Evaluation of YouTube Videos in Video-Assisted Thoracoscopic Pulmonary Lobectomy Education

Abstract

Background:

YouTube^® (YouTube, San Bruno, CA) is the most popular, public domain, free access video source. The educational value of the videos is difficult to determine. This study aimed to determine the evaluation of video-assisted thoracoscopic surgery (VATS) lobectomy videos as an educational source on the YouTube platform.

Materials and Methods:

VATS lobectomy, as a keyword, was searched on YouTube and sorted by the number of visualizations. The top 25 most viewed VATS lobectomy videos uploaded to YouTube were analyzed. The videos were evaluated for critical view of safety (CVS) and LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS).

Results:

There were ∼1670 videos for the search term “VATS lobectomy.” There were 16 primary surgeons from 8 different countries. Most of the videos (n = 19) were affiliated to an academic institution. There was a positive significant correlation between author's h-index and number of likes. Videos showed conformity to CVS assessment with a rate of 56.5%. LAP-VEGaS conformity to educational content (e.g., audio or written commentary) and case presentation was very low.

Conclusions:

Using videos of VATS lobectomy in training may have great potential to improve surgical opinion. YouTube is user driven and these videos are not peer reviewed. This article showed issues concerning safety violations. We believe that professional societies should focus on promoting and disseminating valuable educational videos.

Introduction

Lung cancer still leads, at first place, in cancer-related deaths.¹ Curative anatomic resection is the standard treatment approach in operable lung cancer.² Anatomic lung resections, which started with pneumonectomy ∼100 years ago, have been replaced by lobectomy and segmentectomy over time and also thoracotomies were replaced by video thoracoscopic surgical approaches. With the acceptance of minimally invasive techniques in the surgical field, the number of video-assisted thoracoscopic surgery (VATS) pulmonary lobectomies has also increased and it has been the preferred method especially in early-stage cases.³

Along with technological advances, classical education methods are also changing. Nowadays, online magazines, e-books, various mobile applications, simulations, and online videos are starting to be useful for educational purposes.⁴ Use of technological tools such as the VATS lobectomy assessment tool (VATSAT)⁵ is also an example and it has demonstrated how VATS lobectomy practice evaluation should be conducted.

YouTube^® (YouTube, San Bruno, CA) is a popular video-sharing website that enables watching online videos since 2005. Current trainee and medical faculty students are the first generation to use the Internet for educational purposes.⁶ Although there are many surgical video-sharing websites, YouTube access is much more common among trainees and assistants.⁷ In addition, the interest of the publishers to YouTube has increased as it has several advantages such as easy accessibility, sharing of videos on social media, and allowing comment, like, and dislike options.⁸ Unfortunately, the popularity of YouTube videos is not based on the quality and educational value of the video, but based on the view rate, number of comments, and likes.

The international multispecialty joint trainers and trainees expert committee prepared the LAP-VEGaS (LAParoscopic surgery Video Educational GuidelineS) consensus statement to evaluate the educational value of laparoscopic surgery videos⁹ (Table 1). It clearly stated how to publish surgical training videos using 37 items. The evolution of VATS lobectomy correlates with laparoscopic cholecystectomy.¹⁰ In our study, we aimed to evaluate the educational value of the 25 most watched VATS lobectomy videos on the YouTube platform.

Table 1.

International Multispecialty Joint Trainers and Trainees Expert Committee Laparoscopic Surgery Video Educational Guidelines Consensus Report

Author's information and video introduction

1. The video must include authors' information such as names, institution(s), country, and year of surgery. Contact details of the corresponding author must be provided.

2. It should be specified if the video was presented at national/international meetings or recorded during a live broadcast.

3. The title of the video must include the name of the procedure performed and of the pathology treated.

4. If the video is intended for training, this should be specified and specific learning objectives could be presented. The aim of the video and relevance of the case presented should be stated.

5. In case the procedure is performed by a surgical trainee, it should be mentioned how many previous cases the trainee has performed to contextualize the video.

6. Patient consent should be obtained.

7. A conflicts of interest disclosure must be present.

Case presentation

8. All radiology pictures, videos, and reports should be anonymized and the name of the patient should never be mentioned. All patient recognizable body parts such as eyes and tattoos should be obscured.

9. The video should include one or more slides or audio commentary with formal presentation of the case, including age, sex, American Society of Anesthesiologists (ASA) score, body–mass index, indication for surgery, comorbidities, and history of previous surgery.

10. Results of preoperative imaging should be presented.

11. Preoperative treatments, workup for surgery, and blood test results should also be briefly presented if relevant for the case.

Demonstration of the surgical procedure

12. The position of the patient on the operating table must be clearly demonstrated, including variations during the surgery.

13. The position of the surgical and anesthetic team should be demonstrated, including scrub nurse position and position of extra assistants.

14. The position of trocars must be detailed. It should be mentioned where additional trocars can be inserted in case of unexpected findings or technical difficulties.

15. The site for specimen extraction should be demonstrated.

16. Details of special equipment needed for the procedure should be provided, such as vessel sealer devices, wound protectors, manipulators, and surgical staplers.

17. The surgical procedure should be presented in a standardized step-by-step manner.

18. Every chapter should be clearly introduced and explained. The intraoperative findings need to be demonstrated, with constant reference to the anatomy.

19. Additional maneuvers and suggestions to face progression failure should be demonstrated—for instance, additional ports or assistants, change of the position of the patient, or rescue maneuvers in case of unexpected events such surgical stapler malfunction or equipment failure.

20. Relevant additional intraoperative investigations should be mentioned and demonstrated.

21. Describing the criteria for conversion to open surgery and the site of the incision in case of conversion might be useful in training videos.

22. The open part of the procedure should be mentioned or demonstrated if the video is intended for training.

Outcomes of the procedure

23. Outcomes of the procedure must be presented, including operating time, blood loss, cosmesis with a picture of the healed wounds, length of hospital stay, and postoperative morbidity.

24. Histopathology assessment of the specimen should be presented. In case of malignancy, the number of retrieved lymph nodes and TNM staging should be detailed. Pictures of the specimen are desirable.

Associated educational content

25. Additional educational content must be included. Diagrams, photos, snapshots, and tables should be used to demonstrate anatomical landmarks and relevant or unexpected findings.

26. Audio/written commentary in English must be provided.

Peer review of surgical videos

27. Educational videos must undergo formal peer review before publication. It should be stated if the video has been peer reviewed before publication.

28. Peer review should assess not only the safety of the procedure performed but also the supplementary educational content presented.

29. Peer review should be undertaken by both surgical trainers and trainees.

30. Videos should be amended and resubmitted, where possible, according to the reviewers' comments with a point-by-point answer.

31. Image quality should be assessed. When excessive smoke, low-definition, or suboptimal views are present for more than 25% of the duration of the procedure, the video should be rejected for poor image quality.

32. Video should play at 1x speed. Where video is played faster or slower, the speed should be indicated in the respective video segments (e.g., 2 × , 4 × , and 0.5 × ).

Use of surgical videos in educational curricula

33. Routine video recording of the procedure and review with feedback sessions should be mandatory in every training program.

34. Video recording can be useful to continue professional development even at the completion of the learning curve, to review unusual findings, and to reflect on complications and outcomes.

35. Videos demonstrating unusual cases and management of intraoperative complications should be shared at conferences.

36. Formative assessment of the surgical performance should involve peer review of unedited videos, using standardized assessment tools.

37. The web platform should record the number of times the video has been watched for audit purposes. Moreover, it should allow comments and webchats to facilitate feedback and interaction among trainers and trainees.

Materials and Methods

Study design

A search for “VATS lobectomy” was performed on February 12, 2020, through the website of YouTube. The top 25 videos were evaluated, as sorted by view count. Thoracoscopic lobectomy is described as the anatomic resection of an entire lobe of the lung, using a videoscope and an access incision, without the use of a mechanical retractor and without rib spreading.¹¹ Accordingly, in our study, videos of anatomic lung resection of an entire lobe without using rib spreading and recorded with thoracoscopic cameras by professional surgeons in English are included. It is to be mentioned that uniportal videothoracoscopic lobectomies are still evolving, although (since no techniques were specified in the description mentioned above) all surgical approaches (uni-, bi-, and triportal) are included in this study. Videos that were cartoon–animation, illustrations, and in languages other than English were excluded.

Data were recorded in terms of title and link, type of lobectomy, number of views, number of days online, video length, image quality, and like and dislike numbers (Table 2). The h-index is a number that represents productivity and the impact of a scientist. The surgeons performing the operations in the videos were investigated in terms of h-index through Scopus. In addition, the nationality and hospital of the authors were determined by a general Internet search.

Table 2.

Characteristics of the 25 Selected Videos on VATS Lobectomy (Ordered by Number of Visualizations on February 12, 2020)

No.	Title and link	No. of visualizations	Resected lobe	No. of days online	Length (min)	Image quality (p)	No. of comments	No. of likes	No. of dislikes	CVS conformity percentage (%)	LAP-VeGAS conformity percentage (%)
1	Lobectomia Polmonare Toracoscopica—VATS Lobectomy https://www.youtube.com/watch?v=z_PkyF20sOw	51,625	RUL	2683	8	480	13	82	9	50	21.6
2	VATS Right Upper Lobectomy \| Brigham and Women's Hospital https://www.youtube.com/watch?v=p_9habRkoII	46,831	RUL	430	16	480	0	311	18	62.5	27
3	VATS Lobectomy for Lung Cancer by Raja Flores, MD https://www.youtube.com/watch?v=mhSIqwclHh4	46,178	RUL	3139	10	480	25	154	19	62.5	29.7
4	VATS Left Upper Lobectomy Procedure \| Thoracic Surgeon LA https://www.youtube.com/watch?v=y3J0HTq0wMY	32,453	LUL	2158	19	720	8	56	11	75	21.6
5	VATS Lobectomy Right Upper Lobe—VATS Lobektomie Oberlappen re.—Lungenresektion bei Lungenkrebs https://www.youtube.com/watch?v=YP_t-uQI1Do	30,856	RUL	2883	7	720	6	31	8	87.5	8.1
6	Lung cancer Left lower lobectomy fissureless technique single-port VATS (live surgery) https://www.youtube.com/watch?v=ZBjW67SEbaI	27,136	LLL	2228	25	480	8	34	6	75	18.9
7	VATS Lobectomy Left Lower Lobe https://www.youtube.com/watch?v=-aJD0QRG9XU	24,489	LLL	3411	10	480	4	33	1	62.5	21.6
8	Uniportal VATS left upper lobectomy real speed, not edited (24 minutes) https://www.youtube.com/watch?v=Nlfz5GtGwgQ	19,987	LUL	2453	24	480	3	54	8	62.5	8.1
9	VATS LT LWR LOBECTOMY (HQ) https://www.youtube.com/watch?v=jrWCAXY2uno	18,560	LLL	3949	7	480	0	17	2	37.5	18.9
10	Uniportal VATS right upper lobectomy (Not edited, 26 minutes).Lobectomia pulmonar puerto unico https://www.youtube.com/watch?v=DNMa66thoRA	17,327	RUL	2349	26	480	6	51	7	37.5	5.4
11	Video atlas of thorascopic lobectomy—right lower lobectomy https://www.youtube.com/watch?v=aW0bYSkkWEY	15,252	RLL	1556	9	480	0	62	4	75	18.9
12	Unisurgeon Uniportal VATS right lower lobectomy (NON EDITED SURGERY) https://www.youtube.com/watch?v=Z5WHEr3wY4w	15,325	RLL	1006	33	1080	2	85	6	75	27
13	VATS Lobectomy Left Upper Lobe/VATS Lobektomie Oberlappen links—Lungenresektion bei Lungenkrebs https://www.youtube.com/watch?v=z4bUG8wNUu8	14,334	LUL	2773	14	360	0	18	1	62.5	21.6
14	VATS Upper Lobectomy https://www.youtube.com/watch?v=VntSkqagl3o	12,540	RUL	3149	7	480	7	6	3	62.5	10.8
15	VATS-Lobectomy: Upper Lobe of Right Lung https://www.youtube.com/watch?v=eJ7Aek8auRc	11,479	RUL	2549	3	720	6	24	4	37.5	18.9
16	Uniportal VATS fissureless left upper lobectomy (NON EDITED) https://www.youtube.com/watch?v=JacoYZeVQGc&t=386s	10,083	LUL	850	25	1080	1	84	5	62.5	21.6
17	VATS Lobectomy: Right Upper lobectomy using a fissureless technique https://www.youtube.com/watch?v=lCKY0SSdMNU	9256	RUL	2983	5	360	1	15	1	37.5	10.8
18	Uniportal VATS right upper lobectomy NON EDITED SURGERY https://www.youtube.com/watch?v=mkp6GrPyTd0&t=58s	8581	RUL	838	23	1080	2	63	4	37.5	16.21
19	VATS Right lower lobectomy—Lobectomia inferiore destra toracoscopica https://www.youtube.com/watch?v=RTOrt98rkd8	8160	RLL	2644	5	480	0	6	2	50	35.1
20	Uniportal VATS Right Lower Lobectomy and Lymphadenectomy: Step-by-Step https://www.youtube.com/watch?v=W8En-m6pJzI	7749	RLL	886	24	720	2	64	1	62.5	24.32
21	Left Upper Lobectomy fissureles technique (NON EDITED, LIVE SURGERY) https://www.youtube.com/watch?v=cX1MBvG4vTE	7703	LUL	1153	25	1080	0	50	0	50	29.7
22	Uniportal VATS middle lobectomy (NON EDITED SURGERY) https://www.youtube.com/watch?v=yPschS6Hw-4	7427	RML	1785	15	1080	4	41	3	37.5	27
23	VATS Lobectomy—Right Lower Lobe -3 port https://www.youtube.com/watch?v=ArfmHJSjPQU	7315	RLL	2500	11	480	1	9	2	50	27
24	Fissure based VATS Lobectomy: Right Upper Lobectomy https://www.youtube.com/watch?v=z0Ada1zhJuA	6437	RUL	2997	9	360	0	18	3	62.5	27
25	Video-assisted thoracoscopic lobectomy—left lower lobectomy https://www.youtube.com/watch?v=UnV-5XNk9o4	6191	LLL	1551	10	480	0	17	0	37.5	51.3

CVS, critical view of safety; LAP-VEGaS, LAParoscopic surgery Video Educational GuidelineS; LLL, left lower lobectomies; LUL, left upper lobectomies; RLL, right lower lobectomies; RML, right middle lobectomy; RUL, right upper lobectomies.

Current guidelines recommend the application of critical view of safety (CVS) for surgical safety. There is no current CVS consensus for VATS lobectomy. We designed the VATS lobectomy CVS evaluation stages, in accordance with the stages suggested by Li et al.,¹⁰ the process mentioned in VATSAT evaluation by Jensen et al.,⁵ and based on our clinical experiences.

Ethics committee approval was not taken as the study was an evaluation of public domain surgical videos.

Evaluation of surgical and educational quality

The videos were evaluated for their conformity to VATS lobectomy CVS and LAP-VEGaS. Eight stages were set up for CVS evaluation such as palpation of the tumor and exploration for other pathologies, visualization of all veins before transection, identification of key branches of the pulmonary artery, dissection of the bronchus, ventilation test before transection of the bronchus, retrieval of lobe in bag, air leak test after transection of the bronchus, and dissection of lymph nodes. With LAP-VEGaS, the conformity assessment of the videos was 0 for those that are not eligible and 1 for those that are eligible.

Statistical analysis

Statistical analysis was performed using SPSS 22 (version 22; Statistical Package for the Social Sciences). Kolmogorov–Smirnov and Shapiro–Wilk tests were used for assessing assumption of normality. Parametric values are reported as the mean ± standard deviation, and nonparametric values are reported as median (25–75 percentiles). Spearman correlation was used to determine possible relationships between nonparametric values. Values of P < .05 were accepted as statistically significant.

Results

Video selection process and video characteristics

A total of 1670 uploaded videos were found after the search with the keyword “VATS lobectomy.” After exclusion of cartoons, illustrations, academic information, and robotic operations, the top 25 videos, sorted by view count, were evaluated.

A primary surgeon has been detected in 24 videos (96%). There were 16 different primary surgeons from 8 different countries, especially Spain (n = 8), the United States (n = 5), Italy (n = 3), and Germany (n = 3) (Table 3). Eleven (68.75%) videos were from an academic institute, 4 (25%) videos were from a secondary hospital, and one video was from a professional cardiothoracic surgery website that allows publishing of educational videos on the web (Table 4).

Table 3.

Surgeon Characteristics

Country of origin	No. of videos
Spain	8
United States	5
Italy	3
Germany	3
United Kingdom	2
Argentina	1
Denmark	1
Egypt	1
Unknown	1
Sources of video	No. of videos
Tertiary hospital/academic institution	19
Secondary hospital	5
Unknown	1
h-Index of authors	No. (%)
0–10	8 (50)
>10	8 (50)

Table 4.

Video Features

Video features	Mean/median^*	STD/percentiles^**	Range (min–max)
No. of visualizations	18530.96	13522.60	51,625–6191
No. of days online	2196.12	938.71	430–3949
Length (minutes)	11^*	7.5–24^**	3–33
No. of comments	2^*	0–6^*	0–25
No. of likes	41^*	17.5–63.5^**	6–311
No. of dislikes	4^*	1.5–7.5^**	0–19

Parametric values are reported as the mean – standard deviation.

Nonparametric values are reported as median (25–75 percentiles).

STD, standard deviation.

According to the type of lobectomy, the rates were as follows: right upper lobectomies 40% (n = 10), left upper lobectomies 20% (n = 5), right lower lobectomies 20% (n = 5), left lower lobectomies 16% (n = 4), and the right middle lobectomy (RML) 4% (n = 1) (Table 2).

Twenty-five videos have been watched 463,274 times totally for an average period of 6.1 years. The mean number of days online for 25 videos was 2196.12 (STD = 938.71) and ranged from 430 to 3949. The mean number of visualizations was 18530.96 (STD: 13522.60, range: 51,625–6191). The median length was 11 minutes (percentiles: 7.5–24, range: 3–33). The videos received a median of 2 comments (percentiles: 0–6, range: 0–25) and the number of likes (median: 41, percentiles: 17.5–63.5, range 6–311) was higher than dislikes (median: 4, percentiles: 1.5–7.5, range: 0–19) (Table 4). A significant correlation was detected in the correlation analysis between video length and number of likes (P = .002, ρ = 0.583). No statistically significant correlation was found between other values.

h-Index

Eight (50%) of the 16 different surgeons had an h-index more than 10 (range = 0–53) (Table 3). There was a statistically significant correlation between the h-index of surgeons and number of likes (P = .013, ρ = 0.502). No statistically significant correlation was found among other values.

CVS assessment

Eight stages of CVS were evaluated individually for each of the 25 videos. Conformity was determined as an average of 4.52 (56.5%). The highest conformity was in the left upper lobectomy video, which was ranked 5th by the number of visualizations (video #5 from Table 2) (n = 7, 87.5%) (Table 3). The most applied points were identification of key branches of the pulmonary artery (n = 24, 96%) and retrieval of lobe in bag (n = 24, 96%). The less applied points were determined as palpation of the tumor and exploration for other pathologies (n = 4, 16%) and visualization of all veins before transection (n = 4, 16%) (Table 5).

Table 5.

Critical View of Safety Assessment

CVS assessment	Total over 25 videos	%
Palpation of the tumor and exploration for other pathologies	4	16
Visualization of all veins before transection	4	16
Identification of key branches of the pulmonary artery	24	96
Dissection of the bronchus	23	92
Ventilation test before transection of the bronchus	6	24
Retrieval of lobe in bag	24	96
Air leak test after transection of the bronchus	13	52
Dissection of lymph nodes	14	56

CVS, critical view of safety.

There was a statistically significant correlation between CVS conformity and the number of visualizations (P = .021, ρ = 0.459) and number of dislikes (P = .043, ρ = 0.407). There was no significant correlation between CVS and h-index (P = .96).

LAP-VEGaS conformity

Numbers of views and comments (LAP-VEGaS item 37) were available for all videos. The surgical procedure was presented step by step (LAP-VEGaS item 17) in 80% of 25 videos. The site for specimen extraction was demonstrated in 76% of all videos. The position of trocars was detailed in 72% (LAP-VEGaS item 16) of videos. However, the wide majority of LAP-VEGaS items (n = 15, 40.54%) (Table 6) were not detected in the videos. The most compatible video was no. 25 (51.3%) (Table 3). There was no statistically significant correlation between LAP-VEGaS conformity and other values.

Table 6.

Laparoscopic Surgery Video Educational Guidelines Conformity

Video no.		Total (over 25 videos)	%
Authors' information and video introduction	1	14	56.00
	2	4	16.00
	3	6	24.00
	4	3	12.00
	5	0	0.00
	6	0	0.00
	7	0	0.00
Case presentation	8	7	28.00
	9	7	28.00
	10	4	16.00
	11	2	8.00
Demonstration of the surgical procedure	12	12	48.00
	13	5	20.00
	14	18	72.00
	15	19	76.00
	16	17	68.00
	17	20	80.00
	18	14	56.00
	19	11	44.00
	20	9	36.00
	21	0	0.00
	22	0	0.00
Outcomes of the procedure	23	0	0.00
Outcomes of the procedure	24	4	16.00
Associated educational content	25	0	0.00
Associated educational content	26	0	52.00
Peer review of surgical videos	27	0	0.00
	28	0	0.00
	29	0	0.00
	30	0	0.00
	31	0	0.00
	32	0	0.00
Use of surgical videos in educational curricula	33	0	0.00
	34	0	0.00
	35	0	0.00
	36	0	0.00
	37	25	100.00

Discussion

After the first VATS lobectomies were performed in the 1990s, many articles have been published, comparing VATS lobectomy and lobectomy through thoracotomy. The advantages of VATS lobectomy have been demonstrated. It has been suggested that the current trainee training should include VATS lobectomy and robotic lobectomy.¹² The training videos are available on many platforms on the World Wide Web and they have benefits in surgical and technical guidance. It is obvious that the development of virtual reality platforms such as VATSAT⁵ will have educational benefits. It has been stated that the new-generation VATS surgeons can easily adapt to VATS lobectomies, but they have a higher risk of conversion to open procedure and higher rates of complications compared with experienced surgeons.¹³ Likewise, due to the economic and patient safety-based difficulties of operating room education, learning by watching videos is popular among new learners.¹⁴ Thus, the educational value of the published videos is very important. YouTube is a popular, free access video-sharing platform. Videos shared may be scientifically incompetent and without peer review process.

After LAP-VEGaS conformity evaluation, it was revealed that patient consent (item 6) and conflicts of interest disclosure (item 7) were not specified in the videos. In addition, additional educational content and outcomes of the procedure such as operation time, bleeding amount, length of hospital stay, and postoperative complications were not provided in most of the videos. We stated that YouTube videos do not undergo a standardized peer review process and, accordingly, their educational evaluation cannot be revealed properly. It has been detected that case presentation (items 8, 9, 10, and 11) is not mentioned in many videos. This has a high effect on surgical planning and considering postoperative complications.

The associated educational content section of LAP-VEGaS requires videos to be structured with diagrams, photos, tables, and audio/written English commentary. One of the reasons decreasing the educational value of the included videos might be the nonstructured design. In our study, 8% of the videos were structured and 52% of the videos had audio/written commentary in English. The presence of these elements leads to anatomical landmarks and unexpected findings. Structured videos have the advantage of preventing confusion of anatomical structures and allow the audience to have more clear visuality. In addition, according to LAP-VEGaS practice guidelines, structured evaluation emphasizes a learner-centered approach with specialty- and procedure-specific assessment tools of operative performance that are also applicable to video-based learning. Thus, we believe that the structured videos might help the audience to have more cooperation with the surgical procedure while watching the videos.

In CVS evaluation, it was detected that palpation of the tumor and exploration for other pathologies were performed in 16% of the videos. We believe that palpation of the tumor and exploration for other pathologies will prevent unsuitable operation in conditions such as pleuritis carcinomatosa even if preoperative radiological planning is performed. Visualization of all veins before transection is crucial in evaluating vein variations and preventing vascular injuries. In a study about how to apply VATS lobectomy training, Zwischenberger et al. stated that proper visualization of the hilar region and dissection of all veins may provide safe artery dissection, which is in the next stage.¹² In our study, it was determined that all veins were visualized in 16% of the videos. This is insufficient to reduce the unexpected situations that trainees may encounter. Identification of pulmonary arteries was claimed by Jensen et al.⁵ to be the most important part of the surgery since pulmonary arteries are the cause of intraoperative bleeding in majority of the cases. As our results showed, in 96% of the videos, pulmonary arteries were identified, which supports the idea that surgeons are aware of the importance. The ventilation test before transection of the bronchus is an important step in preventing transection of the wrong bronchus. This process was applied only in 24% of the videos in our study. Application of an air leak test after transection of the bronchus prevents unexpected bronchus fistulas. This step was applied in 52% of the videos. We believe that trainees who decided to apply a VATS lobectomy after watching these videos would be misled. Although there is no standardized lymph node dissection technique, it is very important in surgical staging of lung cancer, and a proper lymph node dissection method is mentioned to facilitate dissection of hilar structures.¹⁵ Lymph node dissection has been performed in only 56% of the videos. We believe that this may complicate the safe dissection of existing hilar structures and mislead the trainees who will perform the tumor surgery.

De'Angelis et al.¹⁶ detected that trainees found YouTube videos more educationally useful than senior surgeons. This has been attributed to their inadequate experience and low capacity in surgical technical evaluation. In the same study, a statistically positive correlation was determined between the percentage of conformity to LAP-VEGaS and number of likes and dislikes. In a recent study, there was no statistically significant correlation between the percentage of conformity to LAP-VEGaS and any other parameter. Rodriguez et al.¹⁷ emphasized that the videos presented suboptimal technique with frequent potentially dangerous safety violations in a study evaluating top 10 laparoscopic cholecystectomy videos.

Chen et al.⁶ have evaluated the most viewed pulmonary lobectomy videos on YouTube and determined a significant correlation between author's h-index and number of visualizations. In our study, we determined a significant correlation between the h-index and number of likes.

There are some limitations to this study. We analyzed VATS lobectomy videos on YouTube only. It is unknown how many members of the audience were thoracic surgery trainees or seniors. Second, the popularity of the video is associated with items such as the number of views, like–dislike, and comments; however, the author's uploading reason may not be for educational purposes, but for promotional videos for the surgeon or hospital. Third, the live surgery time for videothoracoscopic lobectomy is known to be around 2–3 hours. However, the mean time of the videos in our study is 11 minutes. Since the long procedures are edited and condensed into 10–20-minute videos, a major part of the surgery can be accepted as missing. This might be one of the reasons that the educational value of the videos appears to be low when measured with our assessment methods. We evaluated the videos according to their conformity to LAP-VEGaS and CVS and those methods of measurement should be improved.

Conclusions

Videos of VATS lobectomy may have a great potential to improve surgical opinion. There are various video-sharing websites. As the most popular resource of free public domain videos, YouTube is user driven and these videos are not peer reviewed. Adherence to the CVS and conformity to LAP-VEGaS were low and this article showed issues concerning safety violations. We believe that professional societies should focus on promoting and disseminating valuable educational videos.

Ethical Statement

The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Footnotes

Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

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