Henrik Jessen Hansen

Learning thoracoscopic lobectomy

OBJECTIVE Thoracoscopic (video-assisted thoracoscopic surgery (VATS)) lobectomy is a safe and effective method for treating early-stage lung cancer. Despite this, it is still not widely practised, which could be due to a shallow learning curve. We have evaluated the surgical outcome in a training programme at an institution with an established VATS lobectomy programme. We present the surgical data and outcome of the first 50 intended VATS lobectomies performed by a consultant in training as the primary surgeon. METHODS Data were obtained from a prospectively registered surgical database consisting of 262 consecutively intended VATS lobectomies. A single consultant performed 212 intended VATS lobectomies. His first 50 intended VATS lobectomies were excluded, as they were considered to be his learning curve, leaving 162 intended VATS lobectomies, of which 12 were converted to open lobectomy, performed from January 2005 to April 2008. Fifty intended VATS lobectomies were performed by a consultant in a training programme for VATS lobectomies, of which three were converted to open lobectomy from April 2007 to April 2008. The training consultant was experienced in open thoracic surgery and had performed more than 200 minor VATS procedures prior to the training programme. The surgical data and outcome between the 47 VATS lobectomies were compared with the 150 VATS lobectomies performed by the experienced consultant using statistical analysis. RESULTS There were significantly better results for the training consultant regarding prolonged air leak, chest tube duration and length of stay, which probably reflects the careful selection of the patients favouring the training consultant. The operation time was significant longer for the consultant in training (p<0.0001). CONCLUSIONS With careful selection of patients, VATS lobectomy can be taught safely in a surgical institution experienced in VATS lobectomies. Using statistical analysis, the surgical outcome for the training consultant was acceptable in comparison to the outcome of the experienced consultant. The consultant in training did spend more time in the operating theatre (p<0.0001) and we recommend taking that into account when planning future training programmes in VATS lobectomy.

Quantitative sensory testing of persistent pain after video-assisted thoracic surgery lobectomy

BACKGROUND Video-assisted thoracic surgery (VATS) lobectomy may potentially reduce the risk of post-thoracotomy pain syndrome (PTPS). However, it may still carry a risk of intraoperative nerve damage and thereby development of PTPS. Thus, our aim was to present a detailed long-term neurophysiological characterization of PTPS after VATS. METHODS Quantitative sensory testing, using thermal and mechanical stimuli, was performed in 13 PTPS patients and 35 pain-free patients recruited 33 months after VATS lobectomy. RESULTS When comparing the operated side with the control side in PTPS patients, increased thresholds of tactile and warmth detection were observed, while in pain-free patients, increased thresholds of warmth detection, cool detection, and heat pain were demonstrated. At the anterior porthole, pain-free patients displayed increased threshold to thermal detection when compared with the control side. Only side-to-side difference for tactile detection threshold was increased in PTPS patients compared with pain-free patients. Assessment of central sensitization showed no significant differences within or between PTPS and pain-free patients nor did group comparison of area of hypo- and hyperaesthesia to cool. Anxiety and depression scores (HADS) were higher in PTPS patients, but the area of hyper- and hypoaesthesia did not differ significantly between HADS groups. CONCLUSIONS Increased sensory thresholds suggest nerve injury to be present on the operated side in both PTPS and pain-free patients. However, no significant quantitative differences between PTPS and pain-free patients could be found, implicating the presence of factors other than intercostal nerve injury as important for development of PTPS after VATS lobectomy.

Video-assisted thoracoscopic surgery lobectomy for lung cancer is associated with a lower 30-day morbidity compared with lobectomy by thoracotomy.

OBJECTIVES Lung cancer is the most common cause of cancer-related deaths worldwide. Survival is highly dependent on surgery. Video-assisted thoracoscopic surgery (VATS) is increasingly chosen over open thoracotomy (OT) because of the possible benefits of the minimally invasive approach. Consequently, our aim was to compare the 30-day morbidity and mortality for lung cancer patients operated by VATS lobectomy or lobectomy by OT. METHOD Data were obtained from prospective national and regional databases, including patients who underwent lobectomy for lung cancer in the eastern part of Denmark from 1 January 2005 to 31 December 2011. All patients operated before 2009 were re-staged according to the latest International Association for the Study of Lung Cancer lung cancer classification. Patient characteristics, comorbidities, pathology and operative data were assessed using an independent samples t-test, Pearsons χ(2), Fishers exact test and Mann-Whitney test. Morbidity was assessed using multinomial logistic regression adjusted for gender, age, cancer stage, forced expiratory volume in 1 s (FEV1), year of surgery and Charlson comorbidity score. RESULTS In total, 1379 patients underwent lobectomy, 785 patients via VATS and 594 patients via thoracotomy. The two groups were similar in gender and FEV1. The patients operated by VATS were older (P < 0.001), and had a lower Charlson comorbidity score (P = 0.034), higher frequency of adenocarcinomas (P < 0.001) and lower cancer stage (P < 0.001). Among the VATS patients, 285 (36.3%) and among the thoracotomy patients, 288 (48.5%) had minor complications (P < 0.001); and 157 (20.0%) VATS patients and 212 (35.7%) thoracotomy patients had major complications (P < 0.001). The 30-day mortality rate was 1% in the VATS group and 1.5% in the thoracotomy group (P = 0.47). Multinomial logistic regression analysis showed that the prevalence of both minor [odds ratio (OR) = 1.51; 95% confidence interval (Cl) = 1.18-1.96] and major complications (OR = 1.91, 95% Cl = 1.44-2.53) was significantly higher for patients who underwent lobectomy via thoracotomy compared with VATS. CONCLUSION Patients undergoing lobectomy via VATS were less likely to have at least one minor complication within the first 30 postoperative days and less likely to have at least one major complication, compared with patients operated by thoracotomy. These findings remained after adjusting for gender, age, FEV1, cancer stage, year of surgery and Charlson comorbidity score.

Video-assisted thoracoscopic lobectomy using a standardized three-port anterior approach - The Copenhagen experience

Video-Assisted Thoracoscopic Surgery (VATS) lobectomy is now well established and performed all around the world. Formerly there was much debate about the feasibility of the technique in cancer surgery and proper lymph node handling. Although there is a lack of proper randomized studies, it is now generally accepted that the outcome of a VATS procedure is at least not inferior to a resection via a traditional thoracotomy. Several papers have concluded that there is no significant difference in survival rates and that there might even be a better outcome by VATS (1-3). A VATS lobectomy and even more a VATS anatomical segmentectomy is a challenging and technically demanding procedure to perform; and yet there is still no consensus about the basic principles in the technique. Different techniques have been described including the simultaneously stapled lobectomy (4), a VATS assisted operation with some rib spreading (5) and a true VATS lobectomy defined by no rib spreading along with anatomical hilar dissection and only monitor based vision rather than looking through the utility incision. The procedure is performed with up to 5 incisions and is even reported with a uniportal approach (6). Different lobe specific approaches have been reported (7) and a wide variation in instruments and camera positions is seen. At our institution we have a large experience with about 1,000 cases performed by a standardised three-port anterior approach with sequential division of the hilar structures, proper lymph node handling, no rib spreading and vision relying on the monitor only. This allows us to perform VATS lobectomies in the majority of the cases even if there are significant difficulties (8). We find that our standardized three-port anterior approach facilitates the VATS lobectomy, and it is our experience from visiting surgeons that our technique can easily be adapted by many surgeons, especially those who are used to an open anterior approach. The major advantages of the standardized anterior approach are: ❖ The mini-thoracotomy is placed directly over the hilum and the major pulmonary vessels. Easy to clamp the major vessels in case of major bleeding ❖ No need of changing the surgeons’ position or the place of the incision if a conversion is required ❖ The first structures to be transected are the major vessels ❖ The same approach to all lobes makes it easy to reproduce and learn ❖ The lung tissue only pushed backwards gently with peanuts and never grasped with forceps and therefore not torn apart ❖ Easy to teach as the surgeon and the assisting surgeon stand on the same side and use the same monitor. They do not work opposite to each other and therefore maybe against one and another. This facilitates a fluid learning process Indications for VATS lobectomy VATS lobectomy is commonly performed for selected peripherally located T1 or T2 tumours and usually reserved for patient where complications are not expected. We think that the advantages of a minimally invasive approach would also benefit cases that are more advanced and therefore the question in our daily clinically practice is: Are there any contraindications to perform the planned lobectomy as a VATS procedure? At present we find the following contraindications: ❖ T3 or T4 tumours. ❖ Tumours larger than 6 cm. ❖ Tumours visible in the bronchus by bronchoscopy within 2 cm of the origin of the lobe to be resected and where a possible Sleeve resection might be needed. ❖ Centrally placed tumours in the hilum and adherent to vessels. This means that patients with former Tuberculosis, previous cardiothoracic surgery and patients who have received preoperative chemo-radiotherapy are still considered as candidates for a VATS lobectomy. All our patients have a preoperative examination with lung function testing, PET/CT, bronchoscopy and EBUS/mediastinoscopy for preoperative staging (unless it is a peripheral placed T1 tumour on PET). With growing experience, we perform VATS lobectomy in the majority of the cases at our institution, even if they do present with co-morbidity. In the last few years, between 70% and 80% of all cancer lobectomies in our institution were performed by VATS and we now perform well over 200 VATS lobectomies and quite a few anatomical VATS segmentectomies each year (17 in 2011) with a very low conversion rate (2% in 2011).

Learning curve associated with VATS lobectomy

The first VATS lobectomy was performed in 1991 (1). Since then the implementation of VATS lobectomy has been rather slow. Data from the STS database shows a 32% rate of VATS lobectomies in 2006 (2). But it is only the best academic units that report to the STS database. This percentage is hence probably not representative for all the thoracic units in the USA. The implementation in Europe has been even slower than in the USA. But in the past years interest is rising, and in a recent report from The Society for Cardiothoracic Surgery in Great Britain and Ireland, the percentage of lobectomies performed by VATS has increased from 7% to 14% in just one year (2010). The slow adoption despite the obvious advantages is considered by many to be due to a demanding learning curve. The procedure is considered technically demanding and has the risk of uncontrollable bleeding. The introduction of VATS lobectomies in the surgical community was performed by self taught surgeons experienced in open surgery. The approaches varied from anterior, inferior to posterior, using 2-5 ports (3-6). These surgeons were pioneers and in case of intraoperative difficulties, conversion was their only option. The conversion rate was in many cases rather high (6). In Figure 1, the conversion rate and number of VATS lobectomies in Copenhagen between 1999 and 2011 is illustrated. The conversion rate declines with experience and number of cases per year. In the centres of the pioneers, the next generation learned the technique under guided supervision. The conditions for those surgeons’ learning curves were better due to the possibility of learning under supervision by an experienced VATS surgeon and a better possibility for selecting cases suitable for a training surgeon. Furthermore the surgical outcome was very satisfactory with low conversion and complication rates (7,8). Figure 1 Number of VATS lobectomies performed in Copenhagen 1999 to 2011 and conversions in % Since the introduction of VATS lobectomy in 1991, there has been a substantial improvement in the image quality. The introduction of firstly the digital thoracoscopes and later high definition (HD), has made precise dissection close to major vessels possible. Furthermore, several companies have designed curved instruments tailored to VATS surgery and a continuous improvement in these instruments have made it easier to perform and learn the technique. The quality of staplers has also improved significantly resulting in less air leak and fewer bronchial leaks.

Lung cancer screening and video-assisted thoracic surgery.

Introduction: The objective of this study is to report the impact of computed tomography (CT) screening on the use of Video-Assisted Thoracic Surgery (VATS) in a randomized screening trial. Methods: The Danish Lung Cancer Screening Trial is a randomized clinically controlled trial of 4104 smokers and previous smokers who were randomized to either screening with five annual low-dose CT scans or no screening in Copenhagen from 2004 to 2006. The major end point is the effect of CT screening on lung cancer mortality and treatment options. All diagnostic and treatment interventions in both groups were monitored prospectively until 1 to 3 years after the last screening round. Results: By February 1, 2011 68 cases of lung cancer were detected in the screening group. Furthermore, seven patients with a benign nodule underwent surgical treatment because of suspicion of malignancy (12%). Fifty-one of the 68 lung cancer patients were eligible for surgical treatment. Eight patients had open thoracotomy. Of the operations for lung cancer, 84% were performed by VATS in the CT-screened arm, significantly higher than the control arm (p < 0.05). Thirty-six patients had a VATS lobectomy. One patient had a VATS segmentectomy, and four patients had a VATS wedge resection. The seven benign nodules were all treated with VATS. Conclusions: CT screening seems to facilitate the use of VATS in the treatment of lung cancer with an 84% rate in our data. Furthermore, all benign nodules could be removed by VATS. In our view, a basic requirement for a surgical institution to be involved in lung cancer CT screening is a dedicated VATS program.

Regional analgesia for video-assisted thoracic surgery: a systematic review.

Video-assisted thoracic surgery (VATS) is emerging as the standard surgical procedure for both minor and major oncological lung surgery. Thoracic epidural analgesia (TEA) and paravertebral block (PVB) are established analgesic golden standards for open surgery such as thoracotomy; however, there is no gold standard for regional analgesia for VATS. This systematic review aimed to assess different regional techniques with regard to effect on acute postoperative pain following VATS, with emphasis on VATS lobectomy. The systematic review of PubMed, The Cochrane Library and Embase databases yielded 1542 unique abstracts; 17 articles were included for qualitative assessment, of which three were studies on VATS lobectomy. The analgesic techniques included TEA, multilevel and single PVB, paravertebral catheter, intercostal catheter, interpleural infusion and long thoracic nerve block. Overall, the studies were heterogeneous with small numbers of participants. In comparative studies, TEA and especially PVB showed some effect on pain scores, but were often compared with an inferior analgesic treatment. Other techniques showed no unequivocal results. No clear gold standard for regional analgesia for VATS could be demonstrated, but a guide of factors to include in future studies on regional analgesia for VATS is presented.

A new possibility in thoracoscopic virtual reality simulation training: development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy

OBJECTIVES The aims of this study were to develop virtual reality simulation software for video-assisted thoracic surgery (VATS) lobectomy, to explore the opinions of thoracic surgeons concerning the VATS lobectomy simulator and to test the validity of the simulator metrics. METHODS Experienced VATS surgeons worked with computer specialists to develop a VATS lobectomy software for a virtual reality simulator. Thoracic surgeons with different degrees of experience in VATS were enrolled at the 22nd meeting of the European Society of Thoracic Surgeons (ESTS) held in Copenhagen in June 2014. The surgeons were divided according to the number of performed VATS lobectomies: novices (0 VATS lobectomies), intermediates (1-49 VATS lobectomies) and experienced (>50 VATS lobectomies). The participants all performed a lobectomy of a right upper lobe on the simulator and answered a questionnaire regarding content validity. Metrics were compared between the three groups. RESULTS We succeeded in developing the first version of a virtual reality VATS lobectomy simulator. A total of 103 thoracic surgeons completed the simulated lobectomy and were distributed as follows: novices n = 32, intermediates n = 45 and experienced n = 26. All groups rated the overall user realism of the VATS lobectomy scenario to a median of 5 on a scale 1-7, with 7 being the best score. The experienced surgeons found the graphics and movements realistic and rated the scenario high in terms of usefulness as a training tool for novice and intermediate experienced thoracic surgeons, but not very useful as a training tool for experienced surgeons. The metric scores were not statistically significant between groups. CONCLUSIONS This is the first study to describe a commercially available virtual reality simulator for a VATS lobectomy. More than 100 thoracic surgeons found the simulator realistic, and hence it showed good content validity. However, none of the built-in simulator metrics could significantly distinguish between novice, intermediate experienced and experienced surgeons, and further development of the simulator software is necessary to develop valid metrics.

VATS anatomic lung resections—the European experience

Video-assisted thoracoscopic surgery (VATS) has undergone significant evolution over several decades. Although endoscopic instruments continued to improve, it was not until 1992 that the first VATS lobectomy for lung cancer was performed. Despite significant seeding of such procedure in several thoracic units globally, the uptake was slow and frustrating. Many surgeons considered it complex and unsafe being skeptic about its oncological validity. The last decade has witnessed significant change of practice in many thoracic units with a new generation of VATS thoracic surgeons. Additionally the technique has been refined, standardized and proved its validity and superiority in lung cancer treatment.

Spontaneous Rupture of the Urinary Bladder—a Late Complication to Radiotherapy: Case Report

Spontaneous rupture of the urinary bladder is extremely rare. A case of spontaneous intraperitoneal rupture of the urinary bladder 18 years after radiation therapy for testis cancer is reported.