Learning curve of image-guided video-assisted thoracoscopic surgery for small pulmonary nodules: A prospective analysis of 30 initial patients

J Thorac Cardiovasc Surg. 2018 Apr;155(4):1825-1832.e1. doi: 10.1016/j.jtcvs.2017.11.079. Epub 2017 Dec 13.


Objectives: The use of image-guided video-assisted thoracoscopic surgery for simultaneous localization and removal of small solitary pulmonary nodules in a hybrid operation room using C-arm cone-beam computed tomography is gaining momentum. We sought to assess the effect of the learning curve on procedural parameters and clinical outcomes of image-guided video-assisted thoracoscopic surgery for treating patients with small solitary pulmonary nodules.

Methods: Clinical variables and treatment outcomes of the 30 initial patients with solitary pulmonary nodules who were treated with image-guided video-assisted thoracoscopic surgery at Chang Gung Memorial Hospital (Taiwan) were prospectively analyzed. Two sequential groups (groups I and II, n = 15 each) were compared with regard to localization time, radiation doses, and success rates. We used the Pearson's correlation coefficient to investigate the association between the surgical experience and the procedural time.

Results: In the entire cohort, the median size of solitary pulmonary nodules on preoperative computed tomography images was 6 mm (interquartile range, 4.5-9 mm), and their median distance from the pleural surface was 10 mm (interquartile range, 5-15 mm). The median tumor depth-to-size ratio was 1.4 (interquartile range, 0.7-2.5). The clinical parameters were similar between the 2 groups. There was an inverse association between the surgical experience and the procedural time (Pearson's r = -0.6873; P < .001). A significant reduction in localization time (median, 24 vs 49 minutes, respectively; P < .001) and radiation exposure (median, 70.7 vs 224 mGy, respectively; P < .001) was noted in group II (late patients) compared with group I (early patients). Notably, the success rates in groups II and I were similar (93.3% vs 86.7%, respectively; P = . 876).

Conclusions: Our data demonstrate a significant learning curve for image-guided video-assisted thoracoscopic surgery in the treatment of solitary pulmonary nodules as evidenced by decreased localization time and radiation exposure occurring with increased surgical experience.

Keywords: ARTIS zeego; computed tomography; hybrid operating room; image-guided video-assisted thoracoscopic surgery; learning curve; small pulmonary nodules; video-assisted thoracoscopic surgery.

Publication types

  • Comparative Study
  • Video-Audio Media

MeSH terms

  • Clinical Competence*
  • Female
  • Humans
  • Learning Curve*
  • Lung Neoplasms / diagnostic imaging
  • Lung Neoplasms / pathology
  • Lung Neoplasms / surgery*
  • Male
  • Middle Aged
  • Operative Time
  • Pneumonectomy / adverse effects
  • Pneumonectomy / methods*
  • Prospective Studies
  • Radiation Dosage
  • Radiation Exposure
  • Solitary Pulmonary Nodule / diagnostic imaging
  • Solitary Pulmonary Nodule / pathology
  • Solitary Pulmonary Nodule / surgery*
  • Surgery, Computer-Assisted / adverse effects
  • Surgery, Computer-Assisted / methods*
  • Taiwan
  • Thoracic Surgery, Video-Assisted / adverse effects
  • Thoracic Surgery, Video-Assisted / methods*
  • Time Factors
  • Tomography, X-Ray Computed / adverse effects
  • Tomography, X-Ray Computed / methods*
  • Treatment Outcome
  • Tumor Burden