Cases Of Lobectomy Research Articles

A Successful Case of Thoracoscopic Right Lower Lobectomy with Bronchoplasty for Primary Lung Cancer

A Successful Case of Thoracoscopic Right Lower Lobectomy with Bronchoplasty for Primary Lung Cancer

Impacts of thoracoscopic surgery and high grade histologic subtypes on spread through air spaces in small stage I lung adenocarcinomas.

Spread through air spaces (STAS) as a pattern of invasion in lung adenocarcinomas had been recognized by WHO in 2015. Moreover, STAS was associated significantly with aggressive micropapillary or solid components when presented predominant pattern in lung adenocarcinomas, which had a poor prognostic significance. Small amounts of micropapillary or solid with components could also reduce overall survival and recurrence-free survival but its impact on STAS is unknown now. Some studies have demonstrated manipulations of surgeons and pathologists could affect STAS but the degree of these impacts is not clear. We reviewed resected small (≤ 2cm) stage I invasive lung adenocarcinomas by thoracoscopic surgery at our institution from January 2017 to October 2018 (n = 277). Micropapillary or solid pattern was considered to be present when the subtype occupied at least 1% of the entire tumor. Lobectomy and segmentectomy were performed using three portals thoracoscopic surgery. Statistical analysis was performed to analyze the correlations of STAS and clinicopathological characteristics. Moreover, we also analyzed the correlated factors of STAS in solid nodules. STAS was found in 59 of 163 (36.2%) lobectomy cases and 27 of 114 (23.7%) limited resection cases. Lobectomy group showed a higher incidence of STAS compared with limited resection group (p = 0.027), but the difference was disappeared in multivariate analysis, which showed that STAS was significantly correlated to solid nodules and presence of high grade histologic subtype (mircopapillary or solid). However, both lobectomy and presence of high grade histologic subtype were significantly correlated with STAS in solid nodules. The small amounts of high grade histologic subtypes were also associated with STAS. Thoracoscopic surgery could affect STAS to some degree.

Left Hepatic Lobectomy in the Living Donor—Comparison Between Open vs Laparoscopic Surgery

Laparoscopic hepatic surgery dramatically changed surgical practice in the last decades, improving outcomes in correctly selected patients. The reduction of postoperative pain, lower rate of complication, early return to work activities, and better esthetic result have been well described in several studies. The success of these procedures would inevitably clash in the more complex and delicate field of hepatectomy in the living donor. The 2nd International Consensus of the Conference on Laparoscopic Liver Surgery considers laparoscopic hepatectomy in the donor as an ideal procedure. The aim of this study is to compare the results between conventional and laparoscopic surgery; prospective data and retrospective analysis of 55 cases of live liver donor lobectomy were collected between January 2013 and June 2018. The mean age was 30.4 years in the video laparoscopic technique and 32.1 years in conventional surgery; the majority of donors were male in both groups. The mean time of ischemia was 70.2 minutes (range, 50–120 minutes) in laparoscopic surgery and 80.2 minutes (range, 50–165 minutes) in conventional surgery. The surgical time ranged from 270 to 800 minutes (mean, 452 minutes) in laparoscopic surgery and ranged from 300 to 600 minutes (mean, 424 minutes) in conventional surgery. The mean length of hospital stay was 2.2 days in laparoscopy and 3.97 days in conventional surgery. Laparoscopic left liver lobectomy in the living donor is safe and feasible. There was no significant difference in surgical time; however, the time of hospitalization was lower in patients submitted to laparoscopic technique.

Prognostic Impact of Tumor Spread Through Air Spaces in Sublobar Resection for 1A Lung Adenocarcinoma Patients.

This study aimed to clarify differences in the prognostic impact of tumor spread through air spaces (STAS) in lobectomy versus sublobar resection (SR). The study also investigated the frequency and significance of STAS in residual lung segments. This study identified 752 patients with p-stage 1A non-small cell lung cancer (NSCLC) from 2010 to 2012. Recurrence-free survival (RFS) and overall survival (OS) were compared. For proactive simulation of SR, 100 consecutive lobectomy specimens of p-stage 1A NSCLC were selected. The study found STAS in 182 (28.7%) of 634 lobectomy cases and 43 (36.4%) of 118 SR cases. Multivariable analysis showed that STAS was not a prognostic factor in the lobectomy group, but showed a significantly worse prognostic effect for the SR group (RFS, P < 0.001; OS, P < 0.001). In 9 of 100 simulated cases, STAS occurred in residual lung segments. The patients with T1c category disease had a significantly increased risk for the development of STAS in residual lung segments (P = 0.033). For patients with p-stage 1A lung cancer who have undergone SR, STAS is a prognostic indicator of poor outcomes. The presence of STAS does occasionally exist in the residual lung segments.

Initial experience of laparoscopic right lobectomy after portal vein embolization

Background: Portal vein embolization is a technique used before hepatic resection to increase the size of remnant liver after surgery. This therapy redirects portal blood to segments of the future liver remnant, resulting in hypertrophy. The purpose of this study was to find out the safety and feasibility of laparoscopic right lobectomy after portal vein embolization. Methods: All consecutive cases of laparoscopic right lobectomy after portal vein embolization between July 2014 and April 2018 in a tertiary referral hospital were enrolled in this retrospective cohort study. All surgical procedures were performed by one surgeon. There were 14 cases of laparoscopic right lobectomy after portal vein embolization. The group was analysed in terms of donor demographics, preoperative data, postoperative outcomes. Results: The mean age of the donors was 51.3 ± 9.2 years, the mean operative time was 266.4 ± 67.9 minutes and mean postoperative hospital stay was 9.8 days. The number of complications was 2 cases (14.3%) and among them, the Clavien-Dindo classification III or higher complication was 1 (7.1%). There were no mortality cases. Conclusion: Laparoscopic right lobectomy after portal vein embolization was a safe and feasible procedure for selected patients. It showed an acceptable incidence of complications. The authors suggest that laparoscopic right lobectomy after portal vein embolization could be a reasonable operative option for selected patients.

Using the capnogram to assess pulmonary perfusion during a lobectomy: case studies.

Capnography is an effective and non-invasive method for monitoring patients during general anesthesia and can reflect the changes in both the respiratory function as well as the circulatory function. In this paper, we present four cases of lobectomy in which we observed a "chair-like" waveform on performing capnography after the surgery. In all the cases, the appearance of this "chair-like" waveform led to the suspicion of a blockage in the pulmonary artery perfusion, which was then confirmed to be an obstruction in the pulmonary artery on further investigation. This suggests that during lobectomy, capnography can help confirm that the pulmonary circulation is unobstructed. We believe that it is very important to observe the changes of end-tidal carbon dioxide pressure and capnogram during one-lung ventilation, particularly in cases of pulmonary artery anastomosis.

Pulmonary Inflammatory Myofibroblastic Tumor: Surgical Resection and Long-Term Surveillance

Objective: Inflammatory myofibroblastic tumor is a very rare mesenchymal tumor, we share our experience of surgical treatment for inflammatory myofibroblastic tumor. Materials and Methods: From January 2005 to January 2015, 32 patients were recruited in this study including 13 males and 19 females who received surgery and diagnosed as inflammatory myofibroblastic tumor. Postoperative followup was conducted by thoracic surgeons every 3 months until 12 months after surgery, after that every 6 months until 24 months, and then yearly. Results: 32 patients (aged: 9-72 yr, average:37.85 ± 19.42 yr, 13 males and 19 females ) received surgical treatment for inflammatory myofibroblastic tumor (ranged:0.8-8 cm, average:3.84 ± 2.05 cm), including 15 cases of lobectomy, 7 cases of wedge resection, 4 cases of bronchoplasty, 2 case of tracheal tumor resection, 3 cases of sleeve resection and 1 case of wedge resection with biopsy of the chest wall. 31 patients are still alive till now, while one patient die 6 months after the surgery. Conclusion: It suggested that complete resection of the IMT lesions may lead to a promising long-term survival, otherwise it may lead to a compromised outcome.

Erratum to the development of uniportal video-assisted thoracoscopic surgery in São Paulo: from diagnosis to lobectomy.

[This corrects the article DOI: 10.21037/jtd.2016.10.79.].

Atrial fibrillation after lung surgery: incidence, underlying factors, and predictors.

IntroductionCardiac complications are the second most common cause of morbidity and mortality in patients subjected to thoracic surgery after respiratory complications. Postoperative arrhythmia is one of the most common cardiac complications in these patients. It leads to morbidity, increased hospitalization, and high costs for patients.AimTo determine the incidence of atrial fibrillation after lung resection and determine the underlying factors and predictors of this problem.Material and methodsThe participants in this study were composed of all patients who were subjected to lung resection surgery in the past 4 years. The demographic data of the patients and possible postoperative complications, including the incidence of atrial fibrillation, were extracted from patient records. The statistical analysis of data was performed after data collection.ResultsThe incidence of postoperative atrial fibrillation (POAF) in the present study was 7.6% (n = 20), mostly in patients who had a lung parenchyma resection. It occurred due to malignancy (n = 16), squamous cell carcinoma (n = 9), adenoid cystic carcinoma (n = 5), and metastasis (n = 2). The POAF occurred in 34.2% of pneumonectomy cases and 4.5% of lobectomy cases, out of whom 60% were male. There was a significant difference between the two groups of arrhythmia and non-arrhythmia groups regarding the age range. The mean ages of patients with and without arrhythmias were 56.45 ±18.2 and 44.76 ±17.2, respectively.ConclusionsPulmonary malignant pathologies are more likely to develop POAF due to the need for lung resection and possibly mediastinal lymphadenectomy that stimulates the heart and pericardium and the vagus nerve.

Remote-Access Thyroidectomy: A Multi-Institutional North American Experience with Transaxillary, Robotic Facelift, and Transoral Endoscopic Vestibular Approaches

Many remote-access approaches (RAAs) to the thyroid have been described to circumvent anterior neck scarring, including the transaxillary, robotic facelift, and transoral endoscopic vestibular approaches. These techniques have been popularized in Asia, but adoption has been slow in North America. We aimed to examine multi-institutional North American outcomes with RAA thyroidectomy in the context of these institutions' transcervical approach (TCA) outcomes. Cases of lobectomy and total thyroidectomy via transaxillary, robotic facelift, and transoral endoscopic vestibular approaches were reviewed. Demographic characteristics, outcomes, and complications were compared with the same measures in patients undergoing lobectomy and total thyroidectomy via TCA by the primary RAA surgeons at each institution. Patients who underwent parathyroidectomy or other concomitant neck dissection procedures were excluded. Two hundred and sixteen RAA thyroidectomies were attempted (92 transoral endoscopic vestibular approaches, 70 transaxillary, and 54 robotic facelift) and 410 TCA thyroidectomies were performed. There was no difference in mean index nodule sizes between RAA (2.8 ± 1.6 cm) and TCA (2.9 ± 1.9 cm) cohorts (p= 0.72). Median operative times for lobectomy were 146 minutes (range 60 to 343 minutes) and 90 minutes (range 25 to 247 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). Median operative time for total thyroidectomy was 170 minutes (range 100 to 398 minutes) vs 126.5 minutes (range 51 to 260 minutes) for the RAA and TCA cohorts, respectively (p < 0.0001). There was no difference in the rates of permanent recurrent laryngeal nerve injury between the RAA (0 of 216 [0%]) and TCA (0 of 410 [0%]) cohorts (p= 0.99). Remote-access approach thyroidectomy can be performed in a select North American patient population with outcomes comparable with TCA.

A survey on the current development of thoracic surgery in tertiary hospitals of China

Objective: To study the current development of thoracic surgery in China. Methods: Chinese Society for Thoracic and Cardiovascular Surgery and Chinese Association for Thoracic Surgeons jointly conducted a network survey to directors of thoracic surgery departments in the tertiary hospitals in China from November to December 2018. The contents of the survey included the basic information of the hospital and the status of thoracic surgery department in the hospital. Rank sum test was used to compare the data between different regional hospitals Results: A total of 636 tertiary hospitals participated in the survey. The total number of beds for thoracic surgery departments was 30 646, with M(Q(R)) of 40(20) (range: 3 to 393) for each hospital. The total number of thoracic surgeons was 6 747, with M(Q(R)) of 9(6) (range: 1 to 75) in each hospital. In 2015, a total of 312 425 operations were performed in the 636 hospitals, with M(Q(R)) of 268(484.5) (range: 4 to 8 320) for each hospital. The total number of lung cancer surgeries was 146 601 in 2015, with M(Q(R)) of 100(216) (range: 0 to 6 911) operations in each hospital. The total number of esophageal cancer operations was 67 076, with M(Q(R)) of 40(95) (range: 0 to 1 550) in each hospital. Minimal invasive thoracic surgery was performed in 94.3% (601/636) of the hospitals, with 86.6% (551/636) of hospitals carried out video-assisted thoracoscopic (VATS) lobectomy. Among the hospitals performing VATS lobectomy, 89.3% (492/551) of them started to perform the technique after 2006, and 93.1% (513/551) of them do single-direction thoracoscopic lobectomy. A total of 403 640 VATS lobectomies had been performed until 2015, including 163 682 cases of single-direction thoracoscopic lobectomy. In 2015, 73.74% (108 116/146 601) lung cancer operations and 37.44% (25 110/67 076) of esophageal cancer resections were performed by minimally invasive technique. The development level of hospitals among eastern, middle and Western China was different significantly on number of doctors, number of total operations, number of lung cancer surgeries, proportion of minimally invasive lung cancer surgery, number of esophageal cancer surgeries, and proportion of minimally invasive esophageal cancer surgery (χ(2)∶7.65 to 60.8, all P<0.05). Conclusions: The discipline of thoracic surgery, especially the minimally invasive thoracic surgery in China is now experiencing a rapid development. The proportion of minimally invasive lung cancer surgery is higher than that of in the developed countries. However, unbalanced development among different regions is still a great challenge in China.

Two cases of lobectomy for lung cancer after transcatheter aortic valve implantation

BackgroundThe age of patients with lung cancer is advancing, and the number of patients with lung cancer who have cardiac diseases is expected to increase. Recently, the rate of transcatheter aortic valve implantation (TAVI) has increased as treatment for aortic stenosis (AS). TAVI is minimally invasive compared with conventional aortic valve replacement. We herein report two patients with lung cancer who underwent lobectomy after TAVI for severe AS.Case presentationTwo patients with AS and lung cancer were treated with two-stage surgery of TAVI followed by lobectomy. In patient 1 (77 years of age), conventional aortic valve replacement was considered to be risky because of his history of coronary artery disease and thoracic aortic aneurysm and his relatively high logistic euroSCORE. He underwent TAVI followed by right middle and lower lobectomy. In patient 2 (75 years of age), TAVI was chosen because the patient had poor ADL due to spinal canal stenosis and had taken immunosuppressant agents after a kidney transplantation. He underwent TAVI followed by right lower lobectomy. The postoperative course of the two patients was uneventful.ConclusionsTwo-stage surgery of TAVI and lung resection could be a viable option for patients with both lung cancer and severe AS, for whom conventional AVR by an open-heart operation is not indicated.

Management of acute ischemic stroke after pulmonary resection: incidence and efficacy of endovascular thrombus aspiration.

We analyzed acute ischemic stroke by thromboembolism in the early period after lung cancer surgery. A retrospective review of the clinical records of patients who underwent lung resection for primary lung cancer was performed. Patients who underwent lobectomy, bilobectomy, and pneumonectomy were included. The clinical characteristics of the patients, the incidence of atrial fibrillation (Af) after surgery, and the incidence of acute ischemic stroke were analyzed. The clinical courses of patients having acute ischemic stroke were also reviewed. In 4 (0.6%) of 696 patients, acute ischemic stroke occurred in the early period during hospitalization after lung cancer surgery. Acute ischemic stroke occurred within 4 days in three cases and after 4 days in one case. The resection site of the lung was the left side in all cases, and there were three cases of left upper lobectomy and one case of left lower lobectomy. As for the two recent patients, thrombus removal was performed by a neurosurgeon, and both cases achieved successful recanalization. The time between symptom detection and recanalization was 205 and 170min, respectively. One patient was cured without any residual effect of disease, and the other patient's hemiplegia resolved and aphasia improved. Since cerebral infarction impairs the patient's quality of life, thrombus removal should be considered if possible.

Predictors of early lobectomy after birth in prenatally diagnosed congenital pulmonary airway malformation

PurposeThe purpose of this study was to clarify the relationship between congenital pulmonary airway malformation volume ratio (CVR) of bronchial atresia (BA), CVR of congenital cystic adenomatoid malformations (CCAM), and time of surgery after birth. MethodWe retrospectively analyzed data of 36 BA and CCAM cases, prenatally diagnosed as CPAM from 2009 through 2014. ResultsWithin 2 h after birth, 12 neonatal patients underwent emergent (EMG) lobectomy. Five cases of lobectomy were performed urgently (UG) from 12 to 48 h after birth. Four cases of lobectomy were required within 30 days after birth (early = EAG). We performed lobectomy in 15 other patients at 11 months after birth (late = LG). Of the EMG cases, 11 were macrotype CCAM (maximal CVR >2.0), and 4 of 5 UG cases were microtype CCAM (CVR >2.0). Of the EAG cases, 3 of 4 were macrotype CCAM with CVR of <1.5. Of 15 LG, 13 were BA and showed a CVR of 0.13–3.0 (median, 0.78). The CVR of the cases operated on within 48 h after birth was significantly larger than that of the cases operated on after 2 weeks (p = 0.001). ConclusionEMG or UG lobectomy was usually required after birth in CCAM, indicating maximal CVR >2.0. By contrast, elective surgery was performed in most BA cases. Level of evidenceIV.

Non-intubated uniportal video-assisted thoracoscopic surgery-lobectomy in Germany—the first 2 cases

We report the first two cases of non-intubated uniportal lobectomy for lung cancer in Germany performed by Dr. Rivas in June 2018 at the Hannover Medical School. An in-depth look at patient selection, perioperative management and postoperative care is given, and pitfalls are discussed.

Delayed discharge does not decrease the cost of readmission after pulmonary lobectomy

Readmission after pulmonary lobectomy has become a potentially avoidable source of excess health care costs. Initiatives that focus on expedited discharge after lobectomy may decrease costs, but a criticism of this approach is that expedited discharge may be associated with more frequent and more expensive readmissions. We explored whether patients are at greater risk for costly readmission after expedited discharge. The Nationwide Readmission Database was queried for cases of lobectomy for lung cancer between 2010 and 2014. Patients 65 years of age and older were categorized into three groups: patients discharged between hospital day 1 and 3 (expedited), between hospital days 4 and 7 (routine), or discharge after day 8 (late). Risk-adjusted 90-day readmission rates and hospital costs for readmission were compared among groups. A total of 104,905 patients underwent lobectomy for lung cancer during the study period. There were 18,652 (17.8%) expedited discharges, 54,551 (52.0%) routine discharges, and 31,702 (30.2%) late discharges. Compared with the expedited group, patients in the routine discharge group had a 3.2% greater risk-adjusted readmission rate (P < .0001), and patients in the late discharge group had 12.7% greater risk-adjusted readmission rate (P < .0001). After adjustment, expedited discharge was associated with a $4,066 decrease in index hospital costs compared with routine discharge, and a $19,233 decrease compared with late discharges (both P < .0001) but was not associated with costlier readmission (routine mean -$24 ± standard error $153, P = .87; late mean +$2,528 ± standard error $178; P < .0001). Expedited discharge after lobectomy is associated with a greater risk-adjusted readmission rate and greater index hospital costs over routine and late discharge, with no increased costs for readmission. These data demonstrate that prolonged hospital duration of stay does not decrease the risk of 90-day readmission after lobectomy, providing support for protocols that expedite patient discharge and decrease overall health care utilization.

Thoracoscopic one-stage lobectomy and diaphragmatic plication for T3 lung cancer

BackgroundCombined resection of a phrenic nerve is occasionally required in T3 primary lung carcinomas invading the phrenic nerve to completely remove a malignant tumour, resulting in diaphragmatic paralysis. We describe the first case of thoracoscopic lobectomy and diaphragmatic plication as a one-stage surgery for lung cancer invading the phrenic nerve.Case presentationA 56-year-old woman with a T3N0M0 primary adenosquamous carcinoma in the left upper lobe presented with suspicious invasion to the anterior mediastinal fat tissue and left phrenic nerve and underwent left upper lobectomy, node dissection, and partial resection of the anterior mediastinal fat tissue with the left phrenic nerve. Furthermore, thoracoscopic diaphragmatic plication was performed as a concomitant procedure. The patient’s postoperative course was favourable, without any complications, and respiratory function was preserved for 1 year postoperatively.ConclusionsThoracoscopic one-stage lobectomy and diaphragmatic plication for T3 lung cancer invading the phrenic nerve is effective for preservation of postoperative pulmonary function.

Continuous 389 cases of Da Vinci robot-assisted thoracoscopic lobectomy in treatment of non-small cell lung cancer: experience in Shanghai Chest Hospital.

To analyze the perioperative indexes of 389 patients with non-small cell lung cancer in single center after robot-assisted thoracoscopic (RATS) lobectomy, and to summarize the surgical key points in robotic lobectomy. The clinical data of 389 stage I non-small cell lung cancer patients who underwent RATS lobectomy from May 2013 to December 2016 were retrospectively analyzed. Among them, there were 261 females (67.1%) and 128 males (32.9%); aged from 20-76 years old, with a mean age of 55.01 years; with ASA I in 106 cases, ASA II in 267 cases and ASA III in 16 cases; with BMI from 16.87-34.05, averaged at 23.09±2.79. The largest tumor in preoperative chest CT measurement was 0.3-3.0 cm, ranging from 1.29±0.59 cm; with stage Ia in 153 cases, stage Ib in 148 cases, stage Ic in 32 cases, stage IIb in 26 cases and stage IIIa in 30 cases; including 380 adenocarcinomas and 9 squamous carcinomas. The operating time was 46-300 min, averaged at 91.51±30.80 min; with a blood loss of 0-100 mL in 371 cases (95.80%), 101-400 mL in 12 cases (3.60%) and >400 mL in 2 cases (0.60%); there were 4 (1.2%) conversions to thoracotomy, in which 2 patients had massive hemorrhage and 2 patients had extensive dense adhesion; there was no mortality during operation and perioperatively. The drainage on the first day after operation was 0-960 mL, averaged at 231.39±141.87 mL; the postoperative chest tube was placed for 2-12 d, averaged at 3.96±1.52 d; the postoperative hospital stay was 2-12 d, averaged at 4.96±1.51 d, with postoperative hospital stay >7 d in 12 cases (3.60%). The postoperative air leakage was the main reason (35 cases, 9%) for prolonged hospital stay, and there was no re-admitted case within 30 days. All the patients underwent systemic lymph node dissection. The total cost of hospitalization was 60,389.66-134,401.65 CNY, averaged at 93,809.23±13,371.26 CNY. The application of Da Vinci robot surgery system in resectable non-small cell lung cancer is safe and effective, and could make up for the deficiencies of traditional thoracoscopic surgery. The number and level of robot surgery in our center have reached international advanced level, but the relatively expensive cost has become a major limitation in limiting its widespread use. With continuous improvements in robotic technology, its scope of application will be wider, which will inevitably bring new insights in lung surgical technology.

Spread Through Air Spaces Is a Prognostic Factor in Sublobar Resection of Non-Small Cell Lung Cancer

Spread through air spaces (STAS) identified in lung cancer is considered to be a risk factor for recurrence after surgery. The purpose of this study is to clarify the prognostic impact of STAS in sublobar resections. We studied 514 patients with clinical stage IA cancers: 329 underwent lobectomies and 185 underwent sublobar resections. We assessed the prognostic impact of STAS in the cases with a sublobar resection for stage IA lung cancer versus the cases with a lobectomy. STAS was found in 73 of 329 (22.2%) lobectomy cases and 31 of 185 (16.8%) sublobar resection cases. For overall survival, univariate analysis revealed that STAS was not a prognostic factor in the lobectomy group, but it was a significantly worse prognostic factor for the sublobar resection group in both univariate and multivariate analyses. For the recurrence-free rate, multivariate analysis showed STAS was not a risk factor in the lobectomy group, but it was a significant risk factor for the sublobar resection group in both univariate and multivariate analyses. Patients with STAS and sublobar resection had a significantly higher rate of pulmonary metastases than did patients with STAS and lobectomy (8 of 31 [25.8%] vs 6 of 73 [8.2%]). STAS is a prognostic factor of poor outcomes for sublobar resection in patients with lung cancer. The worse prognosis for sublobar resection would be associated with STAS.

2016 Annual report from the Italian VATS Group.

This report highlights the results of the Italian video-assisted thoracoscopic surgery (VATS) Group, launched in mid 2013, which now has a website and an established database with over 4000VATS lobectomy cases recruited from 67 thoracic surgery units across Italy. The year 2016 has been crucial for the following steps: inclusion of a dedicated biostatistician and a 'Survey Analysis & Data Quality Check'; the First Consensus Meeting with statements consequently adopted as Recommendations for the Italian Thoracic Surgery Society and published in a peer-reviewed journal; two papers published under the logo Italian VATS Group and seven abstracts accepted at annual international meetings (European Society of Thoracic Surgeons, European Association of Cardio-Thoracic Surgeons, European Lung Cancer Conference and European Respiratory Society); the institution of a Master Course on VATS lobectomy; the partnership with AME Publishing Company.