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.
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.
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.
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
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.
IntroductionThe 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 analysisThis 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 disseminationApproval 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 summaryThis 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 numberNCT05358158.
Single lung transplantation (SLTx) has been used to treat end-stage lung disease. A common complication after SLTx is hyperinflation of the native emphysematous lung (NLH). Previous attempts to ...reduce the NLH have been tried using surgery, endoscopic valves, etc. with variable outcomes. Lung volume reduction coils can be used for treating hyperinflation in emphysema patients irrespective of collateral ventilation (CV). We here report a case of native lung hyperinflation in SLTx treated with lung volume reduction coils. This treatment appears to be a safe treatment option when dealing with CV-positive NLH in SLTx recipients.
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.
Abstract 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.
PDF