Adopting a standardized anterior approach significantly increases video-assisted thoracoscopic surgery lobectomy rates

Abstract

Video-assisted thoracoscopic surgery (VATS) lobectomy is associated with improved short-term outcomes compared with thoracotomy. Definition of the hilar structures is crucial to safe VATS lobectomy. Several VATS approaches have been described. We report the effect of three surgeons in our institution undertaking standardized anterior approach (SAA) training on the proportion of isolated lobectomies subsequently completed by VATS. Predictors of successful VATS lobectomy were analysed. Three consultant surgeons undertook SAA training at two different time points. Two were performing VATS lobectomy prior to SAA training. Training involved a 2-day visit to an established SAA unit. Lobectomies performed by these surgeons between April 2011 and December 2012 (20 months), before and after training, were recorded prospectively. Bilobectomies, sleeve resections, pneumonectomies and chest wall resections were excluded. VATS lobectomy proportions before and after training were compared. Independent predictors of completion by VATS rather than thoracotomy were identified by multivariable logistic regression. One hundred and sixty-three isolated lobectomies were performed, 97 of these by VATS (59.5%). The mean age was 68.8 (± 10.5) years. Pathology was lung cancer in 137 (84.0%), other primary malignancy in 10 (6.1%), pulmonary metastases in 8 (4.9%) and benign in 8 (4.9%). The VATS lobectomy rate rose from 22.2% before SAA training to 77.3% after, P < 0.001. The effect was significant for both existing and adopting VATS lobectomy surgeons, P = 0.002 to <0.001. The median hospital stay was 4 days after VATS and 5 after thoracotomy, P < 0.001. There were 5 in-hospital deaths after thoracotomy and none after VATS lobectomy, unadjusted P = 0.01. In the final logistic regression model, SAA training was the strongest predictor of successful VATS lobectomy (odds ratio 15.16; 95% confidence interval 6.39, 35.96). Formal training and adoption of the SAA approach were associated with a more than 3-fold increase in our VATS lobectomy rate. The effect was immediate and sustained. This may reflect easier identification of the major structures from the anterior view. In addition, standardization of surgical techniques and perioperative protocols may facilitate efficient team working. VATS lobectomy was associated with a shorter median hospital stay. Units seeking to increase their VATS lobectomy rate should consider group adoption of the SAA approach.