Development of a video-assisted thoracoscopic lobectomy program in a single institution: results before and after completion of the learning curve

Abstract

BackgroundThe development of a video assisted thoracic surgery lobectomy (VATS-L) program provides a dedicated surgical team with a recognized learning curve (LC) of 50 procedures. We analyse the results of our program, comparing the LC with subsequent cases.MethodsFrom June 2012 to March 2015, we performed n = 146 VATS major pulmonary resections: n = 50 (Group A: LC); n = 96 (Group B). Pre-operative mediastinal staging followed the National Comprehensive Cancer Network guidelines. All procedures were performed using a standard anterior approach to the hilum; lymphadenectomy followed the NCCN recommendations. During the LC, VATS-L indication was reserved to clinical stages I, therefore evaluated case by case.ResultsMean operative time was 191 min (120-290) in Group A and 162 min (85-360) in Group B (p <0,01). Pathological T status was similar between two Groups. Lymphadenectomy included a mean of 5.8 stations in Group A and 6.6 in Group B resulting in: pN0 disease: Group A n = 44 (88 %), Group B n = 80 (83.4 %); pN1: Group A n = 3 (6 %), Group B n = 8 (8.3 %); pN2: Group A n = 3 (6 %), Group B n = 8 (8.3 %). Conversion rate was: 8 % in group A (n = 4 vascular injuries); 1.1 % in Group B (n = 1 hilar lymph node disease). We registered n = 6 (12 %) complications in Group A, n = 10 (10.6 %) in Group B. One case (1.1 %) of late post-operative mortality (90 days) was registered in Group B for liver failure. Mean hospital stay was 6.5 days in Group A and 5.9 days in Group B.ConclusionsWe confirm the effectiveness of a VATS-L program with a learning curve of 50 cases performed by a dedicated surgical team. Besides the LC, conversion rate falls down, lymphadenectomy become more efficient, indications can be extended to upper stages.

Thoracoscopic lobectomy for locally advanced-stage non-small cell lung cancer is a feasible and safe approach: analysis from multi-institutional national database

“…Almost 25% of patients had chemotherapy before surgery, but in this cohort, we included different cases that could be differently evaluated on the basis of the clinical experience of the recruiting centre. The initial doubts about VATS-L oncological adequacy for early-stage NSCLC have been overcome, as demonstrated by several authoritative papers (1)(2)(3)(4)(5)(6)(7)(8)(9)(10); the minimally invasive technique and the traditional open technique have proven to be equivalent in terms of overall survival and disease free-survival also for locally advanced NSCLC (10)(11)(12)(13). Unfortunately, our study lacks of mid-and long-term survival results; however, we have some valid oncological data such as the extent of lymphadenectomy and the resection margin status.…”

“…Furthermore, several and authoritative authors demonstrated the efficacy of VATS lobectomy in terms of oncological results and validity of mediastinal intra-operative staging (7)(8)(9)(10), but the use of VATS-L for locally advanced-stage NSCLC is not well established. Some preliminary and single-centre retrospective studies have shown that VATS-L is feasible, safe and effective with long-term oncologic outcomes comparable to lobectomy via thoracotomy (11)(12)(13).…”

Learning curve for port-access thoracoscopic anatomic lung segmentectomy

“…A limitation of this study is its retrospective nature and that it was conducted in a single institute. As also indicated by Gonfiotti and colleagues, 22 several factors can affect the duration and efficacy of the learning curve period; the experience in other complex VATS procedures or in standard open major pulmonary resections; the selection of a dedicated surgical team; the opportunity to concentrate on the learning curve procedures within a short period; and finally, the development of a proctored and stepwise program. Although this study was divided by surgical level, the difficulty of the procedure differs, depending on anatomic variations among each level.…”

Factors during training which predict future use of minimally invasive thoracic surgery

“…Our study results indicate that the curricula of thoracic surgery fellowship programs which incorporate the use of minimally invasive surgery technique appear to be more important when compared to the years since the completion of fellowship for adoption of these methods. The learning curve for minimally invasive lobectomy has been reported to be 50 cases [ 6 , 10 ]. MIE generally has more steps involved and is a longer operation than a lobectomy, but has been increasingly used as an alternative to an open approach [ 9 , 11 , 12 ].…”