Learning curve for video-thoracoscopic pulmonary lobectomy in a low-volume center

Abstract

INTRODUCTION: In the last two decades, lobectomy by video-assisted thoracic surgery (VATS) has
emerged as an alternative to formal thoracotomy and tends to replace it. The VATS approach is associated
with superior perioperative outcomes compared to open thoracotomy. Although a minimum of procedures
is recommended to be performed to acquire competence in large centers, there is little data available on the
VATS lobectomy learning curve in low volume patients’ centers.
OBJECTIVE: To describe the learning curve to acquire competence in VATS pulmonary lobectomy in
low volume patient centers.
MATERIAL AND METHODS: Observational, retrospective and analytical study. The initial experience
of 40 VATS lobectomies was evaluated, from January 2016 to January 2020. The following variables were
evaluated: demographic, clinical, related to surgery, post-operative. The learning curve was evaluated based
on the conversion rate to open surgery and operative time. Furthermore, the patients were divided
chronologically into 2 groups, the first 20 (group A) and the next 20 patients (group B) in order to compare
differences during the learning curve. Statistical analysis: To compare categorical variables, the Chi square
test or Fisher's exact test was used for small expected frequencies. In the case of quantitative variables, the
t-test was performed, and the Mann Whitney test for non-parametric analysis, as appropriate. Differences
between variables were considered significant with a p-value <0.05.
RESULTS: The mean operating time (standard deviation - SD) was 224.5 (53.9) minutes. The conversion
rate was n = 5 (12.5%). The overall complication rate was n = 10 (20%). No mortality was recorded. The
mean (SD) duration of postoperative stay was 6.7 (5.2) days. Patients with postoperative complications
remained hospitalized for more days; 12 (8.5) days in the complicated patients, versus 4.9 (1.1) days in the
uncomplicated (p = 0.0004). No statistically significant differences were observed in operative time,
conversion rate, postoperative complications or hospital stay between Group A and Group B.
CONCLUSION: The conversion rate to open surgery, postoperative complications, and hospital stay in our
series did not differ from that reported in the literature. We present a slightly longer operative time. We did
not observe a significant difference in the variables studied between the first 20 operated patients and the
second 20. However, evaluation with a larger number of patients is necessary to assess when the learning
curve is completed in low-volume centers and the results improve.