Commentary: Why do uniportal video-assisted thoracoscopic lobectomy?

Abstract

Central MessageWhy do a uniportal VATS lobectomy? Because embracing challenges is the only way to grow.See Article page 2487. Why do a uniportal VATS lobectomy? Because embracing challenges is the only way to grow. See Article page 2487. In this issue of the Journal, Ugalde and colleagues1Vieira A. Bourdages-Pageau E. Kennedy K. Ugalde P.A. The learning curve on uniportal video-assisted thoracic surgery: an analysis of proficiency.J Thorac Cardiovasc Surg. 2020; 159: 2487-2495.e2Abstract Full Text Full Text PDF Scopus (14) Google Scholar present a careful learning curve analysis of a very large single-surgeon experience with uniportal video-assisted thoracoscopic (U-VATS) lobectomy. The authors used operative time and conversion to thoracotomy or multiport VATS as key outcome metrics to gauge their proficiency. Their findings indicate that 60 U-VATS lobectomies were needed to complete the initial phase of the learning curve, and an additional 80 U-VATS lobectomies (ie, a total of 140) were required to become proficient. These findings support the recommendation of the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS) that 50 is the cutoff number of cases to overcome the learning curve.2Bertolaccini L. Batirel H. Brunelli A. Gonzalez-Rivas D. Ismail M. Ucar A.M. et al.Uniportal video-assisted thoracic surgery lobectomy: a consensus report from the Uniportal VATS Interest Group (UVIG) of the European Society of Thoracic Surgeons (ESTS).Eur J Cardiothorac Surg. 2019; 56: 224-229Crossref PubMed Scopus (43) Google Scholar Although 60 seems like a reasonable number of cases to get comfortable with a complex procedure, we cannot underestimate the technical challenge of U-VATS lobectomy. The authors work in a high-volume center and already had extensive experience with 2-port VATS lobectomy, and even then they required 60 cases to get comfortable with U-VATS lobectomy. U-VATS lobectomy is not easy to learn even for experienced multiport VATS surgeons, given the differences in vantage point and instrument handling. U-VATS requires that surgeons take the unnerving step of leaving their comfort zone and becoming novices at something again.3Andersen E. Learning to learn.Harv Bus Rev. 2016; 94: 98-101Google Scholar Why do U-VATS lobectomy? We probably can safely assume that U-VATS and multiport VATS lobectomy are oncologically equivalent when performed properly, and that the postoperative recovery from the 2 approaches is similar. It seems unlikely that a clinical trial of U-VATS lobectomy versus multiport VATS lobectomy would demonstrate a significant difference in operative outcomes. Assuming that U-VATS doesn't offer a measurable benefit to patients, why bother? Because innovation is a stepwise process and every step begets further steps to reach an as-yet unimaginable goal.4Andrade R. Bhargava A. No pain, no gain.Eur J Cardiothorac Surg. 2018; 54: 969-970Crossref PubMed Scopus (2) Google Scholar For instance, what would have Dr Evarts A. Graham thought in 1933 if someone had told him that pneumonectomy would be performed via VATS? At that time, this approach would have been inconceivable, and even in the 1980s, VATS anatomic resections were still considered an impossibility. But now we do U-VATS complex sleeve resections and pneumonectomies. What happened in the intervening 7 decades? People chose to leave their comfort zones and to take incremental steps. Individuals who embrace challenges are indispensable agents of change. Incremental steps, such as the development of staplers, muscle-sparing incisions, further development of scopes and instruments, and advances in anesthetic techniques, have made U-VATS anatomic lung resections feasible. Each individual step may seem small, but the additive effect over time can be transformative. U-VATS lobectomy is yet another incremental step in the evolution of thoracic surgery and we cannot predict where it will eventually lead us. A surgeon skilled in U-VATS could be poised to perform subxiphoid and transcervical lung resection and maybe even natural orifice (NOTES) lung resection. This may seem inconceivable now, but so did U-VATS pneumonectomy in 1933. Leaving our comfort zones is the only way to grow. The learning curve on uniportal video-assisted thoracic surgery: An analysis of proficiencyThe Journal of Thoracic and Cardiovascular SurgeryVol. 159Issue 6PreviewMinimally invasive techniques for lung cancer surgery have revolutionized thoracic surgery, and single-port approaches are becoming increasingly used. We analyzed our experience with uniportal video-assisted thoracoscopic surgery for lobectomy to identify the number of procedures necessary to achieve proficiency according to clinical outcomes. Full-Text PDF Open Archive