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J Thorac Cardiovasc Surg 2008;136:376-382
© 2008 The American Association for Thoracic Surgery

General Thoracic Surgery

Thoracoscopic lobectomy: Introduction of a new technique into a thoracic surgery training program

Michael F. Reed, MDa,c,*, Mark W. Lucia, BSb, Sandra L. Starnes, MDa,c, Walter H. Merrill, MDa,c, John A. Howington, MDa,c

a Division of Thoracic Surgery, Department of Surgery, Cincinnati VA Medical Center, Cincinnati, Ohio
b University of Cincinnati College of Medicine, Cincinnati VA Medical Center, Cincinnati, Ohio
c Division of Thoracic Surgery, Department of Surgery, Cincinnati VA Medical Center, Cincinnati, Ohio

Received for publication June 21, 2007; revisions received February 12, 2008; accepted for publication May 5, 2008.

* Address for reprints: Michael F. Reed, MD, Division of Thoracic Surgery, Department of Surgery, University of Cincinnati College of Medicine, 231 Albert B. Sabin Way, PO Box 670558, Cincinnati, OH 45267-0558. (Email: michael.reed{at}uc.edu).


   Abstract
Top
 Abstract
Introduction
 Materials and Methods
 Results
 Discussion
 References
 
Objective: Thoracoscopic lobectomy has been demonstrated to be safe and oncologically sound. However, few thoracic surgeons perform the operation. We hypothesized that use of a predetermined, stepwise plan for introduction of thoracoscopic lobectomy into a thoracic surgical training program would facilitate safe learning of the technique.

Methods: Databases from 2 affiliated institutions were queried to identify all lobectomies during a 4-year period. Our model for introduction of thoracoscopic lobectomy was established expertise in open lobectomy and video-assisted thoracoscopic surgery, participation in a formal thoracoscopic lobectomy course, stepwise introduction of specific techniques used in thoracoscopic lobectomy into the operative approach, proctoring of initial thoracoscopic lobectomies by partners, and teaching of the technique to other thoracic surgeons and residents.

Results: We performed 202 lobectomies: 97 open and 105 thoracoscopic. Mortality was 3.0%. The conversion rate from thoracoscopic to open thoracotomy was 13%. When divided into quartiles, the percentage of lobectomies performed thoracoscopically increased from 18% in the first quartile to 82% in the fourth quartile. With ongoing experience, the procedure was performed at higher frequency by new staff and trainees. Residents performed 0% of thoracoscopic lobectomies in the first quartile, increasing to 54% in the third quartile. In the fourth quartile residents and a new staff surgeon performed 76% of thoracoscopic lobectomies. A resident was the operating surgeon for 37 thoracoscopic lobectomies.

Conclusions: Introduction of thoracoscopic lobectomy into an academic thoracic surgical practice can be achieved safely if a stepwise transition is invoked. Training of thoracic surgical residents and additional staff can thus be effectively accomplished.

Abbreviations and Acronyms CT = computed tomography


   Introduction
Top
 Abstract
 Introduction
Materials and Methods
 Results
 Discussion
 References
 


Formula

Earn CME credits at http://cme.ctsnetjournals.org

 

Thoracoscopic lobectomy was first performed 13 years ago.1Go Worldwide, the procedure has been demonstrated to be safe,1-9Go and its oncologic outcomes are at least equal to those achieved with thoracotomy.1,5,6,10-15Go Thoracoscopic lobectomy can also offer several advantages, including decreased pain, faster return to functional status, and decreased inflammatory response. Despite the positive results with this minimally invasive technique, only 5% of the 40,000 lobectomies performed annually in the United States are done thoracoscopically.1Go

With few thoracic surgeons performing thoracoscopic lobectomy, there has been inadequate opportunity for thoracic surgical trainees to receive sufficient training in this operation. Ng and Ryder16Go demonstrated, in a series of 30 thoracoscopic lobectomies, that a stepwise evolution toward a thoracoscopic approach can offer a safe approach for a trained thoracic surgeon. Ferguson and Walker17Go suggested that thoracoscopic lobectomy can be safely taught to trainee thoracic surgeons, but that it should be coordinated at a national level. Others do not believe that this technique can be taught.17Go Here we predicted that the use of a predetermined stepwise plan for introduction of thoracoscopic lobectomy into a thoracic surgical training program would facilitate safe learning and subsequent teaching of the technique.


   Materials and Methods
Top
 Abstract
 Introduction
 Materials and Methods
Results
 Discussion
 References
 
Patients
Surgical databases from the Division of Thoracic Surgery at the University of Cincinnati College of Medicine and the Cincinnati VA Medical Center were queried to identify all pulmonary lobectomies performed during the 4-year period from July 1, 2002 through June 30, 2006. The study was approved by the University of Cincinnati Institutional Review Board.

Databases and patient records were reviewed for patient demographics, presenting symptoms, medical comorbidities, smoking history, previous cancer, pulmonary function tests, clinical staging by chest computed tomographic (CT) and positron emission tomographic scans, mediastinoscopic results, neoadjuvant therapy, attending surgeon, operating surgeon, operation performed (specific lobe, thoracoscopic or thoracotomy, and conversion), blood loss, operative time, pathologic stage, length of stay, chest tube duration, complications, and mortality.

Statistical Analysis
Operative mortality included all patients who died within 30 days of surgical intervention or within the same hospitalization. Thoracoscopy and thoracotomy groups were compared. Differences in categorical variables, including prolonged air leak, atrial fibrillation, and mortality, were determined by using continuity-adjusted {chi}2 analysis. Ordinal variables, such as chest tube duration and hospital length of stay, were compared by using the nonparametric Wilcoxon rank sum test.

Procedure
Thoracoscopic lobectomy is defined as a video-assisted procedure using anatomic dissection with individual ligation of the vessels and bronchi. No rib spreaders are inserted. The technique of thoracoscopic lobectomy has been well described by others.1Go Briefly, single-lung ventilation is used, and the patient is placed in the lateral decubitus position. A 10-mm port is inserted in the eighth to ninth intercostal space at the anterior axillary line, and a 10-mm port is placed in the sixth intercostal space at the midclavicular line. A 4- to 8-cm utility incision is created in the axilla at the fourth (for upper lobectomy) or fifth (for middle or lower lobectomy) intercostal space. A 10-mm incision is frequently placed in the auscultatory triangle in the sixth intercostal space, particularly when teaching the operation. This additional port allows the staff surgeon to assist more effectively, using retraction for improved exposure or for insertion of added instrumentation. The operating surgeon was defined as the individual who performed the majority of the hilar dissection. When converting to an open approach, the axillary utility incision was extended into a standard axillary thoracotomy.

All consecutive lobectomies were included. Prior thoracic surgery, neoadjuvant therapy, previous cancer, and medical comorbidities were not exclusion criteria. Sublobar resection, including wedge resections and segmentectomies, as well as bilobectomies, pneumonectomies, and sleeve lobectomies, were excluded. All cases were analyzed by using the intent-to-treat approach. Specifically, any planned thoracoscopic lobectomy, even if converted to a thoracotomy, was included in the thoracoscopic group. In one patient pneumonectomy was performed because of intraoperative bleeding. This patient, based on the intent-to-treat principle, was included in the thoracoscopic lobectomy cohort.

Model for Transition to Thoracoscopic Lobectomy
We used a predetermined model for introduction of thoracoscopic lobectomy. First, the attending surgeons are specialists in general thoracic surgery, with established expertise in open lobectomy and video-assisted thoracoscopic surgery.

Second, 2 attending surgeons participated in a formal thoracoscopic lobectomy course (Go Figure 1, time point 1).


Figure 1
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  		Figure 1. Cumulative number of cases performed open versus thoracoscopically. Time points: 1, attending surgeons participate in thoracoscopic lobectomy course; 2, first thoracoscopic lobectomy; 3, new attending thoracic surgeon begins; 4, attending surgeons first teach thoracoscopic lobectomy course. Arrows indicate mortalities. Solid line, Thoracoscopic lobectomy; dashed line, open lobectomy (thoracotomy).

 
Third, rather than immediately proceeding with transition to thoracoscopic lobectomy, a stepwise introduction of specific techniques was used. At first, in planned open lobectomies, we would begin thoracoscopically to gradually introduce the steps required in thoracoscopic lobectomy. For example, we initially took down the inferior pulmonary ligament thoracoscopically and then converted to a thoracotomy. We subsequently progressed to dissection and ligation of pulmonary veins and eventually to ligation of the arterial branches and bronchi, as well as mediastinal lymph node dissection.

Fourth, after using the stepwise introduction of the specific thoracoscopic techniques during open thoracotomy, we then progressed to complete thoracoscopic lobectomy (Figure 1, time point 2). In the initial thoracoscopic lobectomies the attending thoracic surgeons proctored each other.

Fifth, once the attending surgeons believed that they had acquired sufficient experience in thoracoscopic lobectomy, they began to teach others. Residents were transitioned from assistant to operating surgeon based on their demonstrated competence with advanced laparoscopy, video-assisted thoracoscopic surgery, and open lobectomy. They acquired the skills necessary for thoracoscopic lobectomy in a stepwise approach similar to the attending surgeons' strategy. Specifically, the residents first learned less advanced thoracoscopic procedures, such as wedge resection and pleural interventions. When they demonstrated competence in lesser procedures, they were allowed to begin thoracoscopic lobectomies. Initially, they would be taught to achieve exposure, take down the inferior pulmonary ligament, and expose the hilum. With demonstration of adequate technique in starting the operation, they would then advance to hilar dissection, progressing first to venous and bronchial dissection and finally to pulmonary arterial dissection. More recently, we have developed a quarterly resident course in which they are taught the procedure with cadavers. The attending surgeons also began teaching the technique to other thoracic surgeons in courses, both at the University of Cincinnati College of Medicine and as visiting proctors at other sites (Figure 1, time point 4).

Finally, with the recruitment of another attending thoracic surgeon, we used a similar stepwise approach to introducing the specific techniques of thoracoscopic lobectomy and proctored the surgeon for the initial cases (Figure 1, time point 3).


   Results
Top
 Abstract
 Introduction
 Materials and Methods
 Results
Discussion
 References
 
Patient Characteristics
During the 4-year period from July 2002 through June 2006, we performed 202 consecutive lobectomies. In 97 lobectomies a thoracotomy was used, and 105 lobectomies were thoracoscopic (Go Table 1). Patient age, sex distribution, and smoking history were similar between the 2 groups. Additionally, preoperative pulmonary function was similar in the 2 groups. Because this was a consecutive series including all lobectomies, a significant portion of patients had prior malignancies, both intrathoracic and extrathoracic.


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  		Table 1 Patient demographics
 
Choice of Procedure
Thoracoscopic lobectomy was used more frequently for patients with early-stage disease (Go Table 2). In particular, patients with clinical stage IA lung cancer were offered a thoracoscopic approach more often. Similarly, the mean tumor size was smaller in the thoracoscopic lobectomy group. The ideal patient for thoracoscopic lobectomy is one with a small peripheral lesion, at least early in a surgeon's learning curve. Thus as expected, a higher percentage of patients with adenocarcinoma were treated thoracoscopically because this histologic subtype is more commonly peripheral and therefore amenable to a thoracoscopic approach. Also, a higher percentage of patients with stage IB disease underwent open lobectomy, primarily because of large tumor size. Those with stage III disease usually had an open procedure for 2 main reasons: first, patients who had received neoadjuvant therapy were often managed with an open operation because of the potential technical challenges after radiation therapy, and second, a number of patients with occult N2 disease also had larger tumors that were not resected thoracoscopically. In the rare cases performed thoracoscopically after neoadjuvant therapy, the attending physician was the operating surgeon. Typically, 45 to 50 Gy had been used, although there was a range from 40 to 70 Gy.


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  		Table 2 Stage distribution
 
Outcomes
The conversion rate from thoracoscopic to open thoracotomy was 13% (14/105). There were 2, 4, 3, and 5 conversions in the first, second, third, and fourth quartiles, respectively. Ten of the 14 patients had evidence of prior histoplasmosis infection based on CT evidence of calcified pulmonary granulomas or lymph nodes, intraoperative observation of calcified nodes, or pathologic demonstration of calcified nodes. The specific indications for conversion were as follows: dense hilar inflammation or fibrosis (n = 4), hilar inflammation and bleeding (n = 4), pleural adhesions (n = 4), hilar adenopathy and bleeding (n = 1), and bleeding (n = 1). The causes of pleural adhesions were as follows: prior coronary artery bypass with left internal thoracic artery (n = 1), recent thoracic gunshot wound (n = 1), and "unknown" (n = 2). Of the 6 cases converted because of bleeding, one was in the first quartile, 3 were in the second quartile, 2 were in the third quartile, and none were in the fourth quartile. In 3 of these procedures, the resident was initially the operating surgeon. None of these patients had received neoadjuvant therapy. Thus in 4 of the 6 cases with pulmonary arterial bleeding requiring conversion, granulomatous nodal disease contributed to a difficult dissection.

Thirty-day mortality was 3.0% (6/202, Go Table 3). Two (2.1%) deaths occurred in the thoracotomy group, whereas 4 (3.8%) occurred in the thoracoscopic group. One patient died intraoperatively in the thoracoscopic lobectomy group of injury of the first branch of the left pulmonary artery during left upper lobe lobectomy. After conversion to thoracotomy, pulmonary artery repair was achieved, but the patient sustained a ventricular fibrillatory arrest and could not be resuscitated. One patient died postoperatively after planned thoracoscopic right lower lobe lobectomy. During hilar dissection, granulomatous disease caused by histoplasmosis was encountered, and injury to the pulmonary artery required conversion to a thoracotomy with a subsequent right pneumonectomy. The patient died on the eighth postoperative day from adult respiratory distress syndrome. In the 2 deaths in which thoracoscopic lobectomy was converted to open lobectomy because of bleeding, one was with an attending physician as the operating surgeon and one was with a trainee as the operating surgeon. In the left upper lobectomy the same complication can occur in open procedures, and it is thus not certain that the injury would have been avoided with an open approach. In the right lower lobectomy, earlier conversion, when hilar fibrosis from histoplasmosis was encountered, might have prevented the complication. The other deaths were caused by adult respiratory distress syndrome (n = 2: one open lobectomy, died on postoperative day 59; one thoracoscopic lobectomy, died on postoperative day 7), pneumonia (n = 1: open lobectomy, died on postoperative day 22), and pneumonia with gastrointestinal bleed (n = 1: thoracoscopic lobectomy, died on postoperative day 20).


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  		Table 3 Patient outcomes
 
There was no apparent difference in mortality, prolonged air leak, or atrial fibrillation between the thoracoscopic and open groups (Table 3). The incidence of prolonged air leaks in the thoracoscopic and open groups was not different between cases performed earlier in the series and those occurring later in the series. However, length of stay and chest tube duration were shorter after thoracoscopic lobectomy compared with those after thoracotomy. The median length of stay was 4 days for thoracoscopic lobectomy and 5 days for thoracotomy. Median chest tube duration was 3 days for thoracoscopic and thoracotomy approaches, but the sum of scores (Wilcoxon rank sum analysis) was significantly higher for thoracotomy (Table 3).

Teaching Thoracoscopic Lobectomy
We used a stepwise approach to the incorporation of thoracoscopic lobectomy into our academic thoracic surgery practice. After a period of proctoring each other, the 2 attending surgeons then performed the procedure independently as operating surgeons. After the attending surgeons became confident in their ability to routinely perform the operation in a safe manner, we embarked on teaching trainees to perform the operation. The 202 lobectomies were divided into quartiles to determine changes in the accomplishment of thoracoscopic lobectomy and in the development of trainee experience. The percentage of lobectomies performed thoracoscopically increased from 18% (9/50) in the first quartile to 82% (42/51) in the fourth quartile (Go Figure 2).


Figure 2
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  		Figure 2. Number of lobectomies performed thoracoscopically versus open. The cases were divided into equal quartiles.

 
With ongoing attending thoracic surgeon experience, the procedure was performed at higher frequency by trainees (Go Figure 3). Additionally, we recruited an attending surgeon who had just completed a thoracic surgical residency. We taught the procedure to the new surgeon in a stepwise manner, and we then proctored the individual through the initial cases as the operating surgeon. There was a steady increase in the number of cases performed by trainees. In the first quartile residents performed 0% (0/9) of thoracoscopic lobectomies as the operating surgeon. This increased to 29% (7/24) in the second quartile and 54% (14/26) in the third quartile. In the fourth quartile residents performed 38% (16/42) of cases. However, during the fourth quartile, the new staff surgeon began performing thoracoscopic lobectomies, accounting for 38% (16/42) of cases (Figure 1). Thus, during the fourth quartile, residents and the new staff surgeon were both considered trainees in the procedure, and they collectively performed 76% (32/42) of thoracoscopic lobectomies. In total, a resident served as the operating surgeon for 37 of the 105 thoracoscopic lobectomies.


Figure 3
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  		Figure 3. Number of thoracoscopic lobectomies performed by attending surgeons compared with trainees. The cases were divided into equal quartiles.

 

   Discussion
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
References
 
Thoracoscopic lobectomy has been conclusively demonstrated to be a safe operation1-9Go without increased bleeding, morbidity, or cost.18-21Go Many experienced thoracic surgeons have demonstrated several advantages of the minimally invasive technique, including decreased pain, shorter hospital stay, earlier return of functional status, improved postoperative pulmonary function, and decreased inflammatory response.20,22-25Go Most importantly, it is equally effective as a cancer operation, with similar postoperative survival compared with that of the open approach. Lobectomy performed thoracoscopically is the same operation as lobectomy performed through a thoracotomy, with individual ligation of the vessels and bronchi, as well as identical lymph node sampling or dissection.1Go Recently, the use of thoracoscopic lobectomy was shown to enable more effective administration of adjuvant chemotherapy than lobectomy by means of thoracotomy.26Go Despite these advantages, this minimally invasive technique is used for only a small minority of lobectomies.

There are few absolute contraindications to thoracoscopic lobectomy, and the approach has been used for higher-stage disease, sleeve lobectomy, and after neoadjuvant therapy. Yet the ideal patient for thoracoscopic lobectomy, particularly early in a surgeon's experience performing the operation, is one with a peripheral T1 or T2 lesion without nodal disease. Our experience demonstrates that adoption of this approach to patient selection is a safe strategy in the transition to routinely performing thoracoscopic lobectomy (Table 2).

Conversion to open lobectomy was not uncommon in our experience. A major reason for the conversion rate is that histoplasmosis is endemic in the Cincinnati area, often making hilar dissection challenging. Therefore careful review of the preoperative chest CT scan is essential, focusing on calcifications in the hilum, especially at the origin of the lobar bronchus that is to be divided. In this series a number of patients with stage IA or IB disease were not offered thoracoscopic lobectomy because of hilar calcification.

A significant limitation to greater application of thoracoscopic lobectomy appears to be the perceived difficulty in learning the operation.16,17Go Accordingly, there is limited opportunity for thoracic surgical trainees to learn the operation. The learning curve appears to vary, both for residents and staff, depending on their experience with open lobectomy and with less complex thoracoscopic procedures. For experienced practitioners, the stepwise approach of introducing defined portions of the operation, rather than abruptly transitioning from an open to a thoracoscopic approach, allows the learning curve to be tailored to the individual surgeon. For example, experienced surgeons might require more cases during which the initial steps of exposure and thoracoscopic visualization are mastered, whereas later steps (eg, hilar dissection) require less time to learn. However, residents with significant experience in minimally invasive operations, but not open lobectomy, appear to have little difficulty with visualization and minimally invasive instrumentation but progress much slower through the later stages of the procedure while learning the anatomic details and technical challenges of hilar dissection. Future surgical training will certainly use novel simulation models and centralized training facilities. However, the well-established model of surgical attending physicians learning new techniques from others, mastering them, and then teaching the method to residents is rational and practical. Here we demonstrate that introduction of thoracoscopic lobectomy into an academic thoracic surgical practice can be achieved safely if a stepwise transition is invoked. By using this approach, training of additional staff, as well as thoracic surgical residents, can be effectively accomplished.


   Acknowledgments
 
We thank Jay Asplan for generous assistance with data collection and analysis. We also appreciate the expert statistical assistance provided by Laura E. James, MS.


   Footnotes
 
Read at the Thirty-third Annual Meeting of the Western Thoracic Surgical Association, Santa Ana Pueblo, NM, June 27–30, 2007.


   References
Top
 Abstract
 Introduction
 Materials and Methods
 Results
 Discussion
 References
 

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