High-volume intensive training course: a new paradigm for video-assisted thoracoscopic surgery education

High-volume intensive training course: a new paradigm for video-assisted thoracoscopic surgery... Abstract OBJECTIVES The emergence of ultra-high-volume centres promises new opportunities for thoracic surgical training. The goal of this study was to investigate the effectiveness of a novel observership course in teaching video-assisted thoracoscopic surgery (VATS) at an ultra-high-volume centre. METHODS Two-week courses in VATS at a specialist unit now performing >10 000 major lung resections annually (>50 daily on average) were attended by 230 surgeons from around the world from 2013 to 2016. An online survey preserving responder anonymity was completed by 156 attendees (67.8%). RESULTS Attendees included 37% from Western Europe, 18% from Eastern Europe and 17% from Latin America. Experience with open thoracic surgery for more than 5 years was reported by 67%, but 79% had less than 5 years of VATS lobectomy experience. During the course, 70% observed over 30 uniportal VATS operations (including 38% observing over 50), and 69% attended an animal wet lab. Although 72% of the responders attended the course less than 12 months ago, the number of ports used (P < 0.001), operation times (P < 0.001) and conversion rates (P < 0.001) reported by the responders were reduced significantly after the course. Improvements in the problem areas of tissue retraction, instrumentation, stapler application and coordination with the assistant during VATS were reported by 56%, 57%, 58% and 53%, respectively. Of those who had attended other VATS courses previously, 87% preferred the training from this high-volume course. CONCLUSIONS High-volume intensive observership training at an ultra-high-volume centre may improve VATS proficiency in a short period of time, and may provide a time-efficient modality for future thoracic surgical training. Education, Training, Video-assisted thoracic surgery, Uniportal INTRODUCTION In the second decade of the 21st century, 2 strong emerging trends in thoracic surgery appear to be shaping the future of this specialty. The first is the increasingly rapid development of minimally invasive techniques in thoracic surgery [1, 2]. Video-assisted thoracic surgery (VATS) has already been established as the approach of choice for the surgical management of early stage lung cancer [3]. Over the past decade, conventional VATS has been joined by the rapid emergence of robot-assisted surgery and by ‘next generation’ VATS techniques—including needlescopic, 2-port, uniportal and even subxiphoid VATS [1, 2, 4, 5]. Although there is fervent demand to learn these new techniques, the ideal platform for VATS training has not yet been entirely defined [6–9]. Traditional training in cardiothoracic surgery requires trainees to go on attachment at specialist units for months or even years [6, 10–12]. This is costly for the trainee and his/her parent unit in terms of time away from work. More ‘cost-efficient’ training paradigms have not yet been designed or adopted. The second trend is the emergence of ultra-high-volume centres (UHVCs) in thoracic surgery—especially in Asia [12, 13]. Traditionally, a thoracic surgery unit would be defined as having ‘high volume’ in lung cancer if it performs 70–150 lung cancer operations annually [14, 15]. In China, for example, UHVCs have emerged, each of which performed more than 10 000 such lung cancer resections in 1 year [13]. This volume equates to an average of 40–50 major lung resections per working weekday. For the surgical trainee, these numbers may mean that large clinical experiences can be acquired in a relatively short time [16]. Fortuitously, surgeons at those UHVCs also tend to be highly skilled at advanced VATS—further enhancing the quality of VATS training provided [13, 17, 18]. What has hitherto not been shown is whether the latter trend can address the needs of the former trend. The goal of this study was to assess whether an intensive training course at a UHVC can effectively train surgeons in advanced VATS within a short period of time. METHODS The Tongji University Shanghai Pulmonary Hospital in Shanghai, China performed 10 392 major lung resections in the calendar year of 2016 [13]. The majority of these operations were performed for the treatment of lung cancer, and 9401 operations (90.5%) were performed using a minimally invasive approach (conventional, uniportal or subxiphoid/subcostal VATS). High-volume intensive training course in video-assisted thoracic surgery Beginning in mid-2013, the Shanghai Pulmonary Hospital initiated a highly intensive course in VATS techniques for surgeons from around the world (Figs 1 and 2; Video 1). The course lasts for 2 weeks and consists of daily observation of operations performed at the hospital. The full details of the course are provided in Supplementary Material, Appendix S1. Video 1 Introductory video for the Shanghai Pulmonary Hospital uniportal video-assisted thoracoscopic surgery course. Video 1 Introductory video for the Shanghai Pulmonary Hospital uniportal video-assisted thoracoscopic surgery course. Close Figure 1: View largeDownload slide Departmental morning meeting at the Shanghai Pulmonary Hospital. Course attendees from around the world participate in the case discussion and share their own experiences. Figure 1: View largeDownload slide Departmental morning meeting at the Shanghai Pulmonary Hospital. Course attendees from around the world participate in the case discussion and share their own experiences. Figure 2: View largeDownload slide Teaching in the operating room. Course faculty members demonstrate video-assisted thoracoscopic surgery operations and explain their techniques, tips and tricks. In this photo, uniportal video-assisted thoracoscopic surgery is being demonstrated with a novel robotic arm used to hold the camera. Figure 2: View largeDownload slide Teaching in the operating room. Course faculty members demonstrate video-assisted thoracoscopic surgery operations and explain their techniques, tips and tricks. In this photo, uniportal video-assisted thoracoscopic surgery is being demonstrated with a novel robotic arm used to hold the camera. Online questionnaire survey As of December 2016, 230 international surgeons attended this course, and all were invited to complete a cross-sectional online survey on their experiences with this course. The institutional review board waived review for this survey. The survey comprised 32 questions (Supplementary Material, Appendix S2). Questions were provided with multiple choice answers so that responses could be standardized and categorized for statistical analysis. The questions focused on the following issues: Who the attendees were in terms of personal and professional background; What exposure they received during the course; How their practice may have changed from before to after attending the course; Their general satisfaction with the course. The entire survey was sited on a free-access online survey platform. All 230 surgeons who had attended the course were invited to complete the survey via a link sent by email. Only those invited could access the survey and each invitee could only answer the survey once. Importantly, the system did not ask for or record the identity of each responder. All responders were assured in the invitation email that their identities would be kept completely blinded from the authors. This was to encourage each responder to give entirely truthful answers without any concern about others judging them. It also served to eliminate any personal biases on the part of the authors when analysing the data collected. A deadline of 3 weeks was set for the attendees to complete the survey, and reminder emails were sent during this period. Statistical analysis Statistical analyses were performed using Microsoft Excel 2013 (version 15.0.4953.1001; Microsoft Corporation, USA) and MedCalc Statistical Software version 14.12.0 (MedCalc Software bvba, Ostend, Belgium). Crosstab analyses between categorical variables were tested using the χ2 test, and associations with continuous variables were tested using the unpaired t-test. A P-value of <0.05 was taken to indicate significance. RESULTS By the deadline, 156 surgeons who had attended the course completed the survey, giving a response rate of 67.8%. Not all of those responding gave a reply to all of the questions; hence the total number of replies to each question may be fewer than 156. Of the responders, 64 (47%) had attended the course less than 6 months ago, 34 (25%) 6–12 months ago, 19 (14%) 12–18 months ago, 10 (7%) 18–24 months ago and 9 (7%) more than 24 months ago. Not all attendees stayed for the full 2 weeks of the course, with 31% of responders only staying for 7 days or less. Course attendee backgrounds Table 1 summarizes the responses to the survey questions regarding the backgrounds of the course attendees. Table 1: Summary of the nationalities and professional backgrounds of the responders to the survey Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  VATS: video-assisted thoracoscopic surgery. Table 1: Summary of the nationalities and professional backgrounds of the responders to the survey Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  VATS: video-assisted thoracoscopic surgery. The nationalities of the attendees are varied, and there have been attendees from every continent. The most common origin was Western Europe (54 attendees, 37%), followed by Eastern Europe (27 attendees, 18%) and Latin America (25 attendees, 17%). None of the attendees were from China. That is because the Shanghai Pulmonary Hospital hosts surgeons from across China in attachments in Chinese separately from this course (which is conducted in English). Attendees tend to be experienced thoracic surgeons, with only 1% never having performed an open lobectomy, and 67% having 5 years or more experience with lobectomy via open thoracotomy. However, 31% have had less than 1 year’s experience with VATS lobectomy, and only 31% have had 5 years or more experience with VATS lobectomy. Experience received during the course Table 2 summarizes the experience received by the attendees during their 2-week course at the Shanghai Pulmonary Hospital. Table 2: Summary of the experience received by the responders to the survey during the high volume intensive training course Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  VATS: video-assisted thoracoscopic surgery. Table 2: Summary of the experience received by the responders to the survey during the high volume intensive training course Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  VATS: video-assisted thoracoscopic surgery. Of the responders, 70% observed more than 30 uniportal VATS major lung resections during the course. In addition, 24% observed more than 10 operations performed using a subxiphoid or subcostal uniportal approach [18]. In contrast, 58% of responders chose to observe fewer than 10 cases performed using the more conventional multi-portal VATS approach (2 ports or more). During the course, 91% of responders observed operations performed by more than 3 different surgeons. Indeed, 51% observed operations performed by more than 5 different surgeons. Effect of the high-volume intensive training course on practices Table 3 summarizes the differences reported by the attendees in key aspects of their surgical practice before and after their 2-week course at the Shanghai Pulmonary Hospital. These differences reflect the impact of the course on their technique. Table 3: Summary of key aspects of the surgical practice of the responders to the survey before and after attending the high volume intensive training course Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  VATS: video-assisted thoracoscopic surgery. Table 3: Summary of key aspects of the surgical practice of the responders to the survey before and after attending the high volume intensive training course Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  VATS: video-assisted thoracoscopic surgery. Having attended the course, there was a trend for a greater proportion of lobectomies using VATS. Before the course, only 45% of responders performed over 50% of their lobectomies using VATS, but after the course this proportion increased to 60% (P = 0.063). The course also influenced how VATS was performed. Prior to attending the course, the most popular number of ports for VATS lobectomy was 3. After the course, the most popular number of ports was just 1 (P < 0.001). Key parameters used to assess VATS skills also improved among responders after they completed the course. Prior to the course, 61% of responders typically required more then 120 min to perform a VATS lobectomy, and this proportion dropped to 45% after the course (P < 0.001). Prior to the course, 27% of responders had to convert from a VATS to an open approach in more than 1-in-10 cases, and this rate dropped to 9% of responders after the course (P < 0.001). Table 4 summarizes what the responders identified as their key problem areas when performing VATS lobectomy before the course. Before the course, over half of responders agreed or strongly agreed that they encountered problems with tissue exposure/retraction, instrument handling and stapler application. After the course, the proportions of responders who agreed or strongly agreed that they had improved in these 3 areas were 56%, 57% and 58%, respectively. Table 4: Summary of key problem areas in their own practice identified by the responders to the survey before and after attending the high volume intensive training course   Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1    Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1  VATS: video-assisted thoracoscopic surgery. Table 4: Summary of key problem areas in their own practice identified by the responders to the survey before and after attending the high volume intensive training course   Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1    Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1  VATS: video-assisted thoracoscopic surgery. Of those responding, 36% reported that they had received a promotion at work since they had attended the course. Satisfaction with the course Table 5 summarizes the views of the responders regarding various aspects of the course. Over 90% agreed or strongly agreed that they were: satisfied with the number of cases observed; satisfied with the variety of cases observed; satisfied with the teaching received; glad they came to the course and happy to recommend this course to a friend/colleague. Of the 74 responders who had previously attended other thoracic surgery training courses, 64 (86%) felt that the current high-volume intensive training course was better than the one(s) they previously attended and none thought it was worse. Table 5: Summary of the views of the responders to the survey to various aspects of the high volume intensive training course Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  n/a: did not attend/complete the wetlab. Table 5: Summary of the views of the responders to the survey to various aspects of the high volume intensive training course Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  n/a: did not attend/complete the wetlab. Specifically regarding the wetlab, over half of those who attended the wetlab were satisfied with the adequacy of time provided, the adequacy of faculty supervision, and the opportunity to apply what was observed in the operating rooms during the course. The final question of the survey invited responders to freely voice any comments. There were 75 individual responders who gave comments. Of these, 56 (75%) expressed only appreciation for the course with no criticisms. Only 19 (25%) individual responders noted areas for improvement, and their comments included the following: 7 suggestions for opportunities to scrub in and assist in operations 4 suggestions for fewer attendees per course 4 suggestions for more wetlab opportunities 2 suggestions for more didactic lectures 2 suggestions for operation lists written in English DISCUSSION With the ever-increasing demand for training in VATS, existing paradigms for surgical postgraduate training face challenges in terms of both quantity and quality [6, 10, 11]. Regarding quantity, it is imperative that a surgical trainee be exposed to as many operations as feasible during a limited training period. Yet, the trend for reduced working hours for doctors in much of the Western world may potentially lead to insufficient clinical exposure for surgical trainees to achieve an adequate level of surgical competence [10, 11]. Regarding quality, there is today uncertainty about the quality of cardiothoracic surgical training in many countries [10]. In a recent survey of European thoracic surgery trainees, the median score given for quality of training in minimally invasive procedures was only 6.5 (out of 10), and that for teaching/education was only 6 [19]. However, the wish to devote more time and effort towards training is often countered by political and financial pressures on experienced surgeons to provide more clinical service rather than teaching [11]. An important route towards overcoming these challenges may be through building international collaborations for training and education [6]. In this regard, the rise of the UHVCs undoubtedly promises to be a potential solution [12, 13]. The enormous operative volumes at these UHVCs potentially allow larger groups of trainees to obtain high quality training without sacrificing service provision. For the UHVC, time is saved by organizing compact, intensive training courses at only defined times during the year, so that the faculty can focus on service provision for the rest of the year. For the trainee, the course allows a large volume of clinical and operative experience to be obtained within the relatively short span of the training period. The data in Table 2 illustrate exactly how large a volume and how short a period were required to achieve the results demonstrated in the survey. For the trainee’s parent hospital, it means that the trainee is away for only a short time and can quickly return to work after the training. Instead of being away for months or more on a traditional training rotation, the trainee may be away for only 2 weeks. In terms of resources, it should also be noted that this course does not involve any fees, and all travel and accommodation can be selected by the attendee to suit his/her own budget. In theory, this allows the course to cater to trainees who have access to varying levels of supporting resources. The results of this study demonstrate the efficiency of a high-volume intensive training course at a UHVC for delivering VATS training. Such a course can be a time-efficient vehicle for a surgeon to obtain the personal experience that ensures clinical effectiveness. The results show that the 2-week course provides attendees with demonstrable improvement in VATS skills, influence on their approach to VATS and a satisfying educational experience. There are really no other modes of training to which this course can be compared. Traditional training in VATS is effective, but may take years to provide trainees with the volume of cases shared by a UHVC in mere weeks [8, 9]. Simulator and virtual reality training programs have been developed, but have yielded mixed results in terms of providing operative realism, and doubts remain as to whether proficiency with an off-table simulator can ever translate into effective clinical skills [20, 21]. Animal training is also not a feasible method for regular and high-volume training because of ethical and cost issues. In contrast, the 1-day-only animal wet lab in our course has actually proven to be an adequately effective part of the program because it allows attendees to practice what has already been observed. Given that most attendees have already had some thoracic surgical experience, a 1-day wet lab appears to be adequate for them to practice the fundamental skills. It could also be asked whether live surgery broadcasts by video feeds could deliver an experience similar to that of the course. However, we believe they cannot. Live surgery invariably involves surgeons working in unfamiliar situations, whereas in this course, all attendees watch the faculty performing comfortably in their natural environments. Being inside the operating room also allows direct interaction with the surgeon and/or staff, and allows the observant attendee to appreciate the fine details of the surgeon’s movements that may otherwise be easily missed on a video transmission. Furthermore, the logistics of live broadcasts would not allow the sheer volume of operative exposure that attendees can get by shuttling between operating rooms that together handle more than 50 operations per day. The results of this study also raise important points about the future of VATS training that warrant discussion. Owing to word limit considerations, however, a discussion of these points is provided in Supplementary Material, Appendix S3. The points include: The background of the attendees may indicate how thoracic surgery training courses may need to evolve in the future. The particular interests of the attendees during the course may show how future course content needs to be designed. The efficacy of the intensive course suggests that future surgical training may acquire a modular pattern. Despite the promise that high-volume intensive training courses hold for VATS education, the authors acknowledge that this study has limitations. As with any survey, the responses are subject to the personal subjective biases of each responder. There is no way to reliably correlate the reported improvement in operative skills with an objectively assessed improvement within the framework of this study. There is also the possibility of bias in that perhaps only those attendees most satisfied with the course responded to the survey, whereas those unhappy with it did not. It is also interesting to note that more people who attended the course recently responded to the survey compared to those who had attended a longer time ago. This is mostly due to the increasing number of courses being given in recent times compared to when the course was first started, but may also be due to the fact that those who had recently attended were better able to identify how the course had helped their skill development. Given these limitations, we would caution against over-interpretation of and over-reliance on the statistical analyses used in this study per se, other than that they show a distinct difference in self-perception before and after the course. It may also be noted that, with an uncontrolled study, the reported improvements may not be the result of the course. In rebuttal, we would point out that the attendees—who have had years of thoracic surgery experience—have themselves identified problem areas in their own practice and then reported significant improvements just months after attending the course. What this current survey lacks are the data to explain why some attendees experienced more benefit from the course than others. This aspect is the result of our conscious decision to value responder anonymity over an excessively intrusive inquisition into their individual backgrounds. It is also noted that this simple survey study has not fully clarified what operative volumes precisely define a UHVC. We believe that future studies may be required to delineate exactly what operative volumes/intensity would constitute a cut-off below which a high-volume intensive observership course like ours would fail to achieve satisfactory training results. Another potential direction for future study may be whether such a high-volume intensive observership is as effective for training in open surgical skills as it is for VATS. CONCLUSIONS This study demonstrated that a high-volume intensive training course at a UHVC can effectively train surgeons in advanced VATS (particularly uniportal VATS) within a very short period of time, with improvements noted by attendees in their own practice within months after completing the course. The effectiveness of these courses may hold important implications for future training programs in VATS and thoracic surgery. SUPPLEMENTARY MATERIAL Supplementary material is available at ICVTS online. Conflict of interest: none declared. REFERENCES 1 Sihoe ADL. The evolution of VATS lobectomy. In: Cardoso P (ed). Topics in Thoracic Surgery . Rijeka, Croatia: Intech, 2011, 181– 210. 2 Sihoe ADL. The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery. J Thorac Dis  2014; 6: S604– 17. Google Scholar PubMed  3 Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest  2013; 143: e278S– 313S. Google Scholar CrossRef Search ADS PubMed  4 Veronesi G, Galetta D, Maisonneuve P, Melfi F, Schmid RA, Borri A et al.   Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg  2010; 140: 19– 25. Google Scholar CrossRef Search ADS PubMed  5 Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez L et al.   Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg  2013; 95: 426– 32. Google Scholar CrossRef Search ADS PubMed  6 Ilonen IK, McElnay PJ. Research and education in thoracic surgery: the European trainees’ perspective. J Thorac Dis  2015; 7: S118– 21. Google Scholar PubMed  7 Brunelli A, Falcoz PE, D’Amico T, Hansen H, Lim E, Massard G et al.   European guidelines on structure and qualification of general thoracic surgery. Eur J Cardiothorac Surg  2014; 45: 779– 86. Google Scholar CrossRef Search ADS PubMed  8 Ferguson J, Walker W. Developing a VATS lobectomy programme—can VATS lobectomy be taught? Eur J Cardiothorac Surg  2006; 29: 806– 9. Google Scholar CrossRef Search ADS PubMed  9 Petersen RH, Hansen HJ. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg  2010; 37: 516– 20. Google Scholar CrossRef Search ADS PubMed  10 Sadaba JR, Loubani M, Salzberg SP, Myers PO, Siepe M, Nia PS et al.   Real life cardio-thoracic surgery training in Europe: facing the facts. Interact CardioVasc Thorac Surg  2010; 11: 243– 6. Google Scholar CrossRef Search ADS PubMed  11 Loubani M, Sadaba JR, Myers PO, Cartwright N, Siepe M, Emmert MY et al.   A European training system in cardiothoracic surgery: is it time? Eur J Cardiothorac Surg  2013; 43: 352– 7. Google Scholar CrossRef Search ADS PubMed  12 Sihoe AD. Opportunities and challenges for thoracic surgery collaborations in China: a commentary. J Thorac Dis  2016; 8: S414– 26. Google Scholar CrossRef Search ADS PubMed  13 Sihoe ADL, Han B, Yang TY, Pan C, Jiang G, Fang VWT. The advent of ultra-high volume thoracic surgical centers in Shanghai. World J Surg  2017; 41: 2758– 68. Google Scholar CrossRef Search ADS PubMed  14 Bach PB, Cramer LD, Schrag D, Downey RJ, Gelfand SE, Begg CB. The influence of hospital volume on survival after resection for lung cancer. N Engl J Med  2001; 345: 181– 8. Google Scholar CrossRef Search ADS PubMed  15 Lüchtenborg M, Riaz SP, Coupland VH, Lim E, Jakobsen E, Krasnik M et al.   High procedure volume is strongly associated with improved survival after lung cancer surgery. J Clin Oncol  2013; 31: 3141– 6. Google Scholar CrossRef Search ADS PubMed  16 Depypere L. Reflection on the 1st ESTS-AME prize—the experience of one month clinical fellowship in the 1st Affiliated Hospital of the Medical University of Guangzhou. J Thorac Dis  2016; 8: E221– 4. Google Scholar CrossRef Search ADS PubMed  17 Zhu Y, Liang M, Wu W, Zheng J, Zheng W, Guo Z et al.   Preliminary results of single-port versus triple-port complete thoracoscopic lobectomy for non-small cell lung cancer. Ann Transl Med  2015; 3: 92. Google Scholar PubMed  18 Song N, Zhao DP, Jiang L, Bao Y, Jiang GN, Zhu YM et al.   Subxiphoid uniportal video-assisted thoracoscopic surgery (VATS) for lobectomy: a report of 105 cases. J Thorac Dis  2016; S251– 7. 19 McElnay PJ, Massard G. Thoracic training across Europe: the trainees’ perspective. Eur J Cardiothorac Surg  2015; 47: 395– 6. Google Scholar CrossRef Search ADS PubMed  20 Jensen K, Bjerrum F, Hansen HJ, Petersen RH, Pedersen JH, Konge L. A new possibility in thoracoscopic virtual reality simulation training: development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy. Interact CardioVasc Thorac Surg  2015; 21: 420– 6. Google Scholar CrossRef Search ADS PubMed  21 Sandri A, Filosso PL, Lausi PO, Ruffini E, Oliaro A. VATS lobectomy program: the trainee perspective. J Thorac Dis  2016; 8: S427– 30. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Interactive CardioVascular and Thoracic Surgery Oxford University Press

High-volume intensive training course: a new paradigm for video-assisted thoracoscopic surgery education

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Oxford University Press
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© The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
ISSN
1569-9293
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1569-9285
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10.1093/icvts/ivy038
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Abstract

Abstract OBJECTIVES The emergence of ultra-high-volume centres promises new opportunities for thoracic surgical training. The goal of this study was to investigate the effectiveness of a novel observership course in teaching video-assisted thoracoscopic surgery (VATS) at an ultra-high-volume centre. METHODS Two-week courses in VATS at a specialist unit now performing >10 000 major lung resections annually (>50 daily on average) were attended by 230 surgeons from around the world from 2013 to 2016. An online survey preserving responder anonymity was completed by 156 attendees (67.8%). RESULTS Attendees included 37% from Western Europe, 18% from Eastern Europe and 17% from Latin America. Experience with open thoracic surgery for more than 5 years was reported by 67%, but 79% had less than 5 years of VATS lobectomy experience. During the course, 70% observed over 30 uniportal VATS operations (including 38% observing over 50), and 69% attended an animal wet lab. Although 72% of the responders attended the course less than 12 months ago, the number of ports used (P < 0.001), operation times (P < 0.001) and conversion rates (P < 0.001) reported by the responders were reduced significantly after the course. Improvements in the problem areas of tissue retraction, instrumentation, stapler application and coordination with the assistant during VATS were reported by 56%, 57%, 58% and 53%, respectively. Of those who had attended other VATS courses previously, 87% preferred the training from this high-volume course. CONCLUSIONS High-volume intensive observership training at an ultra-high-volume centre may improve VATS proficiency in a short period of time, and may provide a time-efficient modality for future thoracic surgical training. Education, Training, Video-assisted thoracic surgery, Uniportal INTRODUCTION In the second decade of the 21st century, 2 strong emerging trends in thoracic surgery appear to be shaping the future of this specialty. The first is the increasingly rapid development of minimally invasive techniques in thoracic surgery [1, 2]. Video-assisted thoracic surgery (VATS) has already been established as the approach of choice for the surgical management of early stage lung cancer [3]. Over the past decade, conventional VATS has been joined by the rapid emergence of robot-assisted surgery and by ‘next generation’ VATS techniques—including needlescopic, 2-port, uniportal and even subxiphoid VATS [1, 2, 4, 5]. Although there is fervent demand to learn these new techniques, the ideal platform for VATS training has not yet been entirely defined [6–9]. Traditional training in cardiothoracic surgery requires trainees to go on attachment at specialist units for months or even years [6, 10–12]. This is costly for the trainee and his/her parent unit in terms of time away from work. More ‘cost-efficient’ training paradigms have not yet been designed or adopted. The second trend is the emergence of ultra-high-volume centres (UHVCs) in thoracic surgery—especially in Asia [12, 13]. Traditionally, a thoracic surgery unit would be defined as having ‘high volume’ in lung cancer if it performs 70–150 lung cancer operations annually [14, 15]. In China, for example, UHVCs have emerged, each of which performed more than 10 000 such lung cancer resections in 1 year [13]. This volume equates to an average of 40–50 major lung resections per working weekday. For the surgical trainee, these numbers may mean that large clinical experiences can be acquired in a relatively short time [16]. Fortuitously, surgeons at those UHVCs also tend to be highly skilled at advanced VATS—further enhancing the quality of VATS training provided [13, 17, 18]. What has hitherto not been shown is whether the latter trend can address the needs of the former trend. The goal of this study was to assess whether an intensive training course at a UHVC can effectively train surgeons in advanced VATS within a short period of time. METHODS The Tongji University Shanghai Pulmonary Hospital in Shanghai, China performed 10 392 major lung resections in the calendar year of 2016 [13]. The majority of these operations were performed for the treatment of lung cancer, and 9401 operations (90.5%) were performed using a minimally invasive approach (conventional, uniportal or subxiphoid/subcostal VATS). High-volume intensive training course in video-assisted thoracic surgery Beginning in mid-2013, the Shanghai Pulmonary Hospital initiated a highly intensive course in VATS techniques for surgeons from around the world (Figs 1 and 2; Video 1). The course lasts for 2 weeks and consists of daily observation of operations performed at the hospital. The full details of the course are provided in Supplementary Material, Appendix S1. Video 1 Introductory video for the Shanghai Pulmonary Hospital uniportal video-assisted thoracoscopic surgery course. Video 1 Introductory video for the Shanghai Pulmonary Hospital uniportal video-assisted thoracoscopic surgery course. Close Figure 1: View largeDownload slide Departmental morning meeting at the Shanghai Pulmonary Hospital. Course attendees from around the world participate in the case discussion and share their own experiences. Figure 1: View largeDownload slide Departmental morning meeting at the Shanghai Pulmonary Hospital. Course attendees from around the world participate in the case discussion and share their own experiences. Figure 2: View largeDownload slide Teaching in the operating room. Course faculty members demonstrate video-assisted thoracoscopic surgery operations and explain their techniques, tips and tricks. In this photo, uniportal video-assisted thoracoscopic surgery is being demonstrated with a novel robotic arm used to hold the camera. Figure 2: View largeDownload slide Teaching in the operating room. Course faculty members demonstrate video-assisted thoracoscopic surgery operations and explain their techniques, tips and tricks. In this photo, uniportal video-assisted thoracoscopic surgery is being demonstrated with a novel robotic arm used to hold the camera. Online questionnaire survey As of December 2016, 230 international surgeons attended this course, and all were invited to complete a cross-sectional online survey on their experiences with this course. The institutional review board waived review for this survey. The survey comprised 32 questions (Supplementary Material, Appendix S2). Questions were provided with multiple choice answers so that responses could be standardized and categorized for statistical analysis. The questions focused on the following issues: Who the attendees were in terms of personal and professional background; What exposure they received during the course; How their practice may have changed from before to after attending the course; Their general satisfaction with the course. The entire survey was sited on a free-access online survey platform. All 230 surgeons who had attended the course were invited to complete the survey via a link sent by email. Only those invited could access the survey and each invitee could only answer the survey once. Importantly, the system did not ask for or record the identity of each responder. All responders were assured in the invitation email that their identities would be kept completely blinded from the authors. This was to encourage each responder to give entirely truthful answers without any concern about others judging them. It also served to eliminate any personal biases on the part of the authors when analysing the data collected. A deadline of 3 weeks was set for the attendees to complete the survey, and reminder emails were sent during this period. Statistical analysis Statistical analyses were performed using Microsoft Excel 2013 (version 15.0.4953.1001; Microsoft Corporation, USA) and MedCalc Statistical Software version 14.12.0 (MedCalc Software bvba, Ostend, Belgium). Crosstab analyses between categorical variables were tested using the χ2 test, and associations with continuous variables were tested using the unpaired t-test. A P-value of <0.05 was taken to indicate significance. RESULTS By the deadline, 156 surgeons who had attended the course completed the survey, giving a response rate of 67.8%. Not all of those responding gave a reply to all of the questions; hence the total number of replies to each question may be fewer than 156. Of the responders, 64 (47%) had attended the course less than 6 months ago, 34 (25%) 6–12 months ago, 19 (14%) 12–18 months ago, 10 (7%) 18–24 months ago and 9 (7%) more than 24 months ago. Not all attendees stayed for the full 2 weeks of the course, with 31% of responders only staying for 7 days or less. Course attendee backgrounds Table 1 summarizes the responses to the survey questions regarding the backgrounds of the course attendees. Table 1: Summary of the nationalities and professional backgrounds of the responders to the survey Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  VATS: video-assisted thoracoscopic surgery. Table 1: Summary of the nationalities and professional backgrounds of the responders to the survey Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  Survey questions (n = number of responses to that question)  Responders, %  Which part of the world are you from? (n = 147)   East/Southeast Asia (outside China)  4.8   South Asia  5.4   Middle East  9.5   Western Europe  36.7   Eastern Europe/Russia  18.4   North America  2.0   Latin America  17.0   Africa  2.0   Other  4.1  For how many years have you performed open thoracotomy for major lung resections? (n = 147)   Never  0.7   <1 year  3.4   1–3 years  10.9   3–5 years  18.4   5–10 years  34.0   10–20 years  19.7   >20 years  12.9  For how many years have you performed VATS for major lung resections? (n = 146)   Never  15.1   <1 year  15.8   1–3 years  24.7   3–5 years  23.3   5–10 years  18.5   10–20 years  2.1   >20 years  0.7  VATS: video-assisted thoracoscopic surgery. The nationalities of the attendees are varied, and there have been attendees from every continent. The most common origin was Western Europe (54 attendees, 37%), followed by Eastern Europe (27 attendees, 18%) and Latin America (25 attendees, 17%). None of the attendees were from China. That is because the Shanghai Pulmonary Hospital hosts surgeons from across China in attachments in Chinese separately from this course (which is conducted in English). Attendees tend to be experienced thoracic surgeons, with only 1% never having performed an open lobectomy, and 67% having 5 years or more experience with lobectomy via open thoracotomy. However, 31% have had less than 1 year’s experience with VATS lobectomy, and only 31% have had 5 years or more experience with VATS lobectomy. Experience received during the course Table 2 summarizes the experience received by the attendees during their 2-week course at the Shanghai Pulmonary Hospital. Table 2: Summary of the experience received by the responders to the survey during the high volume intensive training course Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  VATS: video-assisted thoracoscopic surgery. Table 2: Summary of the experience received by the responders to the survey during the high volume intensive training course Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  Survey questions (n = number of responses to that question)  Responders, %  How long did you stay in Shanghai (excluding any holidays in China before/after the course)? (n = 138)   1–3 days  6.5   3–7 days  24.6   7–14 days  52.2   >14 days  16.7  How many cases of uniportal VATS did you observe? (n = 139)   0–10  2.9   10–20  15.1   20–30  12.2   30–50  31.7   >50  38.1  How many cases of multi-portal VATS (2 or more ports) did you observe? (n = 140)   0–10  57.9   10–20  25.7   20–30  5.7   30–50  7.1   >50  3.6  How many cases of sub-xiphoid/sub-costal VATS did you observe? (n = 140)   0–10  75.7   10–20  18.6   20–30  4.3   30–50  0.7   >50  0.7  How many different surgeons did you observe operating? (n = 139)   1  0.0   1–3  9.4   3–5  39.6   >5  51.1  VATS: video-assisted thoracoscopic surgery. Of the responders, 70% observed more than 30 uniportal VATS major lung resections during the course. In addition, 24% observed more than 10 operations performed using a subxiphoid or subcostal uniportal approach [18]. In contrast, 58% of responders chose to observe fewer than 10 cases performed using the more conventional multi-portal VATS approach (2 ports or more). During the course, 91% of responders observed operations performed by more than 3 different surgeons. Indeed, 51% observed operations performed by more than 5 different surgeons. Effect of the high-volume intensive training course on practices Table 3 summarizes the differences reported by the attendees in key aspects of their surgical practice before and after their 2-week course at the Shanghai Pulmonary Hospital. These differences reflect the impact of the course on their technique. Table 3: Summary of key aspects of the surgical practice of the responders to the survey before and after attending the high volume intensive training course Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  VATS: video-assisted thoracoscopic surgery. Table 3: Summary of key aspects of the surgical practice of the responders to the survey before and after attending the high volume intensive training course Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  Survey questions (n = number of responses to that question)  Before the course (% of responders)  After the course (% of responders)  P-value  Approximately how many lobectomies are performed by you personally every year? (n = 146)   <50  62.3  61.0  0.441   50–100  30.8  33.8   100–200  4.8  4.4   200–500  2.1  0.7   500–1000  0.0  0.0   >1000  0.0  0.0  Approximately what percentage of the lobectomies performed by you personally are done by VATS? (n = 146)   0%  18.5  10.9  0.063   0–10%  13.0  8.0   10–25%  10.3  10.2   25–50%  13.0  11.7   50–75%  17.8  22.6   75–90%  15.1  21.9   >90%  12.3  14.6  When performing VATS lobectomy, how many ports do you most commonly use? (n = 146)   1 port  9.9  61.0  <0.001   2 ports  33.1  26.8   3 ports  51.2  10.6   4 ports  5.8  1.6   >4 ports  0.0  0.0  Approximately what is the average time you require to complete a VATS lobectomy (skin-to-skin)? (n = 144)   <90 min  4.3  6.6  <0.001   90–120 min  20.7  43.0   120–180 min  46.6  38.0   180–240 min  25.0  11.6   >240 min  3.4  0.8  Approximately what percentage of your VATS lobectomy operations were converted to open thoracotomy? (n = 143)   <2%  19.0  28.9  <0.001   2–5%  24.1  33.1   5–10%  23.3  28.1   10–25%  23.3  7.4   >25%  10.3  2.5  VATS: video-assisted thoracoscopic surgery. Having attended the course, there was a trend for a greater proportion of lobectomies using VATS. Before the course, only 45% of responders performed over 50% of their lobectomies using VATS, but after the course this proportion increased to 60% (P = 0.063). The course also influenced how VATS was performed. Prior to attending the course, the most popular number of ports for VATS lobectomy was 3. After the course, the most popular number of ports was just 1 (P < 0.001). Key parameters used to assess VATS skills also improved among responders after they completed the course. Prior to the course, 61% of responders typically required more then 120 min to perform a VATS lobectomy, and this proportion dropped to 45% after the course (P < 0.001). Prior to the course, 27% of responders had to convert from a VATS to an open approach in more than 1-in-10 cases, and this rate dropped to 9% of responders after the course (P < 0.001). Table 4 summarizes what the responders identified as their key problem areas when performing VATS lobectomy before the course. Before the course, over half of responders agreed or strongly agreed that they encountered problems with tissue exposure/retraction, instrument handling and stapler application. After the course, the proportions of responders who agreed or strongly agreed that they had improved in these 3 areas were 56%, 57% and 58%, respectively. Table 4: Summary of key problem areas in their own practice identified by the responders to the survey before and after attending the high volume intensive training course   Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1    Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1  VATS: video-assisted thoracoscopic surgery. Table 4: Summary of key problem areas in their own practice identified by the responders to the survey before and after attending the high volume intensive training course   Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1    Before the course: this was one of my main problem areas when performing VATS lobectomy (n = 137) (% of responders)   After the course: I experienced improvement in this problem area when performing VATS lobectomy (n = 137) (% of responders)   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  Strongly disagree  Disagree  Neutral  Agree  Strongly Agree  Exposure/retraction of tissues for dissection  5.1  14.6  29.2  41.6  9.5  6.3  15.7  22.0  40.9  15.0  Handling of instruments for dissection  4.4  18.5  26.7  38.5  11.9  5.5  19.7  18.1  37.0  19.7  Applying/angulation of staplers  2.2  20.4  22.6  45.3  9.5  6.3  14.1  21.9  35.9  21.9  Coordination with assistant(s)  3.7  19.9  33.1  26.5  16.9  5.5  13.4  27.6  35.4  18.1  VATS: video-assisted thoracoscopic surgery. Of those responding, 36% reported that they had received a promotion at work since they had attended the course. Satisfaction with the course Table 5 summarizes the views of the responders regarding various aspects of the course. Over 90% agreed or strongly agreed that they were: satisfied with the number of cases observed; satisfied with the variety of cases observed; satisfied with the teaching received; glad they came to the course and happy to recommend this course to a friend/colleague. Of the 74 responders who had previously attended other thoracic surgery training courses, 64 (86%) felt that the current high-volume intensive training course was better than the one(s) they previously attended and none thought it was worse. Table 5: Summary of the views of the responders to the survey to various aspects of the high volume intensive training course Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  n/a: did not attend/complete the wetlab. Table 5: Summary of the views of the responders to the survey to various aspects of the high volume intensive training course Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  Survey questions  Responders, %   Strongly disagree  Disagree  Neutral  Agree  Strongly agree  n/a  Considering your overall experience during the course in Shanghai, do you agree with these statements?   I was satisfied with the number of cases I observed (n = 134)  1.5  0.7  0.0  16.4  81.3     I was satisfied with the variety of cases I observed (n = 134)  1.5  3.0  1.5  28.4  65.7     I was satisfied with the teaching I received (n = 134)  1.5  2.2  7.5  36.6  52.2     I had enough opportunity to interact with the faculty (n = 134)  0.7  2.2  12.7  32.8  51.5     I was glad I came (n = 133)  1.5  0.0  0.8  13.5  84.2     I would recommend this course to a friend/colleague (n = 132)  1.5  0.0  0.8  12.9  84.8    Regarding the wetlab, do you agree with the following statements?   There was enough time provided (n = 129)  3.9  9.3  14.7  30.2  10.9  31.0   Supervision by faculty was adequate (n = 128)  1.6  0.8  7.8  29.7  28.9  31.3   I could apply what I observed in the operating rooms (n = 127)  1.6  0.8  8.7  26.8  33.1  29.1   Going to the wetlab was better than staying another day in the operating rooms (n = 126)  4.0  13.5  11.9  20.6  18.3  31.7  n/a: did not attend/complete the wetlab. Specifically regarding the wetlab, over half of those who attended the wetlab were satisfied with the adequacy of time provided, the adequacy of faculty supervision, and the opportunity to apply what was observed in the operating rooms during the course. The final question of the survey invited responders to freely voice any comments. There were 75 individual responders who gave comments. Of these, 56 (75%) expressed only appreciation for the course with no criticisms. Only 19 (25%) individual responders noted areas for improvement, and their comments included the following: 7 suggestions for opportunities to scrub in and assist in operations 4 suggestions for fewer attendees per course 4 suggestions for more wetlab opportunities 2 suggestions for more didactic lectures 2 suggestions for operation lists written in English DISCUSSION With the ever-increasing demand for training in VATS, existing paradigms for surgical postgraduate training face challenges in terms of both quantity and quality [6, 10, 11]. Regarding quantity, it is imperative that a surgical trainee be exposed to as many operations as feasible during a limited training period. Yet, the trend for reduced working hours for doctors in much of the Western world may potentially lead to insufficient clinical exposure for surgical trainees to achieve an adequate level of surgical competence [10, 11]. Regarding quality, there is today uncertainty about the quality of cardiothoracic surgical training in many countries [10]. In a recent survey of European thoracic surgery trainees, the median score given for quality of training in minimally invasive procedures was only 6.5 (out of 10), and that for teaching/education was only 6 [19]. However, the wish to devote more time and effort towards training is often countered by political and financial pressures on experienced surgeons to provide more clinical service rather than teaching [11]. An important route towards overcoming these challenges may be through building international collaborations for training and education [6]. In this regard, the rise of the UHVCs undoubtedly promises to be a potential solution [12, 13]. The enormous operative volumes at these UHVCs potentially allow larger groups of trainees to obtain high quality training without sacrificing service provision. For the UHVC, time is saved by organizing compact, intensive training courses at only defined times during the year, so that the faculty can focus on service provision for the rest of the year. For the trainee, the course allows a large volume of clinical and operative experience to be obtained within the relatively short span of the training period. The data in Table 2 illustrate exactly how large a volume and how short a period were required to achieve the results demonstrated in the survey. For the trainee’s parent hospital, it means that the trainee is away for only a short time and can quickly return to work after the training. Instead of being away for months or more on a traditional training rotation, the trainee may be away for only 2 weeks. In terms of resources, it should also be noted that this course does not involve any fees, and all travel and accommodation can be selected by the attendee to suit his/her own budget. In theory, this allows the course to cater to trainees who have access to varying levels of supporting resources. The results of this study demonstrate the efficiency of a high-volume intensive training course at a UHVC for delivering VATS training. Such a course can be a time-efficient vehicle for a surgeon to obtain the personal experience that ensures clinical effectiveness. The results show that the 2-week course provides attendees with demonstrable improvement in VATS skills, influence on their approach to VATS and a satisfying educational experience. There are really no other modes of training to which this course can be compared. Traditional training in VATS is effective, but may take years to provide trainees with the volume of cases shared by a UHVC in mere weeks [8, 9]. Simulator and virtual reality training programs have been developed, but have yielded mixed results in terms of providing operative realism, and doubts remain as to whether proficiency with an off-table simulator can ever translate into effective clinical skills [20, 21]. Animal training is also not a feasible method for regular and high-volume training because of ethical and cost issues. In contrast, the 1-day-only animal wet lab in our course has actually proven to be an adequately effective part of the program because it allows attendees to practice what has already been observed. Given that most attendees have already had some thoracic surgical experience, a 1-day wet lab appears to be adequate for them to practice the fundamental skills. It could also be asked whether live surgery broadcasts by video feeds could deliver an experience similar to that of the course. However, we believe they cannot. Live surgery invariably involves surgeons working in unfamiliar situations, whereas in this course, all attendees watch the faculty performing comfortably in their natural environments. Being inside the operating room also allows direct interaction with the surgeon and/or staff, and allows the observant attendee to appreciate the fine details of the surgeon’s movements that may otherwise be easily missed on a video transmission. Furthermore, the logistics of live broadcasts would not allow the sheer volume of operative exposure that attendees can get by shuttling between operating rooms that together handle more than 50 operations per day. The results of this study also raise important points about the future of VATS training that warrant discussion. Owing to word limit considerations, however, a discussion of these points is provided in Supplementary Material, Appendix S3. The points include: The background of the attendees may indicate how thoracic surgery training courses may need to evolve in the future. The particular interests of the attendees during the course may show how future course content needs to be designed. The efficacy of the intensive course suggests that future surgical training may acquire a modular pattern. Despite the promise that high-volume intensive training courses hold for VATS education, the authors acknowledge that this study has limitations. As with any survey, the responses are subject to the personal subjective biases of each responder. There is no way to reliably correlate the reported improvement in operative skills with an objectively assessed improvement within the framework of this study. There is also the possibility of bias in that perhaps only those attendees most satisfied with the course responded to the survey, whereas those unhappy with it did not. It is also interesting to note that more people who attended the course recently responded to the survey compared to those who had attended a longer time ago. This is mostly due to the increasing number of courses being given in recent times compared to when the course was first started, but may also be due to the fact that those who had recently attended were better able to identify how the course had helped their skill development. Given these limitations, we would caution against over-interpretation of and over-reliance on the statistical analyses used in this study per se, other than that they show a distinct difference in self-perception before and after the course. It may also be noted that, with an uncontrolled study, the reported improvements may not be the result of the course. In rebuttal, we would point out that the attendees—who have had years of thoracic surgery experience—have themselves identified problem areas in their own practice and then reported significant improvements just months after attending the course. What this current survey lacks are the data to explain why some attendees experienced more benefit from the course than others. This aspect is the result of our conscious decision to value responder anonymity over an excessively intrusive inquisition into their individual backgrounds. It is also noted that this simple survey study has not fully clarified what operative volumes precisely define a UHVC. We believe that future studies may be required to delineate exactly what operative volumes/intensity would constitute a cut-off below which a high-volume intensive observership course like ours would fail to achieve satisfactory training results. Another potential direction for future study may be whether such a high-volume intensive observership is as effective for training in open surgical skills as it is for VATS. CONCLUSIONS This study demonstrated that a high-volume intensive training course at a UHVC can effectively train surgeons in advanced VATS (particularly uniportal VATS) within a very short period of time, with improvements noted by attendees in their own practice within months after completing the course. The effectiveness of these courses may hold important implications for future training programs in VATS and thoracic surgery. SUPPLEMENTARY MATERIAL Supplementary material is available at ICVTS online. Conflict of interest: none declared. REFERENCES 1 Sihoe ADL. The evolution of VATS lobectomy. In: Cardoso P (ed). Topics in Thoracic Surgery . Rijeka, Croatia: Intech, 2011, 181– 210. 2 Sihoe ADL. The evolution of minimally invasive thoracic surgery: implications for the practice of uniportal thoracoscopic surgery. J Thorac Dis  2014; 6: S604– 17. Google Scholar PubMed  3 Howington JA, Blum MG, Chang AC, Balekian AA, Murthy SC. Treatment of stage I and II non-small cell lung cancer: diagnosis and management of lung cancer, 3rd ed: American College of Chest Physicians evidence-based clinical practice guidelines. Chest  2013; 143: e278S– 313S. Google Scholar CrossRef Search ADS PubMed  4 Veronesi G, Galetta D, Maisonneuve P, Melfi F, Schmid RA, Borri A et al.   Four-arm robotic lobectomy for the treatment of early-stage lung cancer. J Thorac Cardiovasc Surg  2010; 140: 19– 25. Google Scholar CrossRef Search ADS PubMed  5 Gonzalez-Rivas D, Paradela M, Fernandez R, Delgado M, Fieira E, Mendez L et al.   Uniportal video-assisted thoracoscopic lobectomy: two years of experience. Ann Thorac Surg  2013; 95: 426– 32. Google Scholar CrossRef Search ADS PubMed  6 Ilonen IK, McElnay PJ. Research and education in thoracic surgery: the European trainees’ perspective. J Thorac Dis  2015; 7: S118– 21. Google Scholar PubMed  7 Brunelli A, Falcoz PE, D’Amico T, Hansen H, Lim E, Massard G et al.   European guidelines on structure and qualification of general thoracic surgery. Eur J Cardiothorac Surg  2014; 45: 779– 86. Google Scholar CrossRef Search ADS PubMed  8 Ferguson J, Walker W. Developing a VATS lobectomy programme—can VATS lobectomy be taught? Eur J Cardiothorac Surg  2006; 29: 806– 9. Google Scholar CrossRef Search ADS PubMed  9 Petersen RH, Hansen HJ. Learning thoracoscopic lobectomy. Eur J Cardiothorac Surg  2010; 37: 516– 20. Google Scholar CrossRef Search ADS PubMed  10 Sadaba JR, Loubani M, Salzberg SP, Myers PO, Siepe M, Nia PS et al.   Real life cardio-thoracic surgery training in Europe: facing the facts. Interact CardioVasc Thorac Surg  2010; 11: 243– 6. Google Scholar CrossRef Search ADS PubMed  11 Loubani M, Sadaba JR, Myers PO, Cartwright N, Siepe M, Emmert MY et al.   A European training system in cardiothoracic surgery: is it time? 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A new possibility in thoracoscopic virtual reality simulation training: development and testing of a novel virtual reality simulator for video-assisted thoracoscopic surgery lobectomy. Interact CardioVasc Thorac Surg  2015; 21: 420– 6. Google Scholar CrossRef Search ADS PubMed  21 Sandri A, Filosso PL, Lausi PO, Ruffini E, Oliaro A. VATS lobectomy program: the trainee perspective. J Thorac Dis  2016; 8: S427– 30. Google Scholar CrossRef Search ADS PubMed  © The Author(s) 2018. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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Interactive CardioVascular and Thoracic SurgeryOxford University Press

Published: Mar 27, 2018

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