The increasing use of video assisted thoracic surgery (VATS) lobectomy in the treatment of early stage lung cancer is due to its intrinsic characteristics. It has been described, in fact, that VATS lobectomy reduces postoperative morbidity and mortality, shortens the hospital stay and provides long-term prognosis, which is comparable to lobectomy by thoracotomy (1-5). Due to such reasons, VATS lobectomy is currently the recommended surgical approach for early stage lung cancer (6) and is considered beneficial to patients considered at high-risk for surgery (7).
The importance of increasing the number of surgeons performing VATS lobectomy is thus implicit, implying the necessity of teaching this procedure safely and correctly. However, despite its benefits, VATS lobectomy is generally considered to be technically more difficult compared to lobectomy by thoracotomy and inexperience may be cause of intraoperative complications and eventually mortality (8). Probably, this is one of the reasons why a formal and structured VATS lobectomy program is strongly felt among thoracic surgery trainees during their training years. As a matter of fact, one of the most common training needs cited by trainees is “to train in Video Assisted Thoracoscopic Surgery lobectomy” (9). This is in contrast with the quite common experience of today’s senior surgeons who did not undergo a formal VATS lobectomy training, but instead were self-taught and gained experience and confidence over the years (10,11).
VATS training: feasibility and standards for vats lobectomy teaching
Ferguson and Coll. addressed the feasibility of developing a VATS lobectomy programme in a paper of 2005 (11). In their study, they demonstrated that a VATS lobectomy programme can be safely taught to senior trainees through an appropriate supervision, without affecting mortality, blood loss or postoperative stay and suggested a VATS training coordinated at UK national level.
Generally, in Europe, thoracic surgery training (speciality) is performed in tertiary centres with big volumes of surgery, covering all fields of general thoracic surgery, granting a sufficient number of cases throughout the training. However, training programs differ a lot country-wise, not all centres are set to teach VATS lobectomies and the comparatively low number of surgeons performing VATS lobectomies (12) are the causes that lead trainees to pursue courses and observation periods in centres where VATS is routinely performed.
From a trainee point of view, besides feeling the need of a proper formal VATS lobectomy training, the following points could be of interest in setting-up a training program, with the aim of giving the trainee independence and self-confidence throughout the procedure:
- Stepwise approach to VATS lobectomy and standardization of teaching;
- Off-theatre independent training;
- Evaluation and certification.
Stepwise approach to VATS lobectomy and standardization of teaching
Major surgical approaches are usually entrusted in a stepwise manner to trainees, who gain experience over the training years. As a matter of fact, being it a major lung resection performed mini-invasively and with challenging complexity, enhanced by major surgical skills and dexterity, VATS lobectomy should be no less.
Several and disparate sets of teaching VATS lobectomy have been undertaken, which obviously differ from centre to centre worldwide. Commonly, prior being introduced to VATS lobectomy, trainees are made to gain experience through several minor procedures routinely performed in VATS, such as pneumothoraxes, pleural effusions, pleural biopsies, lung wedge resections, etc. This, in time, improves the trainees skills and creates the necessary confidence with the use of the camera (usually a 30°), orientation and movement coordination (dexterity), staplers and VATS basic instrumentation.
Usually, when it comes to VATS lobectomy, trainees are gradually involved in the procedure by firstly holding the camera and assisting the senior surgeon doing the lobectomy. Through observation and interaction with the senior surgeon who explains the steps of the procedure while performing it, the trainee gets accustomed with the VATS lobectomy technique. In time, trainees are then given the opportunity to advance in a stepwise manner through the procedure, starting from making the ports to the pulmonary ligament dissection and hilum exposure. Once gained sufficient confidence, the next steps will include vessels and bronchus dissection and, lastly, lymphadenectomy, since more complex. Generally, when trainees proceed through the lobectomy, are guided by the senior surgeon and evidently are offered easy lobes first (lower lobectomies). This teaching methodology is perhaps the most widely used because it allows a gradual approach to VATS lobectomy, allowing the trainee to gain confidence. Nevertheless, unfortunately, what is lacking is the standardization of the step-by-step procedure, which instead is essential, at least in the eyes of the trainee. Regardless the way of teaching, standardization of the procedure and of the teaching is strategic and beneficial to the trainee. In fact, it offers a proper and uniform methodology that pays back in reduction or hopefully elimination of errors, which in turn means procedural safety, less intraoperative complication rates (conversions), improved efficiency, less time in completing the lobectomy and low postoperative morbidity.
Trainees involved in a VATS lobectomy programme are usually the senior ones, since have had a sufficient number of procedures performed in traditional open lobectomy and minor VATS, therefore more experienced. However, whether or not prefer teaching VATS lobectomies to senior trainees with or without experience in traditional open lobectomy has been matter of discussion in several papers (13-15). According to those papers, VATS lobectomy remains a safe procedure, even if performed despite limited experience in open lobectomy, and affirm that the previous surgical training has a minimal impact on operative and postoperative outcomes (surgery time, blood loss, conversion rate, chest tube duration, postoperative morbidity and mortality).
Some concerns have been raised regarding the effects of teaching a new surgical approach (VATS lobectomy) in a training centre on the possibility that the learning curve affects the quality standards of the Unit (14,16,17); however, if well organized and structured, the learning curve for video-assisted thoracoscopic lobectomy does not seem to be affected by prior experience in open lobectomy (16).
Off-theatre independent training
Apart the many benefits of performing lobectomies in VATS, one of the reasons of trainees’ interest in VATS is its technologic involvement. In fact, in the recent years, the role and the impact of technology in thoracic surgery have been evidently dramatic. Nowadays basic technology (e.g., computer, internet, videos), once unavailable to most of today’s senior surgeons during their training period, offers a series of advantages. As an example, the opportunity to review the video of the performed VATS procedure in high definition, perhaps along with the senior surgeon, in order to critically analyse it and detect those steps that were troublesome at the time of the operation. Also, on-line videos and tutorials are easily available for interactive study, letting trainees follow eminent surgeons performing surgery from their computers.
How technology has impacted in our daily life and social behaviour is quite evident, and its impact on training surgeons who have grown with the technological development has been deducted, for example, on their endoscopic skills. In fact, the potential linkage between surgical skills and video games has been tackled by some Authors, with evidence of a correlation between video-games skills and surgical ones (9,18,19).
Technological advances such as black box and virtual reality simulators and anatomical VATS models (20,21) consent trainees to practice, improve and maintain dexterity without “learning on patients”, offers plenty of surgical hours of training (22) in a safe and supportive educational climate, available at any time to fit curriculum needs and allows standardized experience for all residents repeatedly, with fidelity and reproducibility (23). Unfortunately, they are not available in all training centres, probably due to their cost, despite its usefulness.
Evaluation and certification
As an end point of any educational programme, also in surgery the need of evaluation and assessment of competences should be taken into consideration for the necessary feedback and certifications. However, assessment of surgical skills is not an easy task. Several problems are faced within surgical assessment of skills, including ethics (is it ethical to assess skills on a patient?), objective and structured judgment and standardization of evaluation.
An attempt to identify a proper tool for VATS surgical skills was made in 2012 by the Copenhagen group (24). The Authors developed an assessment tool that encompassed the judgment of unedited videos of the procedure by two examiners (senior surgeons) who assessed all procedures blinded and independently, according to predefined parameters in a five-point rating scale. Their tool’s inter-rater reliability was found high for the specific procedure but low for the general items, meaning that specific task were well assessed but examiners missed the global performance, yet they were able to avoid potential biases related to relationships through anonymity of the videos.
Other Authors suggested the need of assessing endoscopic surgery skills through simulation, since it provides a safe environment for trainees to evaluate their performance rigorously and reliably without patients’ involvement (23). However, drawbacks of simulation evaluation include the rare availability of a simulator for each VATS training centre, which should be VATS specific, and the difficulty to predict levels of real life surgical skills and possible intraoperative complications (25).
In a proficiency based medical education, testing one’s own skills is basilar to improvement; moreover, in a field like surgery, where surgical skills are related to patient safety and postoperative outcomes, with legal implications too, certifications should be seriously taken into account.
Trainees’ interest in VATS lobectomy is rapidly growing and the need of performing independently and routinely VATS lobectomies for early stage lung cancer will soon be a prerequisite to the new generation of thoracic surgeons.
However, apart some exceptions, VATS lobectomy teaching is not formally set up in all training centres, while the need of formal and standardised educational programmes in such a field are strongly felt among trainees. Perhaps, through the supervision, support and aid from national and European Thoracic Surgery Societies, programs of integration of recognized, standardized and certified training of VATS lobectomy could be planned and undertaken by the training centres, both at national as well as European level.
Conflicts of Interest: The authors have no conflicts of interest to declare.
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