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Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Uniportal video-assisted thoracoscopic surgery (VATS) is the most advanced evolution of the minimally invasive technique, which allows often the possibility to include patients in enhanced recovery programs in order to optimize the therapeutic pathway, shorten the length of stay and reduce hospital costs. Non-intubated VATS procedures allow the performance of surgeries with minimal sedation without general anesthesia, maintaining throughout the operation spontaneous breathing. The principle is to create an iatrogenic spontaneous pneumothorax, which can provide a good lung isolation without the need of a double lumen tube. A survey between the members of the European Society of Thoracic Surgery (ESTS) showed that non-intubated VATS procedures are already performed by a large number of ESTS members for minor procedures. With the publication of new data and the spreading of uniportal VATS in many centers worldwide in the last decades, the application of the non-intubated technique in major procedure like anatomic resections is expected to grow. This technique can potentially be beneficial for high-risk patients but also could be used for the routine procedures as well, but more data are needed to establish the real benefit for these groups of patients., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Senior surgeons who completed their formal surgical training before the video-assisted thoracoscopic surgery (VATS) lobectomy era have had more experience with lobectomy via thoracotomy while their thoracoscopic training background contrasts from younger surgeons. However, this does not seem to have an unfavourable effect on their performance. Despite the literature recognising the critical points of influence of the learning curve for resident surgeons, limited data are focusing on the incremental performance of VATS lobectomy by senior surgeons. The Very Experienced Time-honoUred Surgeons (VETUS) project aims to understand this trend in the VATS group and to introduce an approach to the VATS lobectomy involving senior surgeon. The VETUS project is based on a self-assessment program where the senior surgeon (independently and in complete anonymity) follows a 1-year approach to training in VATS lobectomy. At predefined time intervals, the surgeon will be called to evaluate his performance according to a number of variables such as the choice of VATS lobectomy indications, the number of the port used and length of utility incision, time spent in dissecting the hilar structures and the overall percentage of VATS lobectomy performed in 1 year compared to open. The self-assessment of the VETUS project is a unique opportunity to define the path of a systematic approach to training outside the traditional modalities with the ultimate aim of supporting quality of standardised VATS lobectomy throughout the country., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

We standardised a Ventilation Mechanical Test (VMT) after video-assisted thoracoscopic surgery (VATS) lobectomy that classifies intraoperative alveolar air leaks (IOAALs) in mild, moderate and severe. We assumed that mild IOAALs (<100 mL/min) are self-limiting, whereas severe IOAALs (>400 mL/min) must be treated. An IOAAL between 100 and 400 mL/min was defined moderate and constituted the study population of a prospective multicentre randomised trial on the use of a polymeric biodegradable sealant (Progel TM Pleural Air Leak Sealant, Bard Davol, USA) in case of moderate IOAAL compared with no treatment. We assumed that the standardised VMT allows to accurately selected patients needing treatment, thus limiting unnecessary sealant use. We analysed data of the randomised trial to assess the cost-effectiveness of Progel treatment in VMT selected patients. This is a multicenter randomised controlled trial. Patients with moderate IOAAL were randomised to Progel (group A) or "no treatment" (group B).The primary efficacy endpoint of the study was the postoperative duration of air leakage. The secondary outcome measures included: mean time to chest drain removal, mean length of hospitalisation, the percentage of postoperative complications occurring within two months, and cost of treatment. Between January 2015 and January 2017, 255 VATS lobectomies were performed in 4 centres, 55 met the inclusion criteria, and they were randomly assigned to 2 different groups (28 in the Progel and 27 in the control group). The mean air leakage duration was statistically different between the two groups: in the group A was 1.60 vs. 5.04 days in group B (P<0.001). The average duration of chest drainage was statistically shorter in group A than in the control group (4.1 vs. 6.74 days; P=0.008). The mean time to hospital discharge was also statistically shorter in group A than in group B (5.75 vs. 7.85 days, P=0.026). In the Progel group, a statistically significant reduction of hospitalisation costs compared with the control group was observed (Progel group =12,905₤, Control group =39,690₤; P<0.001). Our standardised VMT helps in reducing the length of hospital stay after VATS lobectomy because in case of IOAALs between 100 and 400 mL/min the use of ProgelTM significantly reduces postoperative air leak, time to drain removal and length of hospitalisation compared with no treatment. This shorter hospital stays results in significant cost saving benefits. Selection of patients with standardised VMT is essential to limit unnecessary intraoperative sealant treatments, thus contributing to limit the costs., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Background: Video-assisted thoracoscopic lobectomy (VATS-L) is a well-established approach for early-stage non-small cell lung cancer (NSCLC) with functional and oncological outcomes similar to thoracotomy. The role of VATS-L in locally advanced stage of NSCLC has not been well standardized. The objective of this study was to evaluate the state of the art in Italy of VATS-L for NSCLC advanced stages using the data from the Italian VATS Group Database., Methods: Between 1st January 2014 and 31th May 2017, 3,720 patients underwent VATS-L at VATS Group participating centres and included in the VATS Group database. Patients were divided into two groups: (A) early stages and (B) locally-advanced stages (tumours with dimension >5 cm (cT2b), cT3, cT4 and/or tumours that received neo-adjuvant chemotherapy). A retrospective study was performed, to evaluate the safety and the oncological adequacy of VATS-L comparing peri-operative outcomes and pathological data., Results: A total of 3,266 (87.7%) patients were included into the group A, while 454 (13.3%) patients formed the group B. VATS-L for locally advanced-stage NSCLC is associated with a longer procedure, a higher estimated blood loss, an increased incidence of conversion (9.3% vs. 13.0%, P=0.018) and a significant higher number of total, hilar and mediastinal dissected lymph nodes. The mortality rate (1.6% vs. 1.5%), the proportion of patients who suffered any complication (24.8% vs. 29.1%) and the hospitalization were not statistically different between the two groups (P=0.880, 0.057 and 0.660, respectively); the overall complication rate was statistically higher in group B (30.4% vs. 37.0%; P=0.04). Patients of group B who required conversion had a statistically significantly higher operative time (P<0.01), blood loss (P<0.01) and hospital stay (P<0.01), but not significantly higher overall morbidity rate (35.5% vs. 28.0%) compared with patients completely operated by VATS., Conclusions: VATS-L for locally advanced-stage NSCLC in Italy is a safe and effective procedure when performed in appropriately selected patients, ensuring peri-operative results similar to those obtained in early-stage tumours., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Video-assisted thoracoscopic (VAT) procedures are emerging for treatment of both benign and malignant thoracic diseases and substituting classical approaches, such as thoracotomies, thanks to several advantages concerning postoperative morbidity rates and overall patients' outcome (i.e., postoperative pain, chronic pain and quality of life). However, a VAT approach needs an established learning curve making procedures as safe as in open surgery. With regard of trainee surgeons, notwithstanding an increasing number of learning tools and strategies, such as simulation programs (i.e., black-boxes, wet labs, cadaver or animal labs, 3D virtual reality simulators) and direct observation both of live surgery and videos with a supportive evidence base from benchtop studies, there remains inconsistent adoption in surgical educations., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.

Video-assisted thoracic surgery (VATS) allows to treat pulmonary and mediastinal diseases although two-dimensional (2D) imaging can make difficult to estimate the morphological and topographical characteristics of a lesion. Some technical aspects have certainly been corrected with the introduction of robot-assisted thoracic surgery (RATS), although not widespread in less economically developed countries. As an emerging imaging system and technique, 3D VATS is an interesting resource for thoracic surgeons and it may be a proper and valid aid in minimally-invasive surgery, but not an alternative or a compromise to the most expensive robotic technology. The purpose of the study was to carefully analyze the different experiences reported in literature in order to evaluate the state of art of 3D VATS method in lung excision., Competing Interests: Conflicts of Interest: The authors have no conflicts of interest to declare.