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Two years of VATS lobectomies – learning curve strategy, mistakes and first results

Authors work in a regional thoracic surgery centre in Hungary which is the division of a general surgical department. The aim of this lecture is to show the process of introducing VATS (video-assisted thoracoscopic surgery) in a provincial thoracic surgery centre in Hungary.

Until the end of 2013 thoracic surgical operations in this department were performed in a classical way. The proportion of VATS was low and it was mainly used for diagnostic operations. The needs for tools and devices for VATS and laparoscopic interventions were competing in those days.

In 2013 the development of VATS was decided. Owing to a successful competition, a new HD (high definition) thoracoscopic equipment was obtained. This way, the concurrence with the laparoscopic operations was finished.

The first step of introducing advanced VATS operations was to visit some centres, where the details of the method could be studied. We visited three thoracic surgery departments. First of all, we were in Ljubljana, Slovenia twice and took part on a VATS training course led and demonstrated by Tomaz Stupnik. We also participated at some live surgical courses organised by the Thoracic Surgery Department of the National Oncological Institute, Budapest, Hungary. One of my colleagues took part on a VATS course in Zaragoza, Spain. Despite being unofficial, checking YouTube videos was also a very useful way of improving our VATS skills.

Our first successful VATS lobectomy was performed in January 2014. Since then, we have performed 1035 thoracic surgery operations and interventions, 726 of them in general anaesthesia, and 309 chest tube in local anaesthesia (1st January 2014 – 29th February 2016). VATS operation happened in 173 cases (24%). Due to our unideal financial background we could perform only 26 three portal VATS lobectomies in this period, all of them for malignancies (24 primary lung cancer and 2 pulmonary metastasis). Some different VATS procedures were also performed, such as apical resections for pneumothorax, wedge resections, mainly for metastases, removal of mediastinal masses, cysts, and oesophageal diverticulum resection. We have also performed early decortications for thoracic empyema, pleura biopsy/pleurodesis and haematoma evacuations for chest traumas.

The conversion rate in case of VATS lobectomies was 7.7% (2/26). We had intraoperative complication in one case only: a bronchial dissection was failed due to wrong way dissection. After a new dissection the bronchial stump closure was repeated and completed successfully. Two superficial port suppuration occurred all of them at the camera-port, where the chest tube was introduced. Prolonged chest tube removal occurred in two cases for minor air leak. The reasons were unknown as the intraoperative air bubble tests were negative in both cases.

The advantages of VATS procedures are well-known and not questionable. By having the financial background for VATS in the future, hopefully we can increase the rate of VATS lobectomies to an ideal level.

Imre Tóth, Péter Mezei, János Hanyik, Balázs Vincze, Sándor Almássy
Borsod-Abaúj-Zemplén County Hospital, Surgical Institute, Department of Thoracic Surgery, Miskolc, Hungary

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