Highlights from the 3rd VATS International

VATS International

VATS International (previously known as Cambridge VATS) is the brainchild of Mr. (Dr.) Marco Scarci.  The Italian surgeon recently made the switch from NHS Papsworth (Cambridge) to the historic Royal London Hospital.  Each year, Dr. Scarci gathers the world’s specialists on minimally invasive surgery to meet here in the United Kingdom to share knowledge and practice techniques for traditional VATS, uniportal approaches (standard and subxyphoid) and robotic surgery.

This is the third year of the conference and it’s reputation for dynamic speakers and controversy continues.  With over 100 attendees, and a wide range of global participation as well as live surgery sessions and a wet lab, Dr. Scarci has had runaway success despite some last-minute challenges posed by his recent defection from the Cambridge facility.  (Having met several members of the rather staid and traditional thoracic surgery department at Cambridge, Dr. Scarci, with his emphasis on minimally invasive surgery, is undoubtedly better-suited to the London-based facility).

Excellent lecture content, dynamic speakers

There were several excellent speakers, making it difficult to narrow the selections for presentation here.  The obvious standout was Dr. Lim, (as discussed in a previous post).

As one of the course directors, and the inventor of the uniportal approach, Dr. Diego Gonzalez Rivas gave several lectures on the technique aspects of uniportal VATS.

Dr. David Waller followed up with a lecture entitled “Intra-operative problems in VATS lobectomy: Avoidance and Management.”  He discussed complicating patient factors such extensive adhesions, anthrocotic lymph nodes,  anatomical variance and incomplete fissures that increase the complexity of uniportal cases.  He also identified common surgical problems such as difficulty identifying the target lesion, development of large air leaks and inadvertent damage to hilum or bronchus with strategies to prevent & manage these issues.  He reviewed surgical techniques on bleeding control/ major vascular injury as well as absolute indications for surgical conversion such as equipment failures, airway injuries and stapler jams.  In closure, he also warned against using conversion rate as an outcome measure.  It was a fairly dry lecture despite being an interesting and important topic.

Among the remaining speakers, the overwhelming theme of change, and evolution along with an underlying sense of defiance continued. These surgeons are here to discuss, learn and practice uniportal surgery even if more traditional surgeons don’t approve.

Some of the best presentations were:

Dr. Alan Sihoe, (Hong Kong) gave a modified lecture called “Reasons not to perform uniportal VATS lobectomy”. This lecture which was adapted from a previous lecture from last year’s conference also addressed criticism of uniportal VATS.  He reviewed the existing literature on uniportal surgery which suggests that uniportal surgery is a safe alternative to other surgical approaches.

 

During the lecture, Dr. Sihoe encouraged surgeons to move past case reports to performing higher level research such as randomized control studies to create evidence in the area of uniportal surgery.  He also encouraged participation in the European database, to gather prospective data on uniportal surgery.  Until there is a larger body of literature utilizing higher levels of evidence, uniportal surgery will continue to face significant (and justifiable) criticism as a fad procedure.  While it wasn’t a ground-breaking lecture by any means, it was also a reminder for thoracic surgeons to think like a researcher.  It was a good follow-up on Dr. Lim’s opening lecture.

Dr. Gaetano Rocco (Italy).

Dr. Rocco, one of the pioneers of the uniportal approach, continued the discussion of the need for evolution and adaptation but with a different approach in a talk entitled, “VATS major pulmonary resection for (very) senior surgeons.  He extended an olive branch to older, experienced thoracic surgeons with limited experience with VATS.  His lecture discussed the ways to remediate older surgeons, and build their skills and comfort level in performing VATS procedures.  His lecture offered a clear-cut and concrete , step-wise curriculum and self-assessment tool for surgeons looking to improve their VATS skills, starting with VATS lobectomy.

 

Dr. Ali Khan (India) delivered two lectures, the first on operating room technology, but it was the second on uniportal surgery for inflammatory and infectious diseases that really piqued my interest.  Part of this is due to my interest in the surgical treatment of tuberculosis, and my great appreciation for empyema as a surgical disease.  Most readers know that reducing the time from presentation/ diagnosis of empyema to surgical decortication is one of my goals in daily practice, so any reminder that the morbidity/ mortality of decortications have been greatly reduced by minimally invasive surgery is always welcome.

 

Honorable mention:  Dr. Alex Brunelli, “Fast track enhanced recovery for MITS”.  Basically a talk on care plans with specific markers for timely progression and discharge.  While this is standard fare for nurses, the use of care plans for many surgeons is unfamiliar territory.  It would have been nice if the care plans were available as a handout for surgeons who are still fine-tuning their own programs.  It also would have been nice for a better breakdown of how specific items reduced the length of stay (how/ how much) or decreased the rate of complications.  Nice to mention care plans but better to have measurable and specific examples.

After the extensive lecture series on the first day of the conference, the second day was devoted to live surgery cases and the practice lab.

Wet Lab 

Since animal research of any kind is tightly controlled in the United Kingdom, 3D printed models were used for the wet lab portion of the course.

This is the first time that this type of model has been used.  While the green plastic  housing looks rudimentary, on closer inspection of the ’tissue’ inside, one gets a better appreciation for the models.  The tissue is soft, and sponge-like.  The lung doesn’t inflate but appears more lifelike than other models.

I don’t have the patience or temperament to shoot video footage, but I did record a couple of seconds so readers could have an idea what the wet lab portion of the course is like.  In the video, Dr. Sihoe is instructing two trainees on the proper technique.

 

Despite its relative youth, VATS International remains one of the best conferences on minimally invasive surgery, inferior to none.  This conference is highly recommended and considered superior to many of the traditional conferences on the topic  (such as the annual Duke conference), due to lecture content on timely topics and controversial issues.  The hands-on wet lab and participation by internationally recognized and globally diverse speakers makes this conference more valuable to attendees looking for exposure to newer surgical techniques.

Thoracics.org 2017 wish list

What would I like to see next year?  As mentioned above, VATS International is one of the better courses available for surgeons interested in uniportal, subxyphoid and other minimally invasive techniques.  But there is still more content I’d like to see –  on nonintubated and awake surgery, for example.

However, with regards for this year’s speaker, an anesthesiologist from Papsworth Hospital, this topic would be better covered by one of the “masters” of the field; Dr. Eugene Pompeo of the Awake Surgical Group or Drs. Hung & Chen.  The “Papsworth Experience” per se is limited to heavy sedation/ general anesthesia without mechanical ventilation.  Patients still have LMAs and are heavily sedated.  One of the main benefits of nonintubated anesthesia is the ability to operate on the medically fragile.  It would be enlightening to hear more about operating on this population from more experienced clinicians.  One of the topics that has been essentially ignored in the literature on this topic, is the implications for thoracic surgeons, anesthesiologists,  operating room and recovery room staff on operating on this population of sicker patients.  I think readers would like to hear about the new challenges in managing patients that were previously inoperable due to serious co-morbidities.

A discussion on developing or actualizing a formal certification process with examination for minimally invasive surgery with suggested curriculum, and case log requirements would be a nice addition.  Blackmon et al. published a credentialing guideline but it’s a multi-part overly complex document full of “levels” of competency.  I’d like to see a discussion on the development of an actual certification to be offered by a surgical licensing body or surgical society.  Since the American agencies would probably take another 20 years to consider the idea, perhaps one of the guest speakers’ native society would be more willing to take on this project?

I’d also like to see at least a limited amount of content on esophageal surgery.  I know, I know..While practice areas for thoracic surgeons vary around the globe, with the rapid rise in esophageal cancer, a lecture on the role of minimally invasive surgical techniques for esophageal surgery would be a great addition to the current roster of topics, particularly if it was given by one of the modern masters of esophageal surgery like Dr. Benny Weksler or Dr. Roy Chen.

Lastly, one of the most enjoyable aspects of this conference is the truly international flavor.  Watching a surgeon from Israel demonstrate uniportal techniques from a practice site in Shanghai brings home the importance of global collaboration.  Hearing surgeons from India, Brazil, France and Canada present data on their practices is critical to gain perspective, and exchange ideas.  It also helps prevent attendees from falling into the trap of “we’ve always done it this way.”  This concept could be expanded to include designated global snapshots, to highlight research or data in specific geographic areas, like Dr. Khan’s lecture on uniportal approaches for infectious and inflammatory disease.

A full lecture on cost containment techniques for surgeons practicing in hardship areas would be a great topic.  Dr. Sihoe touched on the issue during one of his lectures, but since I’ve heard other surgeons talk about the limitations posed by having only one thoracoscope, I’d love to see an equipment representative give a lecture on maintaining thoracoscopes, where to donate old scopes or how to rehab these scopes for a second life.  A talk about modifying existing surgical instruments for surgeons who can’t afford the Scanlan set would be helpful as well.  One of the reasons these courses have been so successful it the fact that they are technically based, so adding a section like this might help spread the uniportal technique to a whole socio-economic and geographic segment of patients that it might not otherwise reach.

This last item might be a tall order for Dr. Scarci and his group but he’s done pretty well thus far.