Early outcomes in 147 consecutive cases of subxiphoid single-port thymectomy and evaluation of learning curves.

OBJECTIVES: The aim of the present study was to examine some initial results and learning curves concerning subxiphoid single-port thymectomy (SSPT), thereby clarifying the safety of this surgical approach and describing the precautions for adopting it. METHODS: From March 2011 to August 2019, a total of 203 patients underwent thymectomy for either anterior mediastinal tumours or myasthenia gravis at Fujita Health University Hospital. Of these 203 patients, 147 patients who had undergone SSPT were selected as participants for the present study. RESULTS: Of the 147 cases, transition to a different approach was required in three (2.0%) cases: two (1.3%) cases transitioned to median sternotomy, whereas one (0.7%) case transitioned to the side chest trans-intercostal approach. The two cases that transitioned to median sternotomy were the second cases for different operators after they began performing this technique. There were six (4.0%) cases with complications and no deaths. The operation time cumulative summation learning curve analysis revealed that the curves descended from the 38th case. In the 83 cases handled by one surgeon, the learning curves descended from the 31st case. CONCLUSIONS: SSPT is a safe modality with few complications and no associated cases of mortality reported. Operators are required to experience 31-38 cases until the operation time for SSPT was stabilized. Special care should be exercised to prevent vascular damage in the vicinity of the innominate veins during the early stages after SSPT introduction.

Robotic Thymectomy: Learning Curve and Associated Perioperative Outcomes.

INTRODUCTION: Recently, robotic-assisted thymectomy (RAT) has emerged as an alternative to either, an open transsternal approach or to a video-assisted thoracoscopic approach, for both thymic tumors and benign lesions. We have reviewed our early experience with RAT to assess the associated learning curve as well as the short-term perioperative outcomes. METHODS: A prospectively collected database was reviewed for patients who underwent RAT for all causes in the period 2012-2016. Robotic thymectomy cases were stratified and compared according to the number of cases performed by each surgeon (≤15 versus >15 cases). A propensity score matching was done to compare perioperative outcomes in patients undergoing robotic and transsternal resection of thymomas. RESULTS: Seventy patients (47 females) with a median age of 52, underwent RAT. The median operative time was 102 min with 5 conversions to an open approach for local invasion (n = 3) or for complete pleural symphysis (n = 2). There were 2 rib fractures and 1 recurrent laryngeal nerve palsy. Median length of chest tube drainage and length of stay were 1 and 3 days, respectively. Operative time and estimated blood loss plateaued after surgeon's initial 15-20 cases, which may reflect the initial learning curve. A comparison between early and late robotic cases showed that with the growing experience, the operative time becomes shorter (94 versus 107 min, P = .018). Propensity score analysis between robotic and transsternal resection of thymoma (n = 22 in each group) showed no significant differences in operative time (P = .79), intraoperative complications (P = .99), or postoperative complications (P = .99). CONCLUSIONS: Robotic thymectomy is feasible and safe, and is associated with comparable perioperative outcomes to the traditional transsternal approach in patients undergoing thymomectomy. An initial learning curve of 15-20 robotic thymectomy cases may be required by the surgeons to adequately perform this relatively novel technique.

Trans-Atlantic Telementoring with Pediatric Surgeons: Technical Considerations and Lessons Learned.

PURPOSE: Although surgical residency training is a structured, regulated system for surgical skill acquisition, after residency or fellowship, no good method exists for practicing surgeons to learn new, developing techniques. Because 1-2-day simulation courses are probably inadequate for teaching a new technique and because it is often unrealistic for a practicing surgeon to leave his or her practice for an extended period of time, surgical telementoring may be a solution by allowing an expert to support a trained surgeon through the learning curve of a new procedure while overcoming geographic distance. In the past we have presented 6 cases of transcontinental telementoring with pediatric surgeons in the United States. We have since expanded the concept to trans-Atlantic telementoring and performed 2 cases with pediatric surgeons in France. MATERIALS AND METHODS: The two telementors and one of the two telementees had previously met through a professional society but had never operated together before this experience. The first procedure was an interval laparoscopic appendectomy to test the process. The second procedure was a thoracoscopic total thymectomy. The technology consisted of the VisitOR1® telementoring robot (Karl Storz GmbH & Co. KG, Tuttlingen, Germany). RESULTS: Both procedures were completed successfully with high satisfaction from both the telementors and telementees. Latency was low, and there was no loss of connection. The telestration and laser pointer features of the robot facilitated the telementoring experience. Challenges included lack of a prior surgical relationship between the mentees and mentors that limited the depth of advice but did not impair the quality of the surgery, as well as poor audio quality that was overcome using headsets. CONCLUSIONS: From this experience, several challenges were identified and addressed. Telementoring may be an effective means of improving adoption of new surgical techniques, ultimately improving patient care.

Learning curve in videothoracoscopic thymectomy: how many operations and in which situations?

OBJECTIVE: Videothoracoscopic learning curve is known to vary among different surgeons, and may be influenced by patients and various situations. We aimed to analyze the learning curve of a surgeon in videothoracoscopic thymic surgery for myasthenia gravis. METHODS: This is a descriptive single-center study using collected clinical data from 90 patients undergoing videothoracoscopic thymic surgery between June 2002 and September 2006. Cumulative summation (CUSUM) model was used to evaluate the learning curve for videothoracoscopic thymectomy operations. Unsuccessful situations were accepted as longer operation time, surgeon-related open conversions, readmissions and postoperative complications. Factors affecting longer operation time (patients with operation time longer than the average) and longer postoperative stay (patients with postoperative hospital stay longer than average) were analyzed. RESULTS: Body mass index (BMI) was the only predictor of longer operation time (23.04+/-2.93 vs 25.61+/-2.70 (p=0.001) independent samples test). The amount of prescribed pyridostigmine was the only factor for longer hospital stay (213.3+/-101.5 mg vs 270. 0+/-122.6 mg (p=0.044) Mann-Whitney U-test). CUSUM analysis demonstrated a learning curve with success rates of 80%, 90% and 98%, respectively in the first 30 patients, the next 31-60 patients and after 60 patients. Median operative time declined with surgeons' experience (p<0.001). CONCLUSIONS: A chest surgeon can have a high success rate in videothoracoscopic thymectomy (98%) after 60 operations.