New frontiers in VATS lobectomy learning: the experience of the thoracic surgery residency program in Milan

Background: Video-assisted thoracoscopic technique (VATS) is being increasingly adopted for the treatment of thoracic diseases, and it is therefore replacing traditional approaches. Young thoracic surgeons are now required to perform VATS anatomical resections, but a solid experience in open surgery is considered essential to face VATS lobectomy. On the other hand, open lobectomy is mostly reserved for complex cases. The aim of this study was to assess the impact of the trainees’ practice on the outcome of VATS major pulmonary resections in a teaching hospital setting. Methods: We retrospectively analysed surgical activity in our University Hospital from January 2011 to August 2019. Inclusion criteria were: lobectomy and anatomical segmentectomy. Exclusion criteria were: bilobectomy, pneumonectomy and anatomical resection with arterial or bronchial plastic and wall resection. We divided the patients in two groups: Group T includes patients operated by a trainee, Group S includes patients operated by a senior surgeon. We collected all demographical and pre-operative data, surgical, postoperative and histological data. We considered 30 and 90 days mortality and overall survival. Continuous variables are expressed as mean values and standard deviation, categorical variables are expressed with absolute and percentage frequencies. Two-sided Chi-square tests or T-tests for unpaired data were performed as appropriate. A p-value <0.05 was considered statistically significant. Results: A total of 857 procedures were performed over the study period. Excluding bilobectomies, pneumonectomies and anatomical resections with arterial or bronchial sleeve or wall resections, we selected 742 interventions: 688 lobectomies (92.7%) and 54 anatomic segmentectomies (7.3%). Residents carried out 58 operations: 43 anatomical resections (74.1%) were performed adopting VATS approach (Group T). Senior surgeons performed 684 operations: 452 anatomical resections (58.7%) in VATS (Group S). There were no statistically significant differences between the two groups in terms of demographic, clinical or pathological factors, operative data, post-operative complications and mortality. Overall survival at 5 years was 74.3% in Group T and 72.2% in Group S. Conclusions: This study shows that trainees, even with partial experience in open lobectomy, can safely perform VATS major pulmonary resections. In our series, trainee practice did not affect surgical time, conversion rate, post-operative outcomes, oncological radicality and mortality. We think that University Hospitals could safely include VATS lobectomy in the training program.