A System for Mixed-Reality Holographic Overlays of Real-Time Rendered 3D-Reconstructed Imaging Using a Video Pass-through Head-Mounted Display-A Pathway to Future Navigation in Chest Wall Surgery

Background: Three-dimensional reconstructions of state-of-the-art high-resolution imaging are progressively being used more for preprocedural assessment in thoracic surgery. It is a promising tool that aims to improve patient-specific treatment planning, for example, for minimally invasive or robotic-assisted lung resections. Increasingly available mixed-reality hardware based on video pass-through technology enables the projection of image data as a hologram onto the patient. We describe the novel method of real-time 3D surgical planning in a mixed-reality setting by presenting three representative cases utilizing volume rendering. Materials: A mixed-reality system was set up using a high-performance workstation running a video pass-through-based head-mounted display. Image data from computer tomography were imported and volume-rendered in real-time to be customized through live editing. The image-based hologram was projected onto the patient, highlighting the regions of interest. Results: Three oncological cases were selected to explore the potentials of the mixed-reality system. Two of them presented large tumor masses in the thoracic cavity, while a third case presented an unclear lesion of the chest wall. We aligned real-time rendered 3D holographic image data onto the patient allowing us to investigate the relationship between anatomical structures and their respective body position. Conclusions: The exploration of holographic overlay has proven to be promising in improving preprocedural surgical planning, particularly for complex oncological tasks in the thoracic surgical field. Further studies on outcome-related surgical planning and navigation should therefore be conducted. Ongoing technological progress of extended reality hardware and intelligent software features will most likely enhance applicability and the range of use in surgical fields within the near future.

Modified surgical incision suturing technique in uniportal video-assisted thoracoscopic pulmonary resection

Background

In recent years, single-hole thoracoscopic surgery technology is widely used in major medical centers and chest-specialized hospitals for the treatment of lung diseases. However, the single-hole minimally invasive surgery method focuses on one incision, and all surgical instruments need to pass through the same hole, resulting in repeated extrusion and tissue damage of the surgical incision. Therefore, we have improved the suture method of conventional surgical incision in order to reduce the probability of wound infection and dehiscence, promote early healing, and reduce the severity of postoperative wound scar, thereby enhancing the postoperative rapid recovery of patients. The purpose of this study is to explore the clinical efficacy of a modified surgical incision suture technique applied to uniportal thoracoscopic pulmonary resection.

Methods

This study retrospectively analyzed 151 patients who were admitted to the Department of Thoracic Surgery and underwent pulmonary resection from January 2019 to October 2021 in the North District of Suzhou Municipal Hospital. The patients were divided into two groups according to the different surgical incision suture methods: a modified group and a conventional group. The postoperative general clinical indexes, incision infection rate, secondary suture rate, postoperative incision pain score, and the severity of postoperative incision scar were compared and analyzed between the two groups.

Results

There were no statistically significant differences between the two groups in terms of chest tube duration or postoperative drainage and postoperative incision pain scores; the incision infection rate (1.3% vs. 6.7%, P<0.05), secondary suture rate (2.6% vs. 9.4%, P<0.05), and postoperative scar score (4.853 vs. 5.543, P=0.03) were better in the modified group than in the conventional group, and the differences between the two groups were statistically significant.

Conclusions

Our modified suture method reduces the chance of infection and splitting and the severity of postoperative incision scar formation, promoting early healing. It can be safely and effectively applied to the incision suture of uniportal thoracoscopic pulmonary resection, enhancing the rapid postoperative recovery of patients.

Collaborative Virtual Reality Real-Time 3D Image Editing for Chest Wall Resections and Reconstruction Planning

The integration of extended reality (XR) technologies into health care procedures presents transformative opportunities, particularly in surgical processes. This study delves into the utilization of virtual reality (VR) for preoperative planning related to chest wall resections in thoracic surgery. Leveraging the capabilities of 3-dimensional (3D) imaging, real-time visualization, and collaborative VR environments, surgeons gain enhanced anatomical insights and can develop predictive surgical strategies. Two clinical cases highlighted the effectiveness of this approach, showcasing the potential for personalized and intricate surgical planning. The setup provides an immersive, dynamic representation of real patient data, enabling collaboration among teams from separate locations. While VR offers enhanced interactive and visualization capabilities, preliminary evidence suggests it may support more refined preoperative strategies, potentially influence postoperative outcomes, and optimize resource management. However, its comparative advantage over traditional methods needs further empirical validation. Emphasizing the potential of XR, this exploration suggests its broad implications in thoracic surgery, especially when dealing with complex cases requiring multidisciplinary collaboration in the immersive virtual space, often referred to as the metaverse. This innovative approach necessitates further examination, marking a shift toward future surgical preparations. In this article, we sought to demonstrate the technique of an immersive real-time volume-rendered collaborative VR-planning tool using exemplary case studies in chest wall surgery.

The SUPER reporting guideline suggested for reporting of surgical technique

Background

Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique. The Surgical techniqUe rePorting chEcklist and standaRds (SUPER) aims to address this gap by defining reporting standards for surgical technique. The SUPER guideline intends to apply to articles that encompass surgical technique in any study design, surgical discipline, and stage of surgical innovation.

Methods

Following the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach, 16 surgeons, journal editors, and methodologists reviewed existing reporting guidelines relating to surgical technique, reviewed papers from 15 top journals, and brainstormed to draft initial items for the SUPER. The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions. The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants.

Results

The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting. The items are divided into six sections: background, rationale, and objectives (items 1 to 5); preoperative preparations and requirements (items 6 to 9); surgical technique details (items 10 to 15); postoperative considerations and tasks (items 16 to 19); summary and prospect (items 20 and 21); and other information (item 22).

Conclusions

The SUPER reporting guideline has the potential to guide detailed, comprehensive, and transparent surgical technique reporting for surgeons. It may also assist journal editors, peer reviewers, systematic reviewers, and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique.

Trial Registration

https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#SUPER.

[Robotics in thoracic surgery]

The increasing diffusion of the robotic-assisted technique in thoracic surgery (RATS) in Germany was initially delayed in comparison with other countries. Therefore, there is a large potential to implement the volume of the surgical procedures performed by RATS.The RATS-technique has many positive aspects. For example, the angulated instruments allow a full wristed dexterity like the human hand, but with a greater range of motion. The surgical Robot has a tremor filter and replicates perfectly the surgeon's movements. Furthermore, the 3D-scope enables an image magnification up to 10 times compared to the normal thoracoscopes. The RATS has also some disadvantages. For example, the operating surgeon sits far away from the patient and is not sterile while performing surgery. This is an important factor in in case of emergency situations, like major bleeding, which often require a conversion to thoracotomy.All robotic systems are built after the same master-slave technology, that allows the operating surgeon to have full control of the master system. The slave system consists of mechanical actuators that respond to the master system's inputs, so the surgical robot will translate every single movement of the surgeon at the console.The main surgical indications for RATS are: mediastinal tumors, diaphragm plication and anatomical lung resection like segment resections, lobectomies or sleeve resections.In the future, the implementation of virtual and augmented reality is expected in the training but also in the planning of RATS-operations.

Reporting guidelines for surgical technique could be improved: a scoping review and a call for action

OBJECTIVES

To identify reporting guidelines related to surgical technique and propose recommendations for areas that require improvement.

STUDY DESIGN AND SETTING

A protocol-guided scoping review was conducted. A literature search of MEDLINE, the EQUATOR Network Library, Google Scholar, and Networked Digital Library of Theses and Dissertations was conducted to identify surgical technique reporting guidelines published up to December 31, 2021.

RESULTS

We finally included 55 surgical technique reporting guidelines, vascular surgery (n = 18, 32.7%) was the most common among the clinical specialties covered. The included guidelines generally showed a low degree of international and multidisciplinary cooperation. Few guidelines provided a detailed development process (n = 14, 25.5%), conducted a systematic literature review (n = 13, 23.6%), used the Delphi method (n = 4, 7.3%), or described post-publication strategy (n = 6, 10.9%). The vast majority guidelines focused on the reporting of intraoperative period (n = 50, 90.9%). However, of the guidelines requiring detailed descriptions of surgical technique methodology (n = 43, 78.2%), most failed to provide guidance on what constitutes an adequate description.

CONCLUSION

Our study demonstrates significant deficiencies in the development methodology and practicality of reporting guidelines for surgical technique. A standardized reporting guideline that is developed rigorously and focuses on details of surgical technique may serve as a necessary impetus for change.

Nonintubated versus intubated thoracoscopic bullectomy for primary spontaneous pneumothorax: A multicenter propensity-matched analysis

BACKGROUND

We aimed at comparing in a multicenter propensity-matched analysis, results of nonintubated versus intubated video-assisted thoracic surgery (VATS) bullectomy/blebectomy for primary spontaneous pneumothorax (PSP).

METHODS

Eleven Institutions participated in the study. A total of 208 patients underwent VATS bullectomy by intubated (IVATS) (N = 138) or nonintubated (NIVATS) (N = 70) anesthesia during 60 months. After propensity matching, 70 pairs of patients were compared. Anesthesia in NIVATS included intercostal (N = 61), paravertebral (N = 5) or thoracic epidural (N = 4) block and sedation with (N = 24) or without (N = 46) laryngeal mask under spontaneous ventilation. In the IVATS group, all patients underwent double-lumen-intubation and mechanical ventilation. Primary outcomes were morbidity and recurrence rates.

RESULTS

There was no difference in age (26.7 ± 8 vs 27.4 ± 9 years), body mass index (19.7 ± 2.6 vs 20.6 ± 2.5), and American Society of Anesthesiology score (2 vs 2). Main results show no difference both in morbidity (11.4% vs 12.8%; p = 0.79) and recurrence free rates (92.3% vs 91.4%; p = 0.49) between NIVATS and IVATS, respectively, whereas a difference favoring the NIVATS group was found in anesthesia time (p < 0.0001) and operative time (p < 0.0001), drainage time (p = 0.001), and hospital stay (p < 0.0001). There was no conversion to thoracotomy and no hospital mortality. One patient in the NIVATS group needed reoperation due to chest wall bleeding.

CONCLUSION

Results of this multicenter propensity-matched study have shown no intergroup difference in morbidity and recurrence rates whereas shorter operation room time and hospital stay favored the NIVATS group, suggesting a potential increase in the role of NIVATS in surgical management of PSP. Further prospective studies are warranted.

Evidence on reporting guidelines for surgical technique in clinical disciplines: a scoping review protocol

Background

The reporting of surgical techniques is of mixed quality, with most at a very minimal level. Reporting guidelines that could be applied to guide surgical technique reporting vary in methodology for development, discipline coverage, dimension coverage and detail requested. However, a scoping review that could indicate the gaps and efforts needed in surgical technique reporting guidelines is lacking and warranted. This study aims to design a methodological rigour protocol to guide the development of a scoping review of surgical technique reporting guidelines.

Methods

This protocol is designed following the 2020 manual proposed by the Joanna Briggs Institute. To further ensure the soundness of the protocol, we also included multidisciplinary professionals (including methodologists, clinicians, and journal editors) to refine the protocol.

Discussion

Seven key steps for developing the scoping review are identified and presented in detail, including (I) identifying the research questions; (II) inclusion criteria; (III) search strategy; (IV) source of evidence selection; (V) data extraction; (VI) analysis of the evidence; and (VII) presentation of the results. Guided by this protocol, the subsequent scoping review will inform us the overview of surgical technique reporting guidelines and precisely guide our direction and next steps in improving surgical technique reporting guidelines.

Trial registration

This protocol is not registered as the PROSPERO database only accepts registration of systematic review protocols while does not accept registration of scoping review protocols.

Developing the surgical technique reporting checklist and standards: a study protocol

BACKGROUND

Standardized and transparent reporting of surgical technique is the cornerstone of effective dissemination, implementation and improvement. However, current reporting of surgical techniques is inadequate. The existing guidelines potentially applied to guide surgical technique reporting are with a minimal highlight of the surgical technique, lack requirements explaining what extent and dimensions need to be described in detail, or are unlikely to extrapolate to a wide range of surgical techniques. This study aims to formulate a rigorous protocol to develop a surgical technique reporting checklist and standards (SUPER) that defines what a clear, comprehensive and detailed surgical technique report should be contained.

METHODS

This protocol is designed following the classic guidance for developing reporting guidelines recommended by the EQUATOR network.

RESULTS

The development team will consist of surgeons (~80%), methodologists, and journal editors. The draft checklist sources will include a scoping review of existing reporting guidelines related to surgical technique, surgical technique articles from 15 top journals published in the last year, and brainstorming by the multidisciplinary development team. The final SUPER checklist will be formed after three rounds of Delphi surveys, one round of face-to-face meeting, and a month-long pilot test. The SUPER checklist will be published as open-access and be used in combination with existing reporting guidelines related to surgical techniques (e.g., IDEAL). This protocol will steer the SUPER checklist's development, allowing us to further elaborate surgical technique reporting for all surgical specialties, and enabling a more favorable experience for surgeons, nurses, medical students, residents, editors, and reviewers.

TRIAL REGISTRATION

This trial is registered at the EQUATOR network on December 18th, 2020. Available at: https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/.

Management of the inter-segmental plane using the "Combined Dimensional Reduction Method" is safe and viable in uniport video-assisted thoracoscopic pulmonary segmentectomy

Background

The management of the intersegmental plane (ISP) is challenging during uniport video-assisted thoracoscopic (VATS) pulmonary segmentectomy. Staplers and electrocautery have been used extensively in ISP management. However, both of them have their respective drawbacks. Currently, we have provided a revised technique termed as "Combined Dimensional Reduction Method" (CDR method), for managing the ISP with combined application of ultrasonic scalpel and staplers. The study aimed to review the outcomes of patients who underwent uniport VATS segmentectomy with or without the CDR method in our institute and assess the feasibility and safety of the CDR method.

Methods

From March 2017 to February 2018, 220 patients who underwent uniport VATS segmentectomy were retrospectively reviewed. By using IQQA software, pulmonary structures were reconstructed as three-dimensional (3D) images, making the targeted structures could be identified preoperatively. For the management of the ISP, in the CDR group, we firstly used the ultrasonic scalpel to trim the 3D pulmonary structure along the intersegmental demarcation, making the remaining targeted parenchyma both sufficiently thin enough and located on a 2D plane; thus, enabling easy use of staplers in managing ISP. Whereas, in the non-CDR group, we only use the staplers to manage the ISPs. The clinical characteristics, complications, and postoperative pulmonary functions were compared between the two groups.

Results

Propensity score analysis generated 2 well-matched pairs of 71 patients in CDR and non-CDR groups. There was no 30-day postoperative death or readmission in either group. The CDR group was significantly associated with the shorter operative time (178.3±35.8 vs. 209.2±28.7 min) (P=0.031) and postoperative stay (4.5±2.3 vs. 5.7±4.2 days) (P=0.041), compared to the non-CDR group. Moreover, no significant difference was observed in blood loss, a period of chest tube drainage, a period of ultrafine tube drainage, and postoperative pulmonary complications between the two groups. Moreover, the recovery rate of postoperative forced expiratory volume in 1 second (FEV1) or vital capacity (VC) at 1 and 3 months after segmentectomy was comparable between them.

Conclusions

The CDR method could make segmentectomy easier and more accurate, and therefore has the potential to be a viable and effective technique for uniport VATS pulmonary segmentectomy.

Focus on specific disease-part 2: the European Society of Thoracic Surgery chest wall database

Background

Data collection has gained a great importance in numerous areas in the last years and also in the medical field. Collecting data is the key to knowledge and consequently improving data quality is fundamental, as the results of the data analysis can have a large impact on the clinical practice.

Methods

Collected data can be employed to assess the performance of surgeons or institutions and to implement hospital´s performance and productivity. The chest wall database is one of the satellites composing the European Society of Thoracic Surgery (ESTS) database and includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The participation to the registry is free and voluntary for the ESTS members. The ESTS chest wall database includes data on risk factors, surgical techniques, processes of care and outcomes related to chest wall pathologies. The collected data are designed for quality control and performance audit. Acquired data are anonymous, independently accessed and encrypted on a Dendrite platform, which provides data security and regular backups. The registry is managed by an external company (KData Clinicak Srl), which works together with the database committee in revising and updating periodically the database.

Results

The ESTS chest wall database is structured in four main sections: preoperative, intraoperative, postoperative and follow up. For each procedure registered in the database are collected a number of different variables regarding the patients' characteristics, the surgical technique, the postoperative course until the discharge and also follow up data. Correction of pectus excavatum is the most common procedures registered in 2017 (392 patients, 67% of all data), followed by pectus bar removal (159 patients, 27% of all procedures).

Conclusions

The ESTS chest wall database is an ambitious European project, which aims to standardize all chest wall procedures in all their aspects.

A benchmarking project on the quality of previous guidelines about the management of malignant pleural effusion from the European Society of Thoracic Surgeons (ESTS) Pleural Diseases Working Group

OBJECTIVES

In the European Society of Thoracic Surgeons (ESTS) survey about management of malignant pleural effusions (MPE), 56% of respondents are not informed of any relevant clinical guidelines and 52%, who are aware of the existence of guidelines, declared that they are in need of updating or revision. The ESTS Pleural Diseases Working Group developed a benchmarking project on quality of previous guidelines on the management of MPE.

METHODS

The Appraisal of Guidelines for Research and Evaluation (AGREE) II instrument was used to assess each guideline. Each item was scored on a 7-point scale. Scores for each domain were calculated. Economic data for the nations which have issued the guidelines were collected from the Organisation for Economic Cooperation and Development health statistics database.

RESULTS

Six guidelines fitted the inclusion criteria and were assessed. Five out of 6 guidelines were produced by a multinational collaboration. Observers would recommend only 2 guidelines with minimal modification. Two areas that received the best score were clarity of presentation and scope and purpose (objectives and health questions target population). The applicability of guideline domain had the lowest score. Multivariate analysis demonstrated that clarity of presentation, international guidelines and publication through medical journal were related to improved scores. A strong correlation was observed between the measures of economic status.

CONCLUSIONS

The quality of guidelines assessed by the AGREE II criteria was found to be extremely variable. Guidelines achieving higher AGREE II scores were more likely to come from the European Union with the direct involvement of scientific societies in their development. It was also recognized that some fundamental unanswered questions remain about the management of MPE.

Surgical approach in oligometastatic non-small cell lung cancer

The vast majority of lung cancer (80%) are non-small cell lung cancer (NSCLC) presenting in huge proportion of patients in a metastatic stage at the time of diagnosis with an overall survival (OS) of only 6 months. Standard treatment at this stage involves systemic platinum based chemotherapy improving the OS for only few months. For the vast majority of patients disease progression occurs and cure cannot achieved. An exception to this general rule is represented by patients with a limited number of metastasis (approximately 7% of patients with metastatic NSCLC): in 1995 Hellman and Weichselbaum introduced the term "oligometastatic" for a selected group of patients with metastatic disease. Several retrospective studies have been published and documented an improved outcome in patients managed surgically. The purpose of this narrative review is to gather all relevant information and present the various clinicopathological and generic aspects of diagnosis, management strategies and prognostic factors in patients with oligometastatic NSCLC. The key for long term survival includes radical treatment of the primary NSCLC, single organ site with either synchronous or metachronous presentation, a disease free interval to be as long as possible and the absence of intrathoracic lymph node spread (N0). A more accurate staging with combination of FDG-PET and CT scan can have on impact on the survival rates due to an increased accuracy in mediastinal staging and in the diagnosis of distant metastasis. No randomized data but only retrospective series are available to date to address this topic: in the future, additional prospective studies will be necessary to provide robust evidence to support the surgical resection as treatment of oligometastatic NSCLC.

Uniportal non-intubated thoracic surgery

Uniportal video-assisted thoracoscopic surgery (VATS) is the most advanced evolution of the minimally invasive technique, which allows often the possibility to include patients in enhanced recovery programs in order to optimize the therapeutic pathway, shorten the length of stay and reduce hospital costs. Non-intubated VATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax, which can provide a good lung isolation without the need of a double lumen tube. A survey between the members of the European Society of Thoracic Surgery (ESTS) showed that non-intubated VATS procedures are already performed by a large number of ESTS members for minor procedures. With the publication of new data and the spreading of uniportal VATS in many centers worldwide in the last decades, the application of the non-intubated technique in major procedure like anatomic resections is expected to grow. This technique can potentially be beneficial for high-risk patients but also could be used for the routine procedures as well, but more data are needed to establish the real benefit for these groups of patients.

Management of Intraoperative Difficulties During Uniportal Video-Assisted Thoracoscopic Surgery

The learning curve of the uniportal video-assisted thoracoscopic surgery (VATS) approach is linked to a larger rate of intraoperative complications, which can lead to an emergency conversion to thoracotomy. Despite technical advancements and the large number of surgical videos posted on specialized websites, live surgery events and experimental courses have significantly contributed to accelerate the learning and evolution of minimally invasive thoracic surgery. Bleeding and other complications are the most dreaded event for many VATS surgeons. This article analyzes possible major intraoperative complications during uniportal VATS and explains how to manage them effectively and safely.

Current practices in the management of malignant pleural effusions: a survey among members of the European Society of Thoracic Surgeons

Objectives

Malignant pleural effusion (MPE) commonly complicates advanced malignancy and their exact management is still undefined. We undertook a survey to determine the current practice among members of the European Society of Thoracic Surgeons (ESTS).

Methods

A cross-sectional survey focused on the current practice of management of MPE was developed by the authors. The questions were outlined after a review of the literature and circulated in an Internet-based survey format.

Results

Computed tomography (125, 92%) and chest X-ray (106, 78%) are the most common imaging modalities performed in the initial evaluation. Video-assisted thoracoscopic surgery for washout and pleurodesis (93, 68%) was reported as the preferred approach to patients with uncomplicated MPE. Sixty-one (45%) of the responding colleagues routinely use large bore chest tubes for draining malignant effusions. Forty-nine (35%) surgeons would not apply suction to the drainage system, whilst 50 (37%) would use -2 kPa or less. Talc (124, 91%) is the most commonly used sclerosing agent for pleurodesis in the context of malignant pleural effusion. The practice of 76 (56%) of the respondents is not informed by any clinical guidelines, whilst 60 (44%) reported adhering to the 2010 British Thoracic Society Pleural Disease Guideline. Seventy-one (52%) declared that the guidance was in need of updating or revision.

Conclusions

This survey demonstrates the lacking adoption of the existing clinical guidance in this field, as well as the need for more contemporary guidelines for a better-informed practice. The ESTS Working Group on the management of MPE has been established for this purpose.

Segmentectomy versus lobectomy for stage I non-small cell lung cancer: a systematic review and meta-analysis

BACKGROUND

In recent years, many factors have revamped the interest in segmentectomies as preferred procedure for stage I non-small cell lung cancer (NSCLC). The aim of this systematic review and meta-analysis is to compare the outcomes of segmentectomy versus lobectomy regarding overall survival (OS) in the surgical treatment of stage I NSCLC, as stated in the conclusions of the largest studies conducted in this field and reported to date.

METHODS

The searching strategy was developed in EMBASE, MEDLINE and Cochrane CENTRAL from 1990 until December 2016. The meta-analysis was performed with the combination of the reported survival outcomes of the individual studies using a random effect model. The OS of the lobectomy group was compared with the segmentectomy group alone. The hazard ratio (HR) and standard error were extracted or calculated for each study using the Kaplan-Meier method.

RESULTS

Regarding the results, most of these studies were based on the retrospective data. The size of the cohorts varied from 17 to 11,520, with a total number of 24,542 patients. The pooled HR was 1.04 [95% confidence interval (CI), 0.92-1.18; P=0.50].

CONCLUSIONS

The survival in the segmentectomy group was not inferior to patients treated with lobectomy. In conclusion, the current meta-analysis disclosed that segmentectomies produce similar survival compared to lobectomy for patients with stage I NSCLC. To establish the role of segmentectomy in early NSCLC, more evidence is needed, in particular, a large numbered, prospective, randomised trials, which should dissolve the uncertainties and the questions raised by retrospective data.

The role of wet lab in thoracic surgery

During the last three decades, minimally invasive surgery has become common practice in all kinds of surgical disciplines and, in Thoracic Surgery, the minimally invasive approach is recommended as the treatment of choice for early-stage non-small cell lung cancer. Nevertheless, all over the world a large number of lobectomies is still performed by conventional open thoracotomy and not as video-assisted thoracic surgery (VATS), which shows the need of a proper training for this technique. Development and improvement of surgical skills are not only challenging and time-consuming components of the training curriculum for resident or fellow surgeons, but also for more experienced consultants learning new techniques. The rapid evolution of medical technologies like VATS or robotic surgery requires an evolution of the existing educational models to improve cognitive and procedural skills before reaching the operating room in order to increase patient safety. Nowadays, in the Thoracic Surgery field, there is a wide range of simulation-based training methods for surgeons starting or wanting to improve their learning curve in VATS. Aim is to overcome the learning curve required to successfully master this new technique in a brief time. In general, the basic difference between the various learning techniques is the distinction between "dry" and "wet" lab modules, which mainly reflects the use of synthetic or animal-model-based materials. Wet lab trainings can be further sub-divided into in vivo modules, where living anaesthetized animals are used, and ex vivo modules, where only animal tissues serve as basis of the simulation-based training method. In the literature, the role of wet lab in Thoracic Surgery is still debated.

Learning curve and established phase for uniportal VATS lobectomies: the Papworth experience

BACKGROUND

Uniportal video-assisted thoracoscopy (VATS) has increasingly gained importance in the thoracic surgery scenario. The use of this technique can reduce postoperative pain and length of stay and gives the surgeon the same operative perspective as open surgery.

METHODS

We retrospectively analysed the data of 73 patients who underwent uniportal VATS lobectomies from November 2014 to December 2015 in our institution. We divided the patients in two groups (group 1: first 30 patients vs. group 2: established phase, 43 patients) to compare and evaluate the data regarding the learning curve. To explore evolution of learning curve, data were plotted to calculate Spearman's Rank-Order Correlation. R (version 3.2.3) was used for statistical analysis.

RESULTS

The median age was 69.9 (group 1) and 68.8 (group 2) years. Mean operative time was 84.9±33.0 (group 1) and 84.8±31.5 (group 2) minutes. The conversion rate was 13.3% in group 1 vs. 9.3% in group 2, showing a significant learning reduction (rho=0.590). Overall morbidity rate was 15.1%. The most common complication consisted in prolonged air leak. Interpolation line of complications showed a significant decrease due to learning curve (rho=0.676). The median length of stay was 4 days in group 1 vs. 3 days in group 2. The 30-day mortality was 3.3% in group 1 and 0% in group 2.

CONCLUSIONS

The comparison between the groups showed that the median length of stay, operative time, conversion rate and 30-day mortality statistically significantly improved in the established phase. Also, complications like prolonged air leak were decreasing in the established phase. In conclusion, the uniportal VATS lobectomy technique can be performed safely from experienced surgeons without major complications and with an acceptable mortality rate.

Single port video-assisted thoracoscopic thymectomy

Over the past decade, video-assisted thoracic surgery (VATS) has started to replace median sternotomy for the resection of non-invasive anterior mediastinal masses, including thymoma. In fact, many studies confirmed that, compared to standard sternotomy, VATS thymectomy results in less post-operative pain, better preserved pulmonary function, improved cosmesis (which can be particularly important to many young female myasthenia gravis patients) and is oncologically feasible for non-invasive thymomas as long as en bloc resection of the tumour is achieved. Classically three ports are used, but the current trend is to reduce the number of ports and minimize the length of incisions to further decrease postoperative pain, chest wall paraesthesia, and length of hospitalization. Uniportal VATS thymectomy for non-invasive mediastinal tumour resection is proven to be a safe and reliable method. In this paper we describe and illustrate our technique for single port VATS thymectomy.

Technical steps in single port video-assisted thoracoscopic surgery lobectomy

Video-assisted thoracoscopic surgery (VATS) has transformed the way of treating patients with lung diseases over the past two decades and this is particularly true referred to patients with lung carcinoma. The indication for surgical treatment could be extended to those patients that were functionally unable to receive a thoracotomy and overall this approach shortened the length of stay in hospital and improved the quality of life of these patients postoperatively. The best VATS technique for lobectomy has not been well defined yet. The VATS approach to lobectomy can be performed via 1-4 incisions without rib spreading with similar outcomes. Over the last few years the single port VATS approach has generated a growing interest in the scientific thoracic surgery community as less invasive for the patients and comfortable for the performing surgeon. The aim of this video-article is to show the different steps of this technique and to provide some tips and tricks to improve and facilitate the execution of the uniportal VATS lobectomy.

Open repair of pectus carinatum

Pectus carinatum is a chest deformity characterized by a protrusion of the sternum and ribs (usually 3-7 ribs). The treatment of these patients varies in relation to age. In younger patients we prefer to use a custom-made brace, surgery is the elective treatment for older patients. The minimally-invasive technique (Abramson procedure) is used rarely and for mild defects, whereas open surgery is still preferred by many surgeons to repair major deformities. In our institution we use a modified Ravitch approach trough a vertical incision, which is performed on top of the most prominent part of the defect. The first step is the mobilisation of the pectoralis muscle to allow the exposure of the skeletal structure of the sternum and of the deformed costal cartilages. The second step is to perform multiple parasternal rib cartilage resections to shorten the overabundant length that causes the deformity, avoiding damaging the perichondrium. The third step consists of a wedge osteotomy at the level of the most prominent point of the sternum. The last step is the remodelling and the stabilization of the chest wall. The sternum stabilization is obtained through the placement of one titanium bar and with the filling of the space created at the osteotomy line with fragments of cartilages or with demineralized bone tissue. The perichondrial sheats of the ribs are sutured to the sternum with absorbable sutures. The postoperative pain management should be a priority in order to avoid further complications. In our institution we use a patient-controlled analgesia (PCA) with morphine on the day of the surgery. On the first postoperative day we remove the PCA and start an oral therapy with the combination of opioids and non-steroidal anti-inflammatory drugs. Early mobilisation is also a milestone in the postoperative management of these patients.

Enhanced recovery pathway for thoracic surgery in the UK

BACKGROUND

Enhanced recovery (ER) refers to a combination of perioperative interventions designed to minimise the impact of surgery on patients' recovery in order to reduce postoperative complications and to allow an early discharge reducing hospital costs.

METHODS

An ER protocol was established at our institution following a review of the best evidence available. We introduced a multi-disciplinary integrated perioperative pathway by engaging with every person involved, including the patients themselves. The programme was monitored using specifically-designed patients related outcome measures (PROMs).

RESULTS

One-hundred and fifty-four ER patients were compared with 171 controls from the year before ER was introduced. There was an 80% increase in same-day admissions, with a net gain of more than 300 patient bed-days. The ER group had a significantly higher number of procedures performed by video assisted thoracoscopic surgery (VATS) (ER, 32.9% vs. 9.4%, P=0.0001) and a lower rate of admission to the intensive care unit (ER, 5.8% versus 12.9%, P=0.04). Patients on the ER programme had a significantly reduced postoperative length of stay (mean ER, 5.2 vs. 11.7 days, P<0.0001). Patient satisfaction was higher in the ER group after a patient survey. The project resulted in a net saving of £214,000 for the Trust for the 2013/2014 financial year. We were also able to increase the number of patients who underwent thoracic surgery in 2013/2014 by 30% (159 patients) compared with 2012/2013.

CONCLUSIONS

The ER pathway has proven to be a safe perioperative management strategy to improve patient satisfaction and to reduce the length of hospital stay and cost after major thoracic surgery, without increasing morbidity or mortality.