Abstract
Objective
The difficulty of surgery, which is related to surgical safety, has only been mentioned as a subjective perception for a long time. There are few studies to quantitatively and systematically evaluate the difficulty of thoracic surgery. This study aims to establish a quantitative evaluation index system for thoracic surgical difficulty, and to evaluate its reliability and validity.
Methods
During the 2 national thoracic surgery academic conferences, the factors that may affect the difficulty of thoracic surgery were evaluated by the thoracic surgeons via semi open questionnaires, and then the evaluation item pool of thoracic surgery difficulty was established. The importance of each indicator in the evaluation item pool was graded by 2 rounds of Delphi method. The average score, full score rate and coefficient of variation of each index were calculated, and the composite index method was used to decide whether to delete the indicator.Finally, the difficulty evaluation scale of thoracic surgery was constructed. The surgical data of patients with thoracic tumors were collected. The scale was used to evaluate the difficulty of thoracic surgery for lung, esophageal, and mediastinal tumors. The reliability and validity of the scale were evaluated by the commonly used difficulty evaluation indexes: Operation time, intraoperative estimated blood loss, Visual Analog Scale (VAS), side injury rate, and blood transfusion rate as standards.
Results
A total of 230 questionnaires were distributed in the 2 rounds of survey, and 149 valid questionnaires were collected after eliminating duplicate questionnaires. Through 2 rounds of Delphi consultation with 20 experts, the difficulty evaluation indexes were scored and screened, and the difficulty evaluation scale of thoracic surgery was established. It included 5 main indexes (surgical decision-making, operation space, separation interface, reconstruction method, and surgical materials) and 16 secondary indexes [American Society of Anesthesiologists (ASA) classification, surgical trauma, operator experience, space size, space depth, space source, space adjacent, interface content, anatomical gap, visual field, interface size, reconstruction complexity, reconstruction scope, autologous materials, artificial biomaterials and instruments]. After weighting, the total score of Thoracic Surgery Difficulty Evaluation Scale was from 1 to 3. A Score at 1 standed for simplicity, and score at 3 standed for difficulty. Further data were collected for 127 cases of thoracic tumor surgery. The difficulty scores of surgery for lung, esophageal, and mediastinal tumor were 1.69±0.26, 1.86±0.18, and 1.56±0.31, respectively, and the Cronbach’s α coefficients of the scale in 3 tumor surgeries were 0.993, 0.974, and 0.989, repectively, and the Spearman Brown coefficients were 0.996, 0.984, and 0.996, respectively. The Spearman correlation coefficients of operation difficulty score with operation time, estimated blood loss, and VAS were 0.360 and 0.634, 0.632 and 0.578, 0.696 and 0.875, respectively (all P<0.05). The incidence of postoperative complications in the difficult operation group (difficulty score >1.85) was higher than that in the non-difficult operation group (P=0.02).
Conclusion
The quantitative Thoracic Surgical Difficulty Assessment Scale has been successfully established, which shows good reliability and validity in thoracic tumor surgery. The Thoracic Surgical Difficulty Assessment Scale has broad application prospects in reducing the difficulty of the surgery, controlling surgical complications, and training surgeons.
Keywords: thoracic surgery, surgical difficulty, Delphi method, assessment scale
Abstract
目的
手术难度关系到手术安全，但长期以来仅作为一种主观感受被描述。目前，对胸外科手术难度进行量化评价的研究较少。本研究旨在使用会议调查结合德尔菲法构建胸外科手术难度量表，并应用于胸部肿瘤手术中以评价其信度和效度。
方法
在2次全国性胸外科会议期间，以半开放性问卷的方式向与会胸外科医生代表调查可能影响手术难度的因素，建立胸外科手术难度评价条目池。利用2轮德尔菲专家咨询法对条目池中各指标的重要性进行评分。计算各指标的平均分、满分率和变异系数，采用综合指数法决定是否删除该指标，构建胸外科手术难度评价量表。收集胸部肿瘤患者的手术资料，应用该量表评价胸外科肺部、食管和纵膈肿瘤手术的难度。以目前常用的难度评价指标：手术时间、术中估计失血量、视觉模拟评分(Visual Analogue Scale，VAS)、副损伤率、输血率作为标准，评价量表的信度和效度。
结果
2轮会议调查一共发放问卷230份，排除重复问卷后回收有效问卷149份。通过20位专家的2轮德尔菲法咨询对各难度评价指标进行评分及筛选，由此形成的胸外科手术难度评价量表包括5项主要指标(手术决策、操作空间、分离界面、重建方法和手术材料)和16项次要指标[美国麻醉医师协会(American Society of Anesthesiologists，ASA)分级、手术创伤、术者经验、空间大小、空间深度、空间来源、空间毗邻、界面内容、解剖间隙、视野、界面大小、重建复杂度、重建范围、自体材料、人工生物材料及器械]。赋予权重后，胸外科手术难度评价量表的总评分为1~3。1分表示极简单，3分表示极困难。进一步收集127例胸部肿瘤手术资料。肺部肿瘤、食管肿瘤及纵隔肿瘤手术的难度评分分别为1.69±0.26、1.86±0.18及1.56±0.31，胸外科手术难度评价量表在3种手术中应用的Cronbach’s α系数分别为0.993、0.974及0.989，Spearman-Brown系数分别为0.996、0.984及0.996。肺部肿瘤手术和纵膈肿瘤手术中手术难度评分与手术时间、术中估计失血量及VAS的Spearman相关系数分别为0.360和0.634、0.632和0.578，以及0.696和0.875(均P<0.05)。困难手术组(手术难度评分>1.85)的术后并发症发生率显著高于非困难手术组(P=0.02)。
结论
成功构建了可量化的胸外科手术难度评价量表，并在胸部肿瘤手术中显示出较好的信、效度。胸外科手术难度评价量表在降低手术难度、控制手术并发症和培训外科医生方面具有广阔的应用前景。
Keywords: 胸外科手术, 手术难度, 德尔菲法, 评价量表
Complex and difficult operations account for a high proportion of thoracic surgery. The complication rate of lung cancer surgery is from 26.0%[1] to 30.3%[2], much higher than that in the upper abdomen (16% to 17%) or lower abdomen (0 to 5%) [3]. The difficulty of operation is closely related to safety, and is an urgent concern of the patient and the surgeon. The commonly used surrogate indicators of surgical difficulty include operation time (OT), estimated blood loss (EBL), subsidiary injury, conversion to open surgery, and Visual Analogue Scale (VAS). Some researchers have established the difficulty evaluation model of endoscopic retrograde cholangiopancreatography (ERCP)[4], radical colectomy[5], and laparoscopic cholecystectomy[6], and applied it to preoperative difficulty prediction and complication analysis.
The Delphi method’s main process is that the investigator designs a questionnaire and organizes some experts according to a certain investigation purpose, and solicit their opinions on it by mail. There is no discussion among the experts. The investigator summarizes the opinions and then gives them back to the experts. After several times of repeated consultation and feedback, the opinions of the experts gradually tend to be concentrated, and finally a collective judgment result with a higher recognition rate is obtained. This method can avoid the defects such as blind obedience and excessive influence of authoritative experts that may appear in collective discussions, and has been widely used in various fields[7-8].
The purpose of this study is to consult and summarize the domestic thoracic surgeons’ views and opinions on the difficulty of surgery via the Delphi method, to construct an evaluation index system for the difficulty of thoracic surgery, and to evaluate its reliability and validity.
1. Subjects and methods
1.1. Collection of items
We collected items by surveying 230 thoracic surgeons from 65 hospitals across the country through expert consultation seminars and 2 rounds of national meetings.
1.2. Determination of Delphi consulting experts
Experts invited for Delphi survey should meet the following conditions: 1) working in a tertiary-level A general hospital; 2) being engaged in thoracic surgery; 3) having an associate senior title or above, with great influence in their respective research fields; 4) having relevant work experience for more than 15 years; 5) being interested in the evaluation of the difficulty of surgery. After selection, 20 experts from 10 tertiary hospitals in 4 provinces/cities across China formed an expert consulting group.
1.3. Implementation of Delphi consulting
In the first round of consultation, we sent experts the “Expert Consultation Form for the Definition of Technical Difficulty of Thoracic Surgery and Evaluation Index System (First Round)” in the form of a letter, which was prepared via the meeting surveys. The experts filled out the questionnaire in a “back-to-back” manner and sent it back. There was no discussion between the experts on the questionnaire content. The researchers summarized the experts’ scores and revision opinions for each item. On this basis, compiled the “Expert Consultation Form for the Evaluation Index System of Thoracic Surgical Difficulty (Second Round)”, and then sent the letter again to the experts. Finally, we collected the experts’ feedback for analysis.
1.4. Evaluation of reliability and validity of the scale
The surgical data of 127 patients with thoracic tumors were collected prospectively, and the scale was used to evaluate the difficulty of thoracic surgery for lung, esophageal, and mediastinal tumors. The Cronbach’s α coefficient and Spearman Brown split-half reliability were used to evaluate the reliability of the scale. Due to the lack of a gold standard for the evaluation of operation difficulty, we took the commonly used surrogate indicators, including operation time, EBL, VAS, blood transfusion rate, and subsidiary injury rate as the standards to evaluate the validity of the scale.
1.5. Statistical analysis
After collecting the data, a value of 0 to 10 points was assigned from “very unimportant” to “very important”. The mean score, full score rate, and coefficient of variation of each indicator were calculated. A comprehensive index was used in the evaluation of secondary indicators: Comprehensive index=mean score×full score rate/coefficient of variation. The ranking of the comprehensive index determined whether to delete the indicator.
With the cut-off of 1.85, the total score of operation difficulty >1.85 was classified as a difficult operation group, and the total score of operation difficulty ≤1.85 was classified as a non-difficult operation group. The incidence of postoperative complications was compared between the 2 groups.
SPSS statistical software (Version 21) and Excel software were used for statistical and datum analysis, including mean calculation, t test, chi-square test. A P<0.05 was considered statistically significant.
2. Results
2.1. Meeting survey
A total of 230 questionnaires were distributed in the 2 rounds of meeting survey, and 149 valid questionnaires were recovered after eliminating duplicate questionnaires. The age of the respondents was (39.2±7.1) years and the working experience was (13.9±9.3) years.
Respondents believed that difficult surgery accounted for about 20% of thoracic surgery. About 80% of the responders believed that the difficulty of operation was related to postoperative complications. A selection pool for surgical difficulty evaluation items including 4 primary indicators and 15 secondary indicators was established. These indicators were used in the follow-up Delphi survey.
2.2. General information of participating experts in Delphi consulting
There were 20 participating experts (12 with senior professional title, 8 with deputy senior professional title), and all of them were thoracic surgeons with rich experience working in a tertiary-level A general hospital. Their ages were (47.9±6.5) years and their working experiences were (24.2±6.5) years.
In the first round of Delphi consulting, 19 valid questionnaires were returned, with a response rate of 95%. In the second round, 16 valid questionnaires were returned, with a response rate of 80%.
2.3. Selection and modification of evaluation indexes
In the first round of consultation, the experts had a high degree of recognition for the 4 first-level indicators, while 3 experts suggested that indicators related to “surgical decision-making” should be added as the first-level indicator. The indicators that rank the bottom third of the comprehensive index of the secondary indicators were: Auxiliary materials, alternative technologies, enhanced technologies, spatial sources, and reconstruction technologies. Combining the comprehensive index score, expert advice, and the professional characteristics of each indicator, after discussion by the research group, we initially modified the indicator system as follows: 1)Adding “surgical decision-making” as the first-level indicator; 2) deleting the second-level indicator “space size” and “interface size”; 3) modifying the secondary indicators under “reconstruction method” to “complexity” and “reconstruction range”; 4) changing the index classification to 3 grades; 5) combining characteristics of thoracic surgery to define indexes. We added the above modifications to the second round of consultation questionnaires to consult other experts. At the same time, the median and upper and lower quartiles of the weights of various indicators in this round of consultation, and the reasons for experts to make their suggestions were included in the second round of Delphi consultation form.
We analyzed the opinions of the experts on the second round of consultation form, and adjusted the scale as follows: 1) Adding the first-level index “surgical decision-making” and the corresponding second-level index “American Society of Anesthesiologists (ASA) grade”, “surgical trauma”, and “experience”; 2) using “complexity” and “reconstruction scope” as the secondary indicators of “reconstruction method”; 3) using “autologous reconstruction materials”, “artificial materials”, and “surgical instruments” as secondary indexes of “materials and instruments”; 4) changing the definition of the index to reflect the characteristics of thoracic surgery; 5) changing the index classification to a three-level classification; 6) refusing to delete “operating space size” and “dissecting interface size”. Finally, 5 first-level indicators and 16 second-level indicators were retained.
The median values of the indicators of the second round were not significantly different from those of the first round, but the coefficient of variation was significantly smaller than that in the first round, showing that the experts’ views on the indicators reached consensus. The consultation ended with the establishment of the Thoracic Surgical Difficulty Assessment Scale (Table 1).
Table 1.
Thoracic Surgical Difficulty Assessment Scale
| Primary indicators | Secondary indicators | Grade | Definition |
|---|---|---|---|
| Surgical decision-making | ASA grade | 1 | ASA grade: 1-2 |
| 2 | ASA grade: 3 | ||
| 3 | ASA grade: 4 | ||
| Surgical trauma | 1 | Small | |
| 2 | Medium | ||
| 3 | Large | ||
| Experience | 1 | Highly experienced | |
| 2 | Not enough experience | ||
| 3 | Lack of experience. It is an innovative technique or in the early stage of the learning curve of the technique | ||
| Operating space | Size | 1 | Large and unlimited |
| 2 | Medium and slightly limited | ||
| 3 | Small and severely limited | ||
| Depth | 1 | Superficial | |
| 2 | Medium | ||
| 3 | Deep | ||
| Adhesion | 1 | No adhesion | |
| 2 | Partial adhesion | ||
| 3 | Severe adhesion | ||
| Adjacent organs | 1 | No important organs are adjacent | |
| 2 | The adjacent organs that may cause complications are easy to be injured | ||
| 3 | The adjacent organs that affect life safety are easy to be injured | ||
| Dissecting interface | Interface content | 1 | No important structure is seen |
| 2 | There are important structures in the interface. | ||
| 3 | There are important structures directly affecting life safety in the interface, such as large blood vessels, heart | ||
| Anatomical space | 1 | The tissue interface is well developed | |
| 2 | The interface is not clear or damaged to a certain extent | ||
| 3 | The tissue interface has been seriously damaged, such as severe dysplasia of lung fissure, tumor invasion of blood vessels, etc | ||
| Vision | 1 | Clear | |
| 2 | Slightly affected | ||
| 3 | Severely affected | ||
| Size | 1 | Small | |
| 2 | Medium | ||
| 3 | Large |
Table 1.
(to be continued)
| Primary indicators | Secondary indicators | Grade | Definition |
|---|---|---|---|
| Reconstruction method | Complexity | 1 | No or simple reconstruction |
| 2 | Medium | ||
| 3 | Complex reconstruction (Such as reconstruction of carina, trachea, and large blood vessels; large defects of the chest wall require transfer of myocutaneous flaps, etc) | ||
| Reconstruction range | 1 | None or small (Such as single blood vessel replacement, simple bronchial formation, or angioplasty) | |
| 2 | Medium (Such as replacement of 2-3 blood vessels, bronchial and pulmonary arteries formation concurrently) | ||
| 3 | Large (Such as replacement of more than 3 blood vessels) | ||
| Materials and instruments | Autologous reconstruction materials | 1 | None |
| 2 | Autologous materials that are simple and easy to obtain, such as pericardium and omentum | ||
| 3 | Complex autologous materials, such as myocutaneous flaps | ||
| Artificial materials | 1 | None | |
| 2 | Widely used Artificial tissue materials, such as titanium plate, steel plate, artificial blood vessel | ||
| 3 | Special artificial materials, such as special customized titanium (steel) plate | ||
| Instruments | 1 | Basic | |
| 2 | Special |
ASA: American Society of Anesthesiologists.
2.4. Weight of indexes
According to the second round of consultation, experts increased their recognition for all the indicators, and the decreased variability showed obvious convergence of opinions. Based on the importance of each indicator, we calculated the weights of each indicator (Table 2).
Table 2.
Weight value of Thoracic Surgical Difficulty Assessment Scale
| Primary indicators | Secondary indicators | Weight |
|---|---|---|
| Surgical decision-making | ASA grade | 0.06 |
| Surgical injury | 0.07 | |
| Experiences | 0.07 | |
| Operating space | Size | 0.05 |
| Depth | 0.05 | |
| Source | 0.05 | |
| Adjacent organs | 0.05 | |
| Dissecting interface | Anatomical space | 0.05 |
| Interface contents | 0.05 | |
| Vision | 0.05 | |
| Size | 0.05 | |
| Reconstruction method | Complexity | 0.10 |
| Reconstruction range | 0.10 | |
| Materials and instruments | Autologous reconstruction materials | 0.07 |
| Artificial materials | 0.06 | |
| Instruments | 0.06 |
ASA: American Society of Anesthesiologists.
After weighting, the total score of Thoracic Surgical Difficulty Assessment Scale was between 1 and 3 points. “1” standed for simplicity and “3” standed for difficulty.
2.5. Evaluation and application of the scale
From December 2013 to February 2014, surgical data of 127 patients with thoracic tumor were collected prospectively, including 89 patients with lung tumor, 18 patients with esophageal tumor, and 20 patients with mediastinal tumor. The surgeon filled in the Thoracic Surgical Difficulty Assessment Scale within one day after operation. At the same time, ASA grade, operation time, EBL, subsidiary injury, blood transfusion, conversion to thoracotomy, and complications were collected (Table 3).
Table 3.
Difficulty score of thoracic tumor surgery (n=127)
| Indexes | Difficulty Score* | ||
|---|---|---|---|
| Lung (n=89) | Esophageal (n=18) | Mediastinal (n=20) | |
| Surgical decision-making | 0.33(0.33, 0.39) | 0.33(0.33, 0.39) | 0.29(0.26, 0.33) |
| Operating space | 0.40(0.30, 0.40) | 0.40(0.35, 0.41) | 0.40(0.25, 0.45) |
| Dissecting interface | 0.35(0.30, 0.40) | 0.37(0.30, 0.45) | 0.38(0.25, 0.44) |
| Reconstruction method | 0.31(0.31, 0.31) | 0.31(0.31, 0.41) | 0.21(0.21, 0.21) |
| Materials and instruments | 0.34(0.26, 0.35) | 0.39(0.31, 0.47) | 0.27(0.24, 0.32) |
| Sum | 1.69±0.26 | 1.86±0.18 | 1.56±0.31 |
*Median (lower quartiles, upper quartiles).
The Cronbach’s α coefficients of the scale in lung, esophagus, and mediastinum tumor surgery were 0.993, 0.974, and 0.989, and the Spearman Brown coefficients were 0.996, 0.984, and 0.996, respectively. In this study, the internal consistency of the scale in lung, esophageal, and mediastinal tumor surgery scores reached more than 0.9, indicating that the scale has good internal consistency in these 3 types of surgery.
Operation time, EBL, VAS, blood transfusion rates, and subsidiary injury rates were used as surrogate indexes to evaluate the validity of the scale.
The difficulty score of lung and mediastinal surgery was significantly correlated with operation time, EBL, and VAS (Table 4). We further compared the difference of difficulty score between patients with or without subsidiary injury and blood transfusion (Table 5).
Table 4.
Correlation between difficulty score and surrogate indexes (n=127)
| Surrogate indexes | Lung | Esophageal | Mediastinal | |||
|---|---|---|---|---|---|---|
| rs | P | rs | P | rs | P | |
| Operation time | 0.360 | 0.010 | 0.047 | 0.854 | 0.634 | 0.003 |
| Estimated blood loss | 0.632 | <0.001 | 0.402 | 0.099 | 0.578 | 0.008 |
| VAS | 0.696 | <0.001 | 0.004 | 0.987 | 0.875 | <0.001 |
rs : Spearman correlation coefficient; VAS: Visual Analogue Scale.
Table 5.
Difference of operation difficulty score between patients with or without subsidiary injury and blood transfusion (n=127)
| Surrogate indexes | Subsidiary injury | P | Blood transfusion | P | ||
|---|---|---|---|---|---|---|
| Yes | No | Yes | No | |||
| Lung | 1.95±0.12 | 1.68±0.25 | 0.021 | 2.07±0.33 | 1.67±0.23 | <0.001 |
| Esophageal | 1.94±0.11 | 1.84±0.19 | 0.420 | 1.77±0.20 | 1.87±0.18 | 0.403 |
| Mediastinal | 2.27±0.14 | 1.52±0.27 | 0.015 | 2.07±0.18 | 1.46±0.24 | 0.001 |
Operation time, estimated blood loss, VAS, blood transfusion rates, and subsidiary injury rates of lung tumor operation and mediastinal tumor operation were correlated with the difficulty score.
In lung tumor surgery, the incidence of postoperative complications in the difficult operation group was higher than that in the non-difficult operation group (P=0.02, Table 6).
Table 6.
Incidence of postoperative complications between the difficult operation group and the non-difficult operation group (n=89)
| Groups | Without complication | With complications | Sum | P |
|---|---|---|---|---|
| Sum | 67 | 22 | 89 | |
| Non-difficult operation group | 55 | 12 | 67 | 0.02 |
| Difficult operation group | 12 | 10 | 22 |
3. Discussion
Resection of huge tumor in thoracic cavity[9-10], reconstruction of large defect of chest wall[11], and reconstruction of trachea and carina are very difficult to solve at present. Difficult surgery often has a higher incidence of complications. How to formulate a surgical plan to reduce the difficulty of the operation and ensure the safety of patients is a problem for thoracic surgeons, especially in the teaching hospitals.
In this study, we investigated the proportion and characteristics of difficult thoracic operations via conference surveys and Delphi consultations, and developed the Thoracic Surgical Difficulty Assessment Scale. The scale could be used to evaluate and analyze the difficulty of surgery from 5 aspects: “surgical decision-making”, “operating space”, “dissecting interface”, “reconstruction method”, and “materials and instruments”. The main indicators of the scale reflect the main components of technology (including operating skills, methods, and tools). Among them, “operating space” and “dissecting interface” mainly evaluate the difficulty and complexity of operating skills, “surgical decision-making” and “reconstruction method” mainly evaluate the difficulty and complexity of surgical methods, and “materials and instruments” reflect the difficulty and complexity of surgical tools and instruments.
Surgical decision-making occurs throughout the entire surgical process. The correct selection of surgical indications, the reasonable design of incisions and surgical procedures, as well as the prevention and countermeasure against possible complications are all manifestations of surgical decisions-making[12]. The difficulty of surgical decision-making is also reflected in the judgment and decision-making difficulty of surgical indications, timing, surgical procedures, safety and efficacy. In this scale, “surgical decision-making” focuses on evaluating the patient’s basic condition, the trauma caused by the operation, and the physician’s experience before surgery. The impact of surgical decision-making on the difficulty of intraoperative operation can be reflected in other indicators.
The operating space can be understood as the space from the incision to the operating surface. This space is the only way of the surgeon using the hands and instruments. Therefore, the limited operating space is a major cause of the difficulty of the operation. Obtaining sufficient and clear operating space is an important step to ensure surgical safety[13-14]. In recent years, minimally invasive surgery in thoracic surgery has developed rapidly. Some researchers have tried to use single-port thoracoscopy to replace standard three-port thoracoscopic surgery. Single-port thoracoscopy has limited space for instruments at the operating hole and often requires a higher level of operating skills and experience[15]. Increasing incisions, jointing incisions or extending incisions can give the surgeons more operating space, thereby reducing the difficulty of the operation.But at the same time, it will also bring greater surgical trauma[16]. During the operation, the surgeon should choose the appropriate operating space according to the specific situation.
The separation interface can be understood as the contact surface between the surgeon’s hand or instrument and the patient’s tissue during the resection or reconstruction operation. Adhesion, inflammation, history of surgery, and history of radiotherapy and chemotherapy will affect the integrity of the separation interface, resulting in an increased difficulty in surgery[17].
Reconstruction is an important part of surgery and the main reason for some difficulties in surgery[18]. Reconstruction is an organic combination of repairing defects, rebuilding functions, and improving appearance. The more complex the reconstruction method and the wider the reconstruction scope is, the more difficult the operation will be.
Difficulty in the obtainment of surgical materials and instruments is an important reason for the difficulty in many thoracic surgeries. For example, in large-scale chest wall reconstruction, autologous materials are rarely used because of the need for additional surgical incisions. Artificial materials, such as stainless steel, titanium alloy, and other hard materials are easily corroded or infected, and their applications are limited. Other materials, such as titanium plate, steel wire mesh, plexiglass plate, have limited applications due to poor combination with the organization and often loose in later stages[19-20]. In recent years, porous mesh materials have been wildly used, such as polypropylene mesh, Marlex mesh, which have good fusion and compliance with tissues, proving to be more suitable for chest wall reconstruction[11]. Instruments can also greatly affect the difficulty of surgery. For example, the linear cutting staplers for endoscopes are originally designed for anastomosis of the gastrointestinal tract, and it is often inconvenient to cut the pulmonary blood vessels. Staplers with a curved tip can often greatly increase the convenience of surgery[15, 21]. Many studies[22-24] have proven that Da Vinci robotic instruments can reduce the difficulty of various operations. The multi-joint device and stereo vision of the Da Vinci robot can reduce the difficulty of intracavitary suture and make reconstruction easier.
The Thoracic Surgical Difficulty Assessment Scale has broad application prospects in reducing surgical complications and training surgeons. It can specifically analyze the operation difficulty for a particular patient and the reasons for the difficulty, so as to help surgeons to find a way to reduce the operation difficulty and optimize the operation plan. The scale can be applied to the training of thoracic surgeons, so that trainees can proceed in an orderly way and step by step from easy to difficult, which helps to shorten the learning curve and reduces the complications during the learning process.
However, there are many types of surgical operations. Surgical concepts, techniques, and operating instruments are constantly evolving, and patient conditions are ever-changing. The determination of the various indicators and weights of this scale needs to be continuously supplemented and improved in practice.
In conclusion, this study has established an evaluation index system for the difficulty of thoracic surgery. The Thoracic Surgical Difficulty Assessment Scale conforms to the graded management of surgery, and has broad application prospects in reducing the difficulty of surgery, controlling surgical complications, and training surgeons.
Contributions: PENG Muyun Conception of study, analysis of data, and manuscript writing; YU Fenglei Conception of study, and administrative support of meeting survey and Delphi consulting. All authors have approved the final version of this manuscript.
Funding Statement
This work was supported by the Key Research and Development Program of Hunan Province (2019SK2253), China.
Conflict of Interest
The authors declare that they have no conflicts of interest to disclose.
AUTHORS’CONTRIBUTIONS
Contributions: PENG Muyun Conception of study, analysis of data, and manuscript writing; YU Fenglei Conception of study, and administrative support of meeting survey and Delphi consulting. All authors have approved the final version of this manuscript.
Note
http://xbyxb.csu.edu.cn/xbwk/fileup/PDF/202205655.pdf
References
- 1. Jeganathan V, Knight S, Bricknell M, et al. Impact of smoking status and chronic obstructive pulmonary disease on pulmonary complications post lung cancer surgery[J/OL]. PLoS One, 2022, 17(3): e0266052 [2022-03-29]. 10.1371/journal.pone.0266052. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Nguyen YL, Maiolino E, de Pauw V, et al. Enhanced recovery pathway in lung resection surgery: program establishment and results of a cohort study encompassing 1243 consecutive patients[J]. Cancers, 2022, 14(7): 1745. 10.3390/cancers14071745. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. García-Miguel FJ, Serrano-Aguilar PG, López-Bastida J. Preoperative assessment[J]. Lancet, 2003, 362(9397): 1749-1757. 10.1016/s0140-6736(03)14857-x. [DOI] [PubMed] [Google Scholar]
- 4. Zhou F, Zhan X, Song C, et al. The assessment of the ASGE-grading system of ERCP: a large-sample retrospective study[J/OL]. Surg Endosc, 2022, Epub ahead of print. 10.1007/s00464-021-09000-0. [DOI] [PubMed] [Google Scholar]
- 5. Kang SB, Park JS, Kim DW, et al. Intraoperative technical difficulty during laparoscopy-assisted surgery as a prognostic factor for colorectal cancer[J]. Dis Colon Rectum, 2010, 53(10): 1400-1408. 10.1007/dcr.0b013e3181e5e0b1. [DOI] [PubMed] [Google Scholar]
- 6. Matsumoto M, Abe K, Futagawa Y, et al. New scoring system for prediction of surgical difficulty during laparoscopic cholecystectomy after percutaneous transhepatic gallbladder drainage[J]. Ann Gastroenterol Surg, 2021, 6(2): 296-306. 10.1002/ags3.12522. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Taze D, Hartley C, Morgan AW, et al. Developing consensus in histopathology: the role of the Delphi method[J]. Histopathology, 2022, Epub ahead of print. 10.1111/his.14650. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Olsen AA, Wolcott MD, Haines ST, et al. How to use the Delphi method to aid in decision making and build consensus in pharmacy education[J]. Curr Pharm Teach Learn, 2021, 13(10): 1376-1385. 10.1016/j.cptl.2021.07.018. [DOI] [PubMed] [Google Scholar]
- 9. Sun YF, Gu C, Shi JX, et al. Reconstruction of mediastinal vessels for invasive thymoma: a retrospective analysis of 25 cases[J]. J Thorac Dis, 2017, 9(3): 725-733. 10.21037/jtd.2017.03.03. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. Chen KN, Xu SF, Gu ZD, et al. Surgical treatment of complex malignant anterior mediastinal tumors invading the superior vena cava[J]. World J Surg, 2006, 30(2): 162-170. 10.1007/s00268-005-0009-x. [DOI] [PubMed] [Google Scholar]
- 11. D’Amico G, Manfredi R, Nita G, et al. Reconstruction of the thoracic wall with biologic mesh after resection for chest wall tumors: a presentation of a case series and original technique[J]. Surg Innov, 2018, 25(1): 28-36. 10.1177/1553350617745954. [DOI] [PubMed] [Google Scholar]
- 12. 冯变喜. 外科决策: 险中求胜[J]. 医学与哲学(临床决策论坛版), 2007, 28(9): 3-7. [Google Scholar]; FENG Bianxi. Surgical decision: failsafe stratigies[J]. Medicine & Philosophy. Clinical Decision Making Forum Edition, 2007, 28(9): 3-7. [Google Scholar]
- 13. Yeo SG, Kim DY, Park JW, et al. Tumor volume reduction rate after preoperative chemoradiotherapy as a prognostic factor in locally advanced rectal cancer[J/OL]. Int J Radiat Oncol Biol Phys, 2012, 82(2): e193-e199 [2012-02-01]. 10.1016/j.ijrobp.2011.03.022. [DOI] [PubMed] [Google Scholar]
- 14. Komatsu S, Ichikawa D, Kubota T, et al. Clinical influence of endoscopic resection on subsequent laparoscopic gastrectomy for gastric cancer[J]. Anticancer Res, 2013, 33(9): 4023-4028. [PubMed] [Google Scholar]
- 15. Wang W, Rao SY, Ma MS, et al. The concept of broad exposure facilitates uniportal video-assisted thoracoscopic mediastinal lymph nodes dissection[J]. J Cardiothorac Surg, 2021, 16(1): 138. 10.1186/s13019-021-01519-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Azenha LF, Deckarm R, Minervini F, et al. Robotic vs. transsternal thymectomy: a single center experience over 10 years[J]. J Clin Med, 2021, 10(21): 4991. 10.3390/jcm10214991. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. 杨昆, 张维汉, 陈心足, 等. 新辅助治疗大体组织反应评级体系的建立和初步应用[J]. 中华胃肠外科杂志, 2018, 21(9): 1032-1038. 10.3760/cma.j.issn.1671-0274.2018.09.011. [DOI] [PubMed] [Google Scholar]; YANG Kun, ZHANG Weihan, CHEN Xinzu, et al. Establishment and preliminary application of tissue response grading system following neoadjuvant chemotherapy[J]. Chinese Journal of Gastrointestinal Surgery, 2018, 21(9): 1032-1038. 10.3760/cma.j.issn.1671-0274.2018.09.011. [DOI] [PubMed] [Google Scholar]
- 18. Zhao J, Zeng QP, Li JG, et al. Uniportal versus multiportal thoracoscopic sleeve lobectomy for the surgical treatment of centrally located lung cancer: a single institution experience[J]. J Thorac Dis, 2020, 12(12): 7145-7155. 10.21037/jtd-20-2695. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Wang L, Yan XL, Zhao JB, et al. Expert consensus on resection of chest wall tumors and chest wall reconstruction[J]. Transl Lung Cancer Res, 2021, 10(11): 4057-4083. 10.21037/tlcr-21-935. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. Mesko NW, Bribriesco AC, Raymond DP. Surgical management of chest wall sarcoma[J]. Surg Oncol Clin N Am, 2020, 29(4): 655-672. 10.1016/j.soc.2020.06.008. [DOI] [PubMed] [Google Scholar]
- 21. Mizutani E, Nakahara K, Miyanaga S, et al. Safe stapling technique for pulmonary vessels with the shortened introducers and curved tips in thoracoscopic surgery[J]. Gen Thorac Cardiovasc Surg, 2015, 63(4): 242-244. 10.1007/s11748-013-0361-y. [DOI] [PubMed] [Google Scholar]
- 22. Tarascó Palomares J, Caballero Boza A, Sánchez Haro E, et al. Really totally robotic SADI-S in a patient with extreme morbid obesity and non-reducible umbilical hernia: case report[J]. Obes Surg, 2020, 30(10): 4171-4173. 10.1007/s11695-020-04802-y. [DOI] [PubMed] [Google Scholar]
- 23. Park JH, Park S, Kang CH, et al. Early outcomes of robotic versus video-assisted thoracoscopic anatomical resection for lung cancer[J]. J Chest Surg, 2022, 55(1): 49-54. 10.5090/jcs.21.128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Geraci TC, Scheinerman J, Chen D, et al. Beyond the learning curve: a review of complex cases in robotic thoracic surgery[J]. J Thorac Dis, 2021, 13(10): 6129-6140. 10.21037/jtd-2019-rts-05. [DOI] [PMC free article] [PubMed] [Google Scholar]