From Triportal to Uniportal Video-Thoracoscopic Lobectomy: The Single Surgeon Learning Curve by CUSUM Chart and Perioperative Outcomes

Background: Uniportal video-thoracoscopic lobectomy has improved postoperative out- comes in lung cancer patients. Thus, thoracic surgeons are increasingly required to learn this new approach. Methods: We evaluate the path of a single surgeon switch- ing from triportal video-thoracoscopic lobectomy to the uniportal, using the cumulative sum (CUSUM) analysis, in a single center to assess the learning curve, enrolling 107 unipor- tal video-thoracoscopic lobectomies consecutively performed. CUSUM analysis detected how many uniportal video-thoracoscopies occur to obtain changes in mean operation time, among all procedures consecutively performed. CUSUM analysis identified the cut-off at the 67th procedure; this value was used to divide all patients into two groups: group A (first 67 patients, early phase) and group B (40 patients, experienced phase). Then, we analyze the perioperative outcomes between the two groups. Results: Gender characteristics of the two groups were statistically similar. Median operative time de- creased significantly after the early phase [188 min (IQR: 151–236) vs. 170.5 (IQR: 134–202) (p-value = 0.02)], respectively. Similarly, during the second phase, the conversions rate de- creased: [10 (15%) (group A) vs. 1 (2%) (group B) (p-value = 0.04)], as did the postoperative complications [28 cases (42%) vs. 9 cases (22%) (p-value = 0.04)] and the length of stay [6 days (IQR 5–9.5) vs. 5 days (IQR 4–8) (p-value = 0.04)], giving evidence of skills acquired in the second phase. Conclusions: CUSUM analysis identified 67 uniportal lobectomies, after which operative time, conversion rate, and perioperative complications significantly decreased; the moving average analysis further supports a progressive reduction in opera- tive time. Despite prior multiportal video-thoracoscopic experience, switching to uniportal video-thoracoscopy requires a distinct learning process.