Crossing the bridge to VATS lobectomy

The benefits of performing an anatomical lobectomy for non-small cell lung carcinoma (NSCLC) by video assisted thoracoscopic surgery (VATS) have been well described^1,2 and the approach is being advocated as the ‘gold standard’ for surgical treatment of early disease.^3-5 Several studies have demonstrated that VATS lobectomy can offer shorter hospital stays and improved postoperative pain while not compromising oncological outcomes.^5-7 However, the uptake of this procedure in the general thoracic surgery population has been slower than expected. In 2013 less than 25% of all lobectomies performed in Europe were by VATS.⁸

We believe that this is partly due to a lack of consensus on how this procedure should be integrated into training programmes. The perception that VATS lobectomy is technically very challenging and the concerns about major intraoperative complications (which can be difficult to control)⁹ have somewhat hindered training. This effect is compounded by the current environment of increased scrutiny on complication rates, waiting times and cost efficiency. Over the last ten years, our unit has slowly transitioned from the conventional approach to VATS as the method of choice in anatomical lung resections for early stage NSCLC. Once all senior surgeons had accomplished the transition, the focus was turned on to the trainees. We present our initial experience with a newly developed training model, which could help bridge the divide between open and VATS lobectomy.

Methods

Two thoracic trainees in the final stages of their training were initiated into this model, supervised by a single consultant. Both trainees had extensive experience with minor VATS procedures (bullectomy, lung biopsy, pleural biopsy) and had performed more than 20 conventional lobectomies. The selected initial training period was six months, during which time the requests for annual/professional leave were coordinated between team members to minimise disruptions and ensure continuity.

The approach for all cases (pre, intra and postoperative) was standardised. Each patient was discussed on the morning of the scheduled surgery by all three team members in a dedicated time slot with focus on intraoperative planning. Particular attention was paid to the computed tomography and relevant anatomy. Key discussion points were the natural course and presence of abnormalities of the venous drainage and pulmonary artery branches.

All operations were performed using a standardised three-port...