Video-Assisted Thoracoscopic Surgery Lobectomy Performed Satisfaction and Complications of Patients During Hands-On Training Courses

Abstract

Aim:

It was aimed to concern about the satisfaction and procedural complications of patients during the thoracoscopy exist of hands-on training in this present study.

Patients and Methods:

The patients with non-small-cell carcinoma underwent video-assisted thoracoscopic surgery (VATS) lobectomy during hands-on training courses at thoracoscopic center in our hospital and collected from January 2009 and December 2014. The rates of satisfaction and complications of patients were compared from hands-on training group and control group. Potential risk factors associated with post-VATS complications of patients and thoracoscopist-related variables were analyzed. There were 54 patients join in six meetings with hands-on thoracoscopy training in our center.

Results:

There was no significant difference between patients for hands-on training group (n = 54) and control group (n = 54), including sex, age, BMI, smoking, PpoFEV1 and comorbidities. The satisfaction rate and the incidence of complication were similar between the two groups.

Conclusion:

Univariate analyses showed that elder age, heart disease, chronic obstructive pulmonary disease, long operative time, and first-time mentorship were significantly associated with post-VATS complications of patients in hands-on training group. We should pay more attention to the characteristics of patent and the experience of mentor before VATS hands-on training courses.

Introduction

Video-assisted thoracoscopic surgery (VATS) lobectomy was performed in 1992¹ for the first time. And the result of existence now is similar to the process of opening up. Meanwhile, it has been reported that the superiority of VATS to open lobectomy with less postoperative pain, fewer operative complications, shortened the hospitalization time and eased the financial burden. At present, the number of VATS lobectomy is on the rise in clinical. However, it is still rare to use minimally invasive technique in operations.^2–8

Hands-on practice workshops are beneficial to the continuing medical education of thoracic surgeon,^9–14 which provide trainees a chance to enhance their thoracoscopic skills, such as VATS and other advanced skills. Due to lacking of local professional knowledge and training chances, hands-on training courses become popular in developing countries. However, patients' satisfaction and complications after these teaching exercises had never been investigated. As trainees may be under special supervision during 1–2 days hands-on teaching course, unfamiliarity trainees, unfamiliarity between trainers and trainees, and longer operative duration, these factors may increase the patients' postoperative complications and uncomfortable risks.

In last few years, a number of thoracoscopy conferences and continuing medical education program with practical (hands on) training were conducted by our hospital. Invite domestic and foreign tutors to cooperate with local organizers conduct hands-on training and teaching. Although the practical training of invited mentors provided Chinese trainees an opportunity to learn the select thoracoscopy skill, patients' satisfaction and safety also should be considered. In this retrospective study, the target was to assess the satisfaction and complications of patients by VATS lobectomy performed during hands-on training courses.

Patients and Methods

Patients

In this unit, VATS lobectomy has become the gold standard for the treatment of early-stage non-small-cell carcinoma (NSCLC) and has become a benign process. The patients with NSCLC underwent VATS lobectomy during hands-on training courses at thoracoscopic center in our hospital and collected from January 2009 and December 2014. Internship training courses allow trainee thoracic surgeons to conduct traditional fellowship training studies directly under the supervision of a tutor (national or foreign). Other trainees can get the programs in the meeting room. Meeting procedures and treatment protocols were reviewed and approved by Ethics Committees in local agencies; internship training and patient demonstration before admission. Get written informed consent from each patient before VATS hands-on training and live demonstrations.

Patients in the control group were selected to have VATS lobectomy for patients with NSCLC, who were referred to the same chest center within 1 month before or after the hands-on training, with similar clinical indications, age, and sex. Thoracic surgeons were with similar experience as the mentors who performed VATS in hands-on training courses, in control group. The characteristics of patients were reviewed and recorded, including sex, age, BMI, smoking, PpoFEV1, comorbidities, perioperative data, and complications. The information was also recorded of physicians and trainees who performed VATS procedures during hands-on training courses.

To guarantee the safety of patients, all trainees had more than 5 years' experience of open lobectomy for lung cancer and were familiar with the anatomy of chest. Besides, they at least did 10 cases of VATS lobectomy in their own hospital. Before VATS lobectomy in patients, the physician and trainee would have a conversation with them and tell them the risk involved in the surgery. And the patients would sign an informed consent before surgery.

Surgical procedure

Patients are placed in the lateral decubitus position under general anesthesia and selected one-lung ventilation. Three incisions were performed by thoracoscopic surgery. Observation port was located in the middle of the axillary line the seventh or eighth intercostal space, Anterior chest wall main port was located in the axillary line the fourth or fifth intercostal space, which is about 3–4 cm in the length. No rib was shrunk. Other auxiliary operation was located in the eighth or nineth intercostal space of the scapular.

The sequence of thoracoscopic lobectomy was similar to conventional lobectomy for thoracotomy. Systemic lymph node dissection was performed after lobectomy.¹⁵ If a large tumor was difficult to remove, it would be appropriate to adjust the closing angle of the lung tissue, and the sachets were lubricated by extensible skin to ease them, The tumor was sliced into several pieces and put into the specimen bag for removal if necessary. For patients undergoing thoracotomy, pass through the fourth or fifth intercostal 10–15 cm posterolateral skin incision. Ribs were backed with the rib spreader. In the case of visual visualization, lobectomy and lymph node dissection are performed.

Evaluation of complications and satisfactions

Complications were defined as any deviation from the normal course of the disease. The concept of perioperative death was understood as death during the same hospitalization as surgery or within 30 days after surgery. Thoracic Morbidity and Mortality system is the basis of grading for all the complications (Table 1).^16–18 Incidence of individuals complications were assessed according to the most serious complications for each patient. Grade I and II complications were defined as mild complications. Grade III and IV were defined as the major complications, and grade V was mortality.

Table 1.

Grading of Complication Following the Thoracic Morbidity and Mortality Classification System

Grading	Definition/treatment performed
Minor complications
Grade I	Adverse event that alters the standard postoperative course without requiring a specific treatment
Grade II	Pharmacologic treatment or minor intervention required
Major complications
Grade IIIa	Surgical, radiologic, endoscopic treatment, or multitherapy required without general anesthesia
Grade IIIb	Surgical, radiologic, endoscopic treatment, or multitherapy required with general anesthesia
Grade IVa	Intensive care unit treatment for single organ dysfunction required
Grade IVb	Intensive care unit treatment for multiple organ dysfunction required
Mortality
Grade V	Adverse event that leads to death

In addition, all patients will complete a questionnaire to evaluate the surgery performed on their body before they leave our hospital. The satisfaction scores on VATS lobectomy were based on a scale of 1–10, in which 1–3 represents not satisfied, 4–7 represents partially satisfied, and 8–10 represents completely satisfied.

Statistical analysis

Data were described as the means ± standard deviation and analyzed statistically with SPSS version 18.0. Quantitative data were analyzed by the t-test if data were normally distributed. If data were not normally distributed, the data were analyzed by the Wilcoxon rank sum test. Classification data were expressed as frequency (percentage) and analyzed by the c2 test, with Yates correcting for continuity as appropriate. P value (the probabilities) less than 0.05 were considered statistically significant. Important predictors (risk factors) identified in the univariate analysis were included in the progressive multiple logistic regression model to identify independent risk factors of post-VATS complications. Goodness-of-fit of the final multivariate model was evaluated using 2-logarithmic likelihood criteria. Subsequent multivariate logistic regression analysis was considered as the major decisive result as it determined those variables that were independently associated with complications, after adjusting for the contribution of other variables.

Results

Patients, mentors, and meetings

From January 2009 to December 2014, there were six conferences on VATS lobectomy hands-on training held in our center. Fifty-four NSCLC patients were recruited in the hands-on training group for VATS lobectomy. Accordingly, 54 NSCLC patients in control group were selected from our hospital. A total of 12 domestic and 6 foreign mentors participated in internship training.

Characteristics of patients

Compared to the control group, there was no significant difference of patients' characteristics in the hands-on training group, including sex, age, BMI, smoking, PpoFEV1, and comorbidities (Table 2). All patients underwent VATS lobectomy for NSCLC.

Table 2.

Characteristics of Patients Undergoing Video-Assisted Thoracoscopic Surgery Lobectomy

Variable	Hands-on training (n = 54)	Control group (n = 54)	P
Age, years (mean)	60.4 ± 19.5	62.0 ± 17.3
Male/female	33/21	37/17	.420
BMI	21.5 ± 3.3	22.1 ± 4.6
Smoking (packs per year) n (%)			.542
≥20	26 (48.1)	21 (38.9)
<20	10 (18.5)	14 (25.9)
Nonsmoker	18 (33.3)	19 (18.5)
PpoFEV1 < 40%	4 (7.4)	5 (35.2)	.728
Hypertension	10 (18.5)	14 (25.9)	.355
Heart disease	12 (22.2)	15 (27.8)	.505
Diabetes	6 (11.1)	8 (14.8)	.567
Chronic obstructive pulmonary disease	5 (9.3)	8 (14.8)	.375

Perioperative data

Both two groups performed successfully of surgical procedures. Compared to the control group, there was no significant difference in size of tumor, type of pathology, location of lesions, and pathological cancer stage in the hands-on training group. Compared to the control group, the average operation time and blood loss were significantly high in the hands-on training group (Table 3).

Table 3.

Perioperative Data

Variables	Hands-on training (n = 54)	Control group (n = 54)	P
Maximum dimension of the tumor (cm)	4.12 ± 2.21	4.51 ± 2.38	.501
Pathology, n (%)
Adenocarcinoma	29 (53.7)	32 (59.3)
Squamous cell carcinoma	24 (44.4)	20 (37.0)	.656
Other	1 (1.9)	2 (3.7)
Location of lesions, n (%)
Right upper lobe	9 (16.7)	16 (29.6)	.567
Right middle lobe	3 (5.6)	2 (3.7)
Right lower lobe	16 (29.6)	13 (24.1)
Left upper lobe	15 (27.8)	15 (27.8)
Left lower lobe	11 (20.4)	8 (14.8)
Operative duration (minutes)	232.2 ± 52.9	184.6 ± 58.9	<.001
Intraoperative blood loss (mL)	315.6 ± 152.8	228.6 ± 161.2	<.001
Duration of drainage (days)	8.2 ± 3.5	7.5 ± 4.3
Length of stay (days)	12.5 ± 5.3	11.6 ± 4.2
Pathological cancer stage, n (%)
Stage I	10 (18.5)	17 (31.5)	.415
Stage II	22 (40.7)	20 (37.0)
Stage III	18 (33.3)	15 (27.8)
Stage IV	4 (7.4)	2 (3.7)

Post-VATS complications and risk factors

In the hands-on training group, post-VATS complications occurred in 9 patients (16.7%), including minor complications (n = 2), major complications (n = 6), and death (n = 1). In the control group, 6 patients (11.1%) developed complications, including minor complications (n = 1), major complications (n = 4), and death (n = 1) (Table 4). The rate of overall complications was higher in the hands-on training group. However, there was no significant difference between two groups (P = .404).

Table 4.

Postoperative Complications of Patients Undergoing Video-Assisted Thoracoscopic Surgery Lobectomy

Grade of complication	Hands-on training (n = 54)	Control group (n = 54)	P
Any complication	9 (16.7)	6 (11.1)	.404
Minor	2 (3.7)	1 (1.9)	.558
Grade I	1 (1.9)	0 (0.0)
Grade II	1 (1.9)	1 (1.9)
Major	6 (11.1)	4 (7.4)	.507
Grade IIIa	2 (3.7)	2 (3.7)
Grade IIIb	1 (1.9)	1 (1.9)
Grade IVa	3 (5.6)	1 (1.9)
Grade IVb	0 (0.0)	0 (0.0)
Mortality	1 (1.9)	1 (1.9)	1.000
Grade V	1 (1.9)	1 (1.9)

According to age, gender, pack year of smoking, BMI, FEV1%, heart disease, diabetes, chronic obstructive pulmonary disease, tumor size, TNM stage operative time, first-time mentorship, foreign mentor, mentor and trainees' cumulative experience, univariate analysis was used for multivariate logistic regression analysis (P < .1). Multivariate logistic regression analysis showed that elder age ≥70 years (odds ratio [OR] = 2.712, 95% confidence interval [CI]: 1.814–4.102, P < .001), heart disease (OR = 1.866, 95% CI: 1.255–2.311, P = .003), chronic obstructive pulmonary disease (OR = 2.712, 95% CI: 0.912–4.211, P = .012), long operative time over 240 minutes (OR = 2.358, 95% CI: 1.416–4.023, P < .001), and first-time mentorship (OR = 1.974, 95% CI: 1.259–3.081, P = .011) were independent risk factors for post-VATS complications in hands-on training group. The results were shown in Table 5.

Table 5.

Definition and Univariate Analyses of Risk Factors for Postvideo-Assisted Thoracoscopic Surgery Complications During Hands-On Training Courses

	Univariate		Multivariate
Variable	N (%)	P	OR (95% CI)	P
Patient related
Female sex	21 (38.9)	.21
Age >70 years	10 (18.5)	<.001	2.712 (1.814–4.102)	<.001
Smoking (packs per year)		.015	1.245 (0.712–1.206)	.369
≥20	26 (48.1)
<20	10 (18.5)
Nonsmoker	18 (33.3)
BMI (kg/m²)		.054	1.357 (0.835–2.143)	.125
>28	3 (5.6)
18–28	38 (70.4)
<18	13 (24.1)
PpoFEV1 < 40%	4 (7.4)	.002	1.856 (0.823–3.685)	.159
Hypertension	10 (18.5)	.112	1.562 (0.625–1.922)	.233
Heart disease	12 (22.2)	<.001	1.866 (1.255–2.311)	.003
Diabetes	6 (11.1)	.061	2.712 (0.912–4.211)	.122
Chronic obstructive pulmonary disease	5 (9.3)	.001	2.352 (1.814–4.102)	.012
Location of tumor		.356	1.088 (0.762–2.102)	.561
Right upper lobe	9 (16.7)
Right middle lobe	3 (5.6)
Right lower lobe	16 (29.6)
Left upper lobe	15 (27.8)
Left lower lobe	11 (20.4)
Tumor size ≥5 cm	17 (31.5)	.038	1.359 (0.850–2.265)	.314
Histology		.005	1.411 (0.699–3.102)	.211
Adenocarcinoma	29 (53.7)
Squamous carcinoma	24 (44.4)
Others	1 (1.9)
Pathological cancer stage		<.001	1.714 (0.866–3.247)	.123
Stage I	10 (18.5)
Stage II	22 (40.7)
Stage III	18 (33.3)
Stage IV	4 (7.4)
Operative time ≥240 (minutes)	26 (48.1)	<.001	2.358 (1.416–4.023)	<.001
Blood loss ≥400 (mL)	21 (38.9)	.126	0.968 (0.577–1.929)
Mentor related
Mentor from other centers	26 (48.1)	.254	1.211 (0.714–2.902)	.563
Foreign mentors	18 (33.3)	.021	1.433 (0.678–3.123)	.456
First-time mentorship	8 (14.8)	.003	1.974 (1.259–3.081)	.038
Cumulative experience <500 cases (VATS)	15 (27.8)	.001	0.942 (0.761–1.394)	.325
Trainee related
Cumulative experience <50 cases (VATS)	34 (63.0)	.071	1.525 (0.818–2.841)	.389
Surgery experience^a <10 years	19 (35.2)	.018	1.336 (0.756–3.011)	.174

Surgery experience means the experience of open lobectomy for lung cancer.

CI, confidence interval; OR, odds ratio; VATS, video-assisted thoracoscopic surgery.

Surgery experience means the experience of open lobectomy for lung cancer.

Meanwhile, we only found long operative time over 240 minutes (OR = 2.469, 95% CI: 1.326–4.126, P < .001) was associated with post-VATS complications in control group. The results were shown in Table 6.

Table 6.

Definition and Univariate Analyses of Risk Factors for Post-Video-Assisted Thoracoscopic Surgery Complications in Control Group

	Univariate		Multivariate
Variable	N (%)	P	OR (95% CI)	P
Patient related
Female sex	37 (68.5)	.215	1.258 (0.714–3.102)	.232
Age >70 years	12 (22.2)	.132	1.458 (0.821–2.012)	.196
Smoking (packs per year)		.254	1.385 (0.625–1.953)	.345
≥20	21 (38.9)
<20	14 (25.9)
Non-smoker	19 (18.5)
BMI (kg/m²)		.063	1.421 (0.735–2.223)	.145
>28	1 (3.6)
18–28	33 (61.1)
<18	20 (37.0)
PpoFEV1 < 40%	5 (35.2)	.015	1.931 (0.821–3.243)	.167
Hypertension	14 (25.9)	.213	1.654 (0.613–1.833)	.236
Heart disease	15 (27.8)	.121	1.745 (0.945–2.451)	.111
Diabetes	8 (14.8)	.054	1.121 (0.912–2.128)	.215
Chronic obstructive pulmonary disease	8 (14.8)	.002	1.623 (0.759–3.102)	.096
Location of tumor		.432	1.136 (0.786–2.135)	.485
Right upper lobe	16 (29.6)
Right middle lobe	2 (3.7)
Right lower lobe	13 (24.1)
Left upper lobe	15 (27.8)
Left lower lobe	8 (14.8)
Tumor size ≥5 cm	19 (35.2)	.046	1.432 (0.849–2.362)	.352
Histology		.007	1.356 (0.686–3.036)	.215
Adenocarcinoma	32 (59.3)
Squamous carcinoma	20 (37.0)
Others	2 (3.7)
Pathological cancer stage		.001	1.658 (0.817–3.142)	.136
Stage I	17 (31.5)
Stage II	20 (37.0)
Stage III	15 (27.8)
Stage IV	2 (3.7)
Operative time ≥240 (minutes)	16 (29.6)	<.001	2.469 (1.326–4.126)	<.001
Blood loss ≥400 (mL)	14 (25.9)	.135	0.972 (0.568–1.846)	.189

CI, confidence interval; OR, odds ratio.

Patients' satisfaction

There were 30 patients (55.6%) who were completely satisfied with the VATS lobectomy and 14 patients (25.9%) who were partially satisfied with the VATS lobectomy in hands-on training group. In controls, the number of patients who were completely satisfied with the VATS lobectomy and who were partially satisfied with the VATS lobectomy were 41 (75.9%) and 10 (18.5%), respectively (Fig. 1). No significant difference of satisfaction rate was observed in these two groups.

FIG. 1.

A survey of the satisfaction of patients who have undergone VATS in hands-on training group and control group. VATS, video-assisted thoracoscopic surgery.

Discussion

Our current retrospective study showed similar rates of satisfaction and overall complication rates during the VATS lobectomy procedure compared with the control group and identified a number of risk factors. As far as we know, this is the first practical training courses report on the clinical outcomes of VATS.

VATS has proven to be a minimally invasive alternative for major lung resection and has many benefits.^19–25 VATS lobectomy is considered to be a technically complicated procedure. The difficulty of getting such technical training may be one of the reasons VATS lobectomy is not widely used.^26–30 Major educational methods of VATS include live demonstration and hands-on training in China. Information about physicians and trainees who performed VATS procedures during hands-on training courses was also recorded. The hands-on training is conducted in small workshops and observes, supervises, and instructs trainees on how to implement one-on-one procedures. In addition, it plays video of the internship program in meeting rooms, where other trainees can watch. Tutors and listeners were all involved in discussing procedural details, VATS tips, and VATS related issues.

Internship training is a common form of training for trainees, but many factors often affect the overall performance of individuals. These include the health status, teaching experience of trainers, trainees operating experience, supervisors and trainees familiar with the working environment, trainees and mentors cooperation and understanding, and other factors of patients. Generally, the mentor would provide the trainees with the greatest opportunity to execute and complete the procedure. When the trainee encounters difficulties, the mentor would take over the thoracoscopy and operation. At the same time, mentor also would answer the questions trainees asked. This process may affect the speed of the procedure and had some bad effects on the patients. All of these factors may contribute to the clinical outcomes of VATS through hands-on training courses.

The hands-on training courses also encountered some vital ethical issues. First, the exposure to the visiting faculty may have many physical and mental benefits to patients. Second, if the procedure performed by the mentor and trainee failed, it's very easy to cause medical tangle in our country. Therefore, knowing the risk factors of VATS in hands-on training courses could help us to avoid some inappropriate clinical outcomes.

We should do some more preparations before the procedure of our study, because the hands-on training of VATS lobectomy is not safe and ethical in every case. First, choosing relatively healthy patients in the training course is very important. In our study, we found that patients with elder age and comorbidities like heart disease and chronic obstructive pulmonary disease had more complications. Second, the mentor should control the speed of the surgery to avoid some bad effects like more blood loss to the patients, because operative time was also a risk factor for post-VATS complication in the hands-on training group. Last, an experienced mentor is the center of the training course that will control the overall situation. In our study, we found that first-time mentorship was also a risk factor for post-VATS complications in the hands-on training group. In addition, only 2 foreign mentors were invited to supervise VATS hands-on training courses in this study, and all of them were world-renowned thoracic surgeons. Compared with those supervised by domestic mentors, the incidence of complication was much lower when the VATS lobectomy was supervised by them.

Patients should be included in the criteria for successful surgery, and subjective evaluation of patients should be included in the success of one of the important factors of surgery. Considering the different educational background, we adopted the simplest 1-to-10 scale to evaluate patients' satisfaction about the procedure performed on their bodies. The results showed that most of the patients were satisfied with the VATS lobectomy both in hands-on training group and control group.

There were some limitations in this study. There were only six conferences with 54 patients included which was a small sample size. Besides, there was only one center included. Therefore, due to the limited number of centers and meetings, risk factors should be carefully interpreted. Therefore, it is need to study more centers and larger sample sizes to identify potential risk factors for the clinical outcomes of VATS lobectomy training.

In conclusion, satisfaction and overall complication were similar in the internship and control groups. Age, heart disease, chronic pulmonary disease, long operative time, and first-time mentorship may be related to post-VATS lobectomy complications.

Ethics Approval and Consent to Participate

Meeting procedures and treatment programs are reviewed and approved by the Ethics Committee of a local institution before training and demonstration can be conducted. All work was carried out in accordance with the Declaration of Helsinki (1964).

Footnotes

Disclosure Statement

No competing financial interests exist.

References

Davies

, Panasuk

. Video-assisted thoracic surgery: Our first 20 cases. Del Med J, 1992; 64:267–272.

Walker

, Pugh

, Craig

, Carnochan

. Continued experience with thoracoscopic major pulmonary resection. Int Surg, 1996; 81:255–258.

Swanson

, Meyers

, Gunnarsson

, et al. Video-assisted thoracoscopic lobectomy is less costly and morbid than open lobectomy: A retrospective multiinstitutional database analysis. Ann Thorac Surg, 2012; 93:1027–1032.

Whitson

, Andrade

, Boettcher

, et al. Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer. Ann Thorac Surg, 2007; 83:1965–1970.

Handy

Jr , Asaph

, Douville

, Ott

, Grunkemeier

, Wu

. Does video-assisted thoracoscopic lobectomy for lung cancer provide improved functional outcomes compared with open lobectomy?. Eur J Cardiothorac Surg, 2010; 37:451–455.

Nicastri

, Wisnivesky

, Litle

, et al. Thoracoscopic lobectomy: Report on safety, discharge independence, pain, and chemotherapy tolerance. J Thorac Cardiovasc Surg, 2008; 135:642–647.

Rueth

, Andrade

. Is VATS lobectomy better: Perioperatively, biologically and oncologically?. Ann Thorac Surg, 2010; 89:S2107–S2111.

Lau

, Martin-Ucar

, Nakas

, Waller

. Lung cancer surgery in the breathless patient—The benefits of avoiding the gold standard. Eur J Cardiothorac Surg, 2010; 38:6–13.

Sánchez-Margallo

, Díaz-Güemes

, Pérez

, Sánchez

, Loscertales

, Usón

. Preliminary results with a training program for thoracoscopic atrial fibrillation therapy. Surg Endosc, 2009; 23:1882–1886.

10.

Connors

, Doty

, Bull

, May

, Fullerton

, Robbins

. Effect of work-hour restriction on operative experience in cardiothoracic surgical residency training. J Thorac Cardiovasc Surg, 2009; 137:710–713.

11.

Petersen

, Hansen

. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg, 2010; 37:516–520.

12.

Fann

, Feins

, Hicks

Jr , et al. Evaluation of simulation training in cardiothoracic surgery: The Senior Tour perspective. J Thorac Cardiovasc Surg, 2012; 143:264–272.

13.

Wan

, Thung

, Hsin

, Underwood

, Yim

. Video-assisted thoracic surgery major lung resection can be safely taught to trainees. Ann Thorac Surg, 2008; 85:416–419.

14.

Ferguson

, Walker

. Developing a VATS lobectomy programme—Can VATS lobectomy be taught. Eur J Cardiothorac Surg, 2006; 29:806–809.

15.

, Li

, Yang

, et al. Completely video-assisted thoracoscopic lobectomy versus open lobectomy for non-small cell lung cancer greater than 5 cm: A retrospective study. Chin Med J (Engl), 2012; 125:434–439.

16.

Dindo

, Demartines

, Clavien

. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg, 2004; 240:205–213.

17.

Salati

, Refai

, Pompili

, Xiumè

, Sabbatini

, Brunelli

. Major morbidity after lung resection: A comparison between the European Society of Thoracic Surgeons Database system and the Thoracic Morbidity and Mortality system. J Thorac Dis, 2013; 5:217–222.

18.

Ivanovic

, Seely

, Anstee

, et al. Measuring surgical quality: Comparison of postoperative adverse events with the american college of surgeons NSQIP and the Thoracic Morbidity and Mortality classification system. J Am Coll Surg, 2014; 218:1024–1031.

19.

Kirby

, Mack

, Landreneau

, Rice

. Lobectomy—Video-assisted thoracic surgery versus muscle-sparing thoracotomy. A randomized trial. J Thorac Cardiovasc Surg, 1995; 109:997–1002.

20.

Ohbuchi

, Morikawa

, Takeuchi

, Kato

. Lobectomy: Video-assisted thoracic surgery versus posterolateral thoracotomy. Jpn J Thorac Cardiovasc Surg, 1998; 46:519–522.

21.

Luketich

, Meehan

, Landreneau

, et al. Videothoracoscopic lobectomy versus open thoracotomy for early-stage non-small-cell lung cancer. Clin Lung Cancer, 2000; 2:56–60.

22.

Sugi

, Kaneda

, Esato

. Video-assisted thoracoscopic lobectomy achieves a satisfactory long-term prognosis in patients with clinical stage IA lung cancer. World J Surg, 2000; 24:27–31.

23.

Nomori

, Horio

, Naruke

, Suemasu

. What is the advantage of a thoracoscopic lobectomy over a limited thoracotomy procedure for lung cancer surgery?. Ann Thorac Surg, 2001; 72:879–884.

24.

Koizumi

, Haraguchi

, Hirata

, et al. Video-assisted lobectomy in elderly lung cancer patients. Jpn J Thorac Cardiovasc Surg, 2002; 50:15–22.

25.

Tatsumi

, Ueda

. Video-assisted thoracic surgery for lung cancer: Is it a feasible operation for stage I lung cancer?. Jpn J Thorac Cardiovasc Surg, 2003; 51:646–650.

26.

Park

, Kim

, Choi

, Chang

, Han

. Video-assisted thoracic surgery (VATS) lobectomy for pathologic stage I non-small cell lung cancer: A comparative study with thoracotomy lobectomy. Korean J Thorac Cardiovasc Surg, 2011; 44:32–38.

27.

Yang

, Wang

, Qu

. Video-assisted thoracic surgery (VATS) compares favorably with thoracotomy for the treatment of lung cancer: A five-year outcome comparison. World J Surg, 2009; 33:1857–1861.

28.

Flores

, Park

, Dycoco

, et al. Lobectomy by video-assisted thoracic surgery (VATS) versus thoracotomy for lung cancer. J Thorac Cardiovasc Surg, 2009; 138:11–18.

29.

Watanabe

, Koyanagi

, Nakashima

, Higami

. How to clamp the main pulmonary artery during video-assisted thoracoscopic surgery lobectomy. Eur J Cardiothorac Surg, 2007; 31:129–131.

30.

Demmy

, Curtis

. Minimally invasive lobectomy directed toward frail and high-risk patients: A case-control study. Ann Thorac Surg, 1999; 68:194–200.