The variability of practice in minimally invasive thoracic surgery for pulmonary resections

Thoracic surgeons participating in this survey seemed to have clearly indicated their perception of VATS major lung resections, in particular VATS lobectomy. 1. The acronym VATS as a short form of "video-assisted thoracic surgery" was the preferred terminology. 2. According to the respondents, the need or use of rib spreading served as the defining characteristic of "open" thoracic surgery. 3. It was most commonly suggested that VATS lobectomy is performed by means of two or three port incisions with the addition of a minithoracotomy or access incision. 4. Rib spreading (shearing) was not deemed acceptable as part of a strictly defined VATS procedure. 5. Although there was no general consensus, respondents suggested that the preferred approach for visualization in a VATS procedure was only through the video monitor. 6. Although minimally invasive procedures for lung resection are still mainly being used for diagnostic and minor therapeutic purposes, young surgeons seemed to be more likely to recommend VATS lung surgery for major pulmonary resections than their more senior colleagues. 7. The survey confirmed that the use of the standard posterolateral thoracotomy is still widespread. Almost 40% of the surgeons claimed to use the standard posterolateral thoracotomy for more than 50% of their cases and less than 30% use it for less than 5% of cases. 8. The major reasons to perform VATS lobectomy were perceived to be reduced pain and decreased hospitalization. 9. Approximately 60% of the surgeons claimed to perform VATS lobectomy in less than 5% of their lobectomy cases. Younger consultants reported using VATS lobectomy in up to 50% of their lobectomy cases. There was the suggestion that lack of resources could justify the minor impact of VATS lobectomy in the thoracic surgical practice in middle- to low-income countries. 10. The currently available scientific evidence on safety and effectiveness, and technologic advancements were emphasized as the two factors having a major impact on the development of minimally invasive thoracic surgical practice. 11. Any lack of popularity of VATS lobectomy was presumed to be caused by several equally important factors. Resistance to change by more senior surgeons ranked highly among younger surgeons, however, as an explanation for the slow adoption of this technique. Senior surgeons. however, seemed to focus their attention on the steep learning curve of VATS lobectomy. In addition, surgeons from middle- to low-income countries recognized certain financial and logistic difficulties as major determinants of the lack of popularity of VATS lobectomy. 12. Most surgeons thought that robotic thoracic surgery represented an evolution of VATS. Nevertheless, almost 30% did not think current robotic methods meet the criteria for minimally invasive surgery. More than 90% of the participants stated that they did not perform robotic thoracic surgery. This was reportedly because of costs. but also because of the fact that robotic approaches have not yet demonstrated a distinct advantage over nonrobotic VATS procedures. 13. It was suggested that in every unit or department there should be at least one surgeon with a specific interest and capability in VATS lobectomy. The younger surgeons. however, seemed to envisage more widespread competency being optimal. 14. Most suggested that training in VATS lobectomy be done in a stepwise fashion starting from the classical open technique. Older surgeons wanted to see this as an extracurricular activity following completion of the current training curriculum rather than included in the traditional training program. In the opinion of the thoracic surgeons taking part in this survey, pulmonary resections not performed according to these standards could not be called VATS procedures but should be included within the MITS category at large, along with other diagnostic and therapeutic interventions. In addition, the survey confirmed that the time-honored muscle-dividing thoracotomy is still widely used. The opportunity for a progressive move toward the routine use of less invasive approaches for major pulmonary resections, however, is already well within sight. Given the results of the ESTS survey supporting a stepwise teaching process leading to VATS lobectomy, hybrid and minimally invasive open lung resections (discussed elsewhere in this issue) collectively defined as MITS may serve as starting point in this process to expand the appropriate use of VATS lobectomy in the modern thoracic surgical practice.