Learning curve for uniportal video-assisted thoracoscopic surgery lobectomy—results from 120 consecutive patients

Xiaochuan Liu, Xiaosang Chen, Yaxing Shen, Hao Wang, Mingxiang Feng, Lijie Tan, Thomas A. D’Amico


Background: Uniportal video-assisted thoracoscopic surgery (VATS) is considered a technically demanding procedure. The learning curve, which directly influences the adoption of uniportal VATS, has not been described. In this study, we aimed to describe the learning curve for uniportal VATS lobectomy from our single center’s experience.
Methods: Uniportal VATS lobectomy was started in October 2013 in Zhongshan Hospital, Fudan University. Since then, a total of 120 consecutive patients who underwent uniportal VATS lobectomy were retrospectively enrolled. Surgical videos were reviewed to determine the operation time, to which cumulative sum (CUMSUM) method was applied to evaluate the learning phases of the procedure. Accordingly, patients’ clinical features in different phases were collected and compared to determine the learning curve for uniportal VATS lobectomy.
Results: Among the 120 consecutive patients reviewed from October 2013 to September 2014, the CUMSUM curve showed its inflection at patient number 44: the first 30 patients were in the ascending phase, the second 30 patients were in the plateau phase, and the remaining patients were in the descending phase. Comparable CUMSUM results were recorded both from upper and not-upper lobectomy. Intra-operatively, more repeated stapler attempts (73% versus 13% and 5%, P<0.001) and higher conversion rate (17% versus 7% and 2%, P=0.028) were recorded in ascending phase vs. the plateau phase and descending phase, respectively. Post-operatively, the morbidity, mortality and the length of hospital stay were similar before and after the learning curve cases.
Conclusions: In a center with conventional VATS experience, the learning period of uniportal VATS lobectomy was characterized by repeated stapler attempts, and the volume requirements would be approximately 30 cases to reach the performance plateau. Upper lobectomy seemed not more difficult to learn than lower or middle lobectomy in uniportal VATS.