Training in Thoracic Surgery: From Virtual Simulation to Real Practice

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In this video, the authors report how they were able to simulate a lung lobectomy in uniportal video-assisted thoracoscopic surgery (VATS) by developing a 3D rib cage and lung model, which is useful for training residents in lung resections. 

A training center for minimally invasive surgery was established at the authors’ university hospital in 2005. The center was organized by a multidisciplinary team that included engineers, computer scientists, economists, and doctors, and was named EndoCAS (Endoscopic Computer-Assisted Surgery). It is located within the grounds of Azienda Ospedaliero-Universitaria Pisana (AOUP), Italy. 

EndoCAS' mission is to become the reference center in Italy for training residents in minimally invasive surgical procedures through simulation. The first step was to obtain accreditation from the American College of Surgeons (ACS) in 2013, and now the EndoCAS center at the University of Pisa is the only Italian center accredited by the ACS, offering a unique learning experience in Italy. 

At the EndoCAS center, thoracic surgery residents can participate in training sessions aimed at helping them acquire fundamental knowledge about minimally invasive instruments, familiarize themselves with these instruments, and develop appropriate skills. 

The authors organized a course in which, following short theoretical lessons, the residents engaged in practical sessions through virtual simulators, such as LapSim, with the goal of transferring moments of the surgical procedure—such as performing endoscopic sutures, tying knots, coagulating a vessel—into exercises where basic skills were acquired. Several selected tasks were trained, and the scores of all trainees were saved in each simulator. 
Once basic movements were acquired, the authors recreated a simulation of an actual surgery. They involved a team of biomedical engineers and asked them to create a realistic model of the lung parenchyma and chest wall, inside which they placed their realistic lung. 

A full-size chest cage model that included all the bone structures present in a hemithorax (sternum, vertebrae, and ribs) was created based on CT images using a 3D printer. Three of these ribs (in the fourth and fifth intercostal spaces, which are usually used for access in surgical procedures on the lung in uniportal VATS) were designed to be mobile as if they were terminating in joints. This model was attached to the operating bed by a support that allowed it to be immobilized and covered with tissue simulating human skin. Inside the chest, a 3D model of the lung was placed, made with biological material that is strikingly similar to the sponge-like texture of lung lobes, in tandem with the vessel network and lymph node positions of the actual human body. The consistency of the structures realistically simulated the consistency of human tissues and allowed for the coagulation of tissues by energy devices that were the same as those used in the operating room. 

The trainee residents have access to surgical tools that are commonly used in the operating room for VATS procedures, such as vacuum devices, ring pliers, and scissors, and energy devices to perform the dissection of the tissue layers. The sectioning of the bronchial, vascular, and scissural lung parenchyma was made using mechanical suturing machines. To perform a lobectomy procedure, operators have a 10 mm, 30-degree endoscopic camera that transmitted images by cable to a monitor, allowing visualization inside the chest model. Trainees sequentially alternated between the roles of the first operator, assistant, and scope holder. 

Access to the chest cavity for uniportal VATS was made at the fifth intercostal space. A soft tissue retractor was then placed, and the optics along with the surgical instruments were inserted into the chest cavity, allowing the procedure to begin.  

The authors decided to perform a lower right lobectomy in this specific case, simulating a malignant lung tumor. The senior surgeon oversaw and directed the procedure at all times, providing step-by-step instructions to learners, advice on how to insert instruments into the chest cavity, and the best gripping techniques for the lung parenchyma. 

Initially, trainees explored the pleural cavity, pulmonary parenchyma, and mediastinum. At this stage, the trainees practiced moving the various lobes to expose the hilar vascular structures and the main lymph node stations. Sutures were color-coded to facilitate the recognition: red for arterial vessels, blue for venous vessels, yellow for bronchial structures, black for lymph nodes, and grey for nervous structures. 

The dissection of tissues using the energy device was then started to isolate the structures that needed to be resected near the hilum. 

The surgeons released the lower lobe by resecting the pulmonary ligament and removing the lymph node station 9. After identifying the vein afferent to the lower lobe and taking care to save the afferent to the middle lobe, they isolated this structure, which they would return to later for its section using staplers. 

Then, the surgeons approached the intersection between the large and small fissure, with the aim of identifying the arterial crossroads. By continuing the interlobar posterior and anterior dissection, enough space was created to insert staplers with gold and blue charges to complete the separation of the fissures, isolating the lower lobe from the upper and middle lobes. To facilitate the positioning of the stapler for separating the front portion of the fissure, an endoloop was used.  

At this point, the authors completed the isolation of the arterial structures of the lower lobe (artery of the base pyramid and artery for the apical segment of the lower lobe), taking care to also identify the artery that supplied the middle lobe. 

Once control of all vascular structures was obtained, the resection began. The surgeons started with the vein for the lower lobe, using a powered vascular stapler (PVS) with a white charge of 35 mm to resect in two phases— the trunk of the base pyramid and then the vein vessel from the apical segment of the lower lobe. Next, the surgeons approached the arterial branch, again using a 35 mm PVS. 

After removing some hilar lymph node stations that prevented a safe resection, the bronchus was the last structure to be resected, as often happens in pulmonary resections of this type, given its posterior position to the other structures. To complete this step, a stapler with a black charge 45 mm was used.  

Once the resection was completed, the specimen was removed from the uniportal access using surgical bags. Finally, a lymphoadenectomy of stations 2R and 4R was preformed, taking care to display and save the right recurrent nerve, and the exercise was considered concluded. 

The authors hope that this can serve as the beginning of a journey for residents, guiding them toward greater autonomy during real surgical procedures in the operating room. The video concludes with the senior resident performing the steps of the pulmonary ligament dissection and the division and suturing of the arterial and venous branches during a pulmonary lobectomy with the support of the attending surgeon. 

References

1. Pontiki AA, Rhode K, Lampridis S, Bille A. Three-Dimensional Printing Applications in Thoracic Surgery. Thorac Surg Clin. 2023 Aug;33(3):273-281. doi: 10.1016/j.thorsurg.2023.04.012. PMID: 37414483.

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