title: Video-assisted thoracoscopic lobectomy: which is the learning curve of an experienced consultant?
abstract: BACKGROUND
  This study evaluates the number of video-assisted thoracic surgery-lobectomies (VATS-lobectomies) required for an experienced consultant thoracic surgeon to obtain competence and to perform standard quality surgery.
  
  
  METHODS
  We have analysed the initial VATS-experience (January 2012 to September 2014) of a confirmed senior consultant who has performed 145 consecutive anatomic resections by thoracoscopy. After excluding bilobectomies, segmentectomies, and lobectomies for infectious disease, we have focused into 119 consecutive lobectomies, classified into 4 chronologic groups of 30 each. We have considered: demographics; pathology; postoperative outcomes; conversion rate; morbidity. We compared the 4 groups in a Bayesian inference model (very strong probability of a difference if Pr>95% or <5%; strong probability if 95%>Pr>80% or 5%<Pr<20%).
  
  
  RESULTS
  There was a very strong probability of difference of group 1 (first 30 lobectomies) compared to the 3 other groups: less incomplete fissures (Pr1<2=0.019, Pr1<3=0.037, Pr1<4=0.046), more node samplings (Pr1>2=0.977, Pr1>3=0.96, Pr1>4=0.997) and, conversely, less radical dissections (Pr1<2=0.022, Pr1<3=0.039, Pr1<4=0.003), less harvested nodes (Pr1<2≤0.001, Pr1<3≤0.001, Pr1<4≤0.001), less pleural adhesions (Pr1<2=0.077, Pr1<3=0.044). Instead, there was a very strong probability of difference of group 4 compared to the first three groups (first 90 lobectomies): lower conversion rate (Pr1>4=0.992, Pr3>4=0.996, Pr2>4=0.995), lower duration of the operation (Pr1>4=0.946, Pr2>4=0.901, Pr3>4=0.932), less air leak (Pr1>4=0.936, Pr2>4=0.97) and shorter chest tube drainage (Pr1>4=0.94, Pr2>4=0.94, Pr3>4=0.937), as well as shorter hospital stay (Pr2>4=0.94, Pr3>4=0.937).
  
  
  CONCLUSIONS
  The learning curve was bimodal. After the initial 30 lobectomies, oncologic quality of the procedure improved and stabilized. The surgeon became less selective and accepted to proceed with more complex cases (incomplete fissures, pleural adhesions). Efficiency was obtained after 90 lobectomies (shorter operative time and lower conversion rate).
authors.affiliation: Department of Thoracic Surgery, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Place de l'Hôpital 1, 67000 Strasbourg, France.
authors.forename: Antonio
authors.initials: A
authors.lastname: Mazzella
authors.affiliation: Department of Thoracic Surgery, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Place de l'Hôpital 1, 67000 Strasbourg, France;; EA 7213: Tissue and Vascular Stress in Transplant, Translational and Epidemiologic Approach, Strasbourg University, Strasbourg, France.
authors.forename: Anne
authors.initials: A
authors.lastname: Olland
authors.affiliation: Department of Thoracic Surgery, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Place de l'Hôpital 1, 67000 Strasbourg, France.
authors.forename: Pierre Emmanuel
authors.initials: PE
authors.lastname: Falcoz
authors.affiliation: Department of Thoracic Surgery, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Place de l'Hôpital 1, 67000 Strasbourg, France;; EA 3430: Tumor Progression and Micro-environment, Translational and Epidemiologic Approach, Strasbourg University, Strasbourg, France.
authors.forename: Stephane
authors.initials: S
authors.lastname: Renaud
authors.affiliation: Department of Thoracic Surgery, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Place de l'Hôpital 1, 67000 Strasbourg, France.
authors.forename: Nicola
authors.initials: N
authors.lastname: Santelmo
authors.affiliation: Department of Thoracic Surgery, Hôpitaux universitaires de Strasbourg, Nouvel Hôpital Civil, Place de l'Hôpital 1, 67000 Strasbourg, France;; EA 3430: Tumor Progression and Micro-environment, Translational and Epidemiologic Approach, Strasbourg University, Strasbourg, France.
authors.forename: Gilbert
authors.initials: G
authors.lastname: Massard
keywords: Video-assisted thoracic surgery (VATS); learning curve; learning tools; lung, lobectomy