory thermal tests did not predict persistent postoperative pain, except preoperative pin-prick sensitivity was higher in patients with PPP. Postoperative pain 7 days after surgery was significantly higher in PPP patients. Preoperative pain originating from remote areas did not predict PPP. Conclusion The incidence of PPP, nerve damage (based on QST) and pain-related functional impairment following VATS was lower than reported following thoracotomy. No psychological or other factors predicted PPP. These findings call for further large-scale studies to support VATS to decrease PPP.

To investigate whether the use of routinely obtained chest X-rays is necessary after elective VATS.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 pneumothorax5 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.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 (p0.001), 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 pneumothorax5 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.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.

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.

As thoracic surgeons, we strive to improve treatment with each procedure and aim at performing low-risk operations with an optimal oncologic outcome. Although the number of randomized controlled trials (RCTs) in thoracic surgery has increased, there are still relatively few RCTs published within the field and much of the existing evidence is based on retrospective studies (1).

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.

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.

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.

Background Video-assisted thoracic surgery (VATS) lobectomy may potentially reduce the risk of post-thoracotomy pain syndrome (PTPS). However, it may still carry a risk of intraoperative nerve damage and thereby development of PTPS. Thus, our aim was to present a detailed long-term neurophysiological characterization of PTPS after VATS. Methods Quantitative sensory testing, using thermal and mechanical stimuli, was performed in 13 PTPS patients and 35 pain-free patients recruited 33 months after VATS lobectomy. Results When comparing the operated side with the control side in PTPS patients, increased thresholds of tactile and warmth detection were observed, while in pain-free patients, increased thresholds of warmth detection, cool detection, and heat pain were demonstrated. At the anterior porthole, pain-free patients displayed increased threshold to thermal detection when compared with the control side. Only side-to-side difference for tactile detection threshold was increased in PTPS patients compared with pain-free patients. Assessment of central sensitization showed no significant differences within or between PTPS and pain-free patients nor did group comparison of area of hypo- and hyperaesthesia to cool. Anxiety and depression scores (HADS) were higher in PTPS patients, but the area of hyper- and hypoaesthesia did not differ significantly between HADS groups. Conclusions Increased sensory thresholds suggest nerve injury to be present on the operated side in both PTPS and pain-free patients. However, no significant quantitative differences between PTPS and pain-free patients could be found, implicating the presence of factors other than intercostal nerve injury as important for development of PTPS after VATS lobectomy.

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.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.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).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.

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 tobectomies 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.

The indications for the resort to sealants during thoracic surgery are still controversial w1x. The multiplicity of commercially available products, the lack of consistent, irrefutable evidence for their efficacy and the delicate relationship with industry call for a clarification of the status quo within the thoracic surgical community. The results of a survey conducted during the proceedings of a Satellite Symposium taking place during the last 2006 joint EACTS-ESTS meeting in Stockholm are hereafter reported. Two hundred and forty participants to a Satellite Symposium on the use of a specific, commercially available, sealant were asked to anonymously respond through a power-vote system to six multiple-choice questions aimed at establishing the current standards of practice. No additional demographic data nor information on professional experience were required to participate in the survey. The answers were collected via an electronic (‘power vote’) system and displayed by percentage at the end of the questionnaire (see Figures). The analysis of the results was as follows (Figs. 1–3).

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.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.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.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.

This article reports the introduction of VATS (video-assisted thoracic surgery) lobectomy in lung cancer patients in our department.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.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.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.