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Video-Assisted Thoracic Lung Surgery: Is There a Barrier to Widespread Adoption?

2010; Elsevier BV; Volume: 89; Issue: 6 Linguagem: Inglês

10.1016/j.athoracsur.2010.02.100

1552-6259

Anthony P.C. Yim,

Voice and Speech Disorders

Dr Yim has no conflicts of interest to disclose. Dr Yim has no conflicts of interest to disclose. The advent of video-endoscopic surgery has revolutionized the way we practice surgery. Dr. Ralph Lewis and colleagues were among the first to apply this new technique in general thoracic surgery in the late 1980s [1Lewis R.J. Caccavale R.J. Sisler G.E. Special report: video-endoscopic thoracic surgery.N J Med. 1991; 88: 473-475PubMed Google Scholar]. Prior to that, this group had long been practicing direct diagnostic thoracoscopy using either a bronchoscope or mediastinoscope without video assistance with excellent results [2Lewis R.J. Kunderman P.J. Sisler G.E. Mackenzie J.W. Direct diagnostic thoracoscopy.Ann Thorac Surg. 1976; 21: 536-539Abstract Full Text PDF PubMed Scopus (42) Google Scholar]. The first major symposium on video-assisted thoracic surgery (VATS) took place in San Antonio, Texas, in January 1992 just before the Society of Thoracic Surgeons Annual meeting spearheaded by Drs Michael Mack, Rodney Landreneau, Stephen Hazelrigg, and Keith Naunheim. The proceedings of that meeting were subsequently published as 33 articles in the 56th volume of The Annals of Thoracic Surgery in 1993. This set the stage for widespread dissemination of this new technique worldwide. Two decades have now passed since its introduction; has VATS really changed the practice of thoracic surgery? In 1997, Mack and colleagues [3Mack M.J. Scruggs G.R. Kelly K.M. Shennib H. Landreneau R.J. Video-assisted thoracic surgery: has technology found its place?.Ann Thorac Surg. 1997; 54: 211-215Abstract Full Text Full Text PDF Scopus (87) Google Scholar] published a survey on members of the General Thoracic Surgery Club asking the role in their practice; members of this club were predominantly from North America. Two hundred of the 229 members (87%) responded to the questionnaire. Two-thirds of the respondents were academic surgeons and about three-quarters of them had over ten years experience in general thoracic surgery. Video-assisted thoracic surgery was the preferred approach (over 50% response) for the management of pleural disease, lung biopsy, recurrent pneumothorax, and sympathectomy. The majority of respondents thought that VATS was an acceptable approach for the diagnosis of the indeterminate pulmonary nodule and of anterior and posterior mediastinal of early empyema, clotted hemothoraces, limited lung cancer treatment, and benign esophageal disease; VATS was thought to be unacceptable or investigational for thymectomy, lobectomy, and lung volume reduction surgery. Video-assisted thoracic surgery represented a small portion of the total thoracic procedure performed; 60% of respondents used VATS less than 20% and 38.1% expressed concern regarding overuse. The main limitation was thought to be in the management of oncologic disease. Anatomic lung resection, mostly for cancer, occupies a major part of a thoracic surgeon's workload. Therefore, for VATS to make a major impact on thoracic practice, its role in anatomic lung resection deserves closer attention. In 1998, we published a questionnaire survey of 45 thoracic surgeons worldwide who were believed to practice VATS lobectomy either because of their publications or because of personal knowledge [4Yim A.P. Landreneau R.J. Izzat M.B. Fung A.L. Wan S. Is video-assisted thoracoscopic lobectomy a unified approach?.Ann Thorac Surg. 1998; 66: 1155-1158Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar]. Thirty-three (73.3%) who completed the questionnaire were analyzed; 48% from North America, 30% from Asia, 15% from Europe, and 3% each from South America and Australia. Considerable variations exist regarding preference for VATS lobectomy, their approaches to mediastinal and hilar lymph nodes, and the exact operative techniques. The latter ranged from a purely endoscopic technique to one that was more appropriately termed minithoracotomy with video assistance when the surgeons operate primarily by looking through the utility thoracotomy. Most surgeons practicing VATS lobectomy continued with the individual ligation technique, except for one group of surgeons who adopted the simultaneous stapling approach to the lobar vessels and bronchus. Initial concerns of VATS lobectomy focused on the technical feasibility and safety followed by oncologic clearance. These issues have been adequately addressed and VATS is believed by many to be the approach of choice for resection of clinical stage I lung cancer [5Whitson B.A. Groth S.S. Duval S.J. Swanson S.J. Maddaus M.A. Surgery for early-stage non-small cell lung cancer: a systematic review of the video-assisted thoracoscopic surgery versus thoracotomy approaches to lobectomy.Ann Thorac Surg. 2008; 86: 2008-2018Abstract Full Text Full Text PDF PubMed Scopus (533) Google Scholar]. Science is advanced in small increments. The purists who are looking for data from a large randomized study to change their practice will be disappointed because that study may never come. Having said that, VATS demands learning a new set of manual skills compared with conventional surgery. We examined whether VATS major lung resection could be safety taught to residents without compromising surgical outcome by comparing the cases operated by residents under supervision with those operated by senior attending surgeons [6Wan I.Y. Thung K.H. Hsin M.K. Underwood M.J. Yim A.P. Video-assisted thoracic major lung resection can be safely taught to trainees.Ann Thorac Surg. 2008; 85: 416-419Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar]. The data were collected prospectively but the analysis was retrospective in nature. From January 2002 to October 2006, 111 patients with clinical stage I and II lung cancer underwent VATS major resection; 46% of the procedures were performed by attending surgeons and 54% by supervised residents at the Prince of Wales Hospital in Hong Kong. Patients' demography and risk factors were comparable between the two groups. Residents took longer than experienced attendings, but there was no significant difference in intraoperative or postoperative complications and outcomes between groups. Therefore, we concluded that VATS can be safely taught to residents without compromising outcome and it should be an integral part of a thoracic residency program. In the two decades since the introduction of VATS it has significantly changed thoracic surgery practice as the approach of choice for procedures like diagnostic wedge lung resection, thoracodorsal sympathectomy, and primary pneumothorax surgery. Video-assisted thoracic surgery is gaining increasing acceptance for more complex procedures like major lung resection, esophagectomy, and thymectomy. On the other hand, although highly complex procedures like en bloc chest wall resection, bronchoplastic procedures, and extrapleural pneumonectomy have been attempted using the VATS approach, the vast majority of surgeons currently would stay away from this. I believe the major barrier to widespread adoption of VATS is not in the technique, the training, or even the cost, but in the mindset. Thoracic surgeons, by their nature and training, tend to be conservative. We spend years learning to do a few operations well. To ensure reproducible, consistent results, we follow the same routine every time we operate, and postoperative care follows a protocol. We tend to resist changes which by their very nature introduce an element of uncertainty to the outcome. Although there is nothing wrong with this approach from the purely technical standpoint, this mindset does not prepare us to evolve with time. Thoracic surgeons of today, including both those trained and those in training, should keep an open mind. This open-mindedness refers not only to embracing new technique and technology, but also to acceptance with grace that we will eventually be surpassed by those coming after us. Only by going through this process can real advancement be made. I teach my residents the way I operate, but also encourage them to visit other centers with a large volume in VATS. The biggest compliment a student can give to his or her teacher is to exceed that teacher.