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Initially described in 1992 (1), thoracoscopic (VATS) lobectomy is unquestionably the greatest upheaval in thoracic surgery community since the introduction of one-lung ventilation by Carlens in 1949 (2).In the last twenty years, after several initial uncertainty about its adoption, VATS lobectomy slowly but constantly propagates worldwide and, nowadays, most international guidelines suggest the adoption of this minimally invasive approach for early-stage lung cancer, over the traditional “open” approaches (3,4). Indeed, several single- and multi-institutional studies, as well as national registry analysis, showed that VATS lobectomy adoption permits a shorter chest tube duration, a shorter length of hospital stay, fewer postoperative complications, and a lower or comparable perioperative mortality vs. classic thoracotomy (5-13). Moreover, the recent results of UK multicentric VIOLET randomized controlled trial corroborated these statements, demonstrating an association between VATS lobectomy and enhanced short-term clinical outcomes when compared with open surgery for non-small cell lung cancer (NSCLC) (14,15).

Background: This study evaluates the number of video-assisted thoracic surgery-lobectomies (VATS-lobectomies) required for an experienced consultant thoracic surgeon to obtain competence and to perform standard quality surgery. Methods: We have analysed the initial VATS-experience (January 2012 to September 2014) of a confirmed senior consultant who has performed 145 consecutive anatomic resections by thoracoscopy. After excluding bilobectomies, segmentectomies, and lobectomies for infectious disease, we have focused into 119 consecutive lobectomies, classified into 4 chronologic groups of 30 each. We have considered: demographics; pathology; postoperative outcomes; conversion rate; morbidity. We compared the 4 groups in a Bayesian inference model (very strong probability of a difference if Pr>95% or Pr>80% or 5% Results: There was a very strong probability of difference of group 1 (first 30 lobectomies) compared to the 3 other groups: less incomplete fissures (Pr 1 =0.019, Pr 1 =0.037, Pr 1 =0.046), more node samplings (Pr 1>2 =0.977, Pr 1>3 =0.96, Pr 1>4 =0.997) and, conversely, less radical dissections (Pr 1 =0.022, Pr 1 =0.039, Pr 1 =0.003), less harvested nodes (Pr 1 ≤0.001, Pr 1 ≤0.001, Pr 1 ≤0.001), less pleural adhesions (Pr 1 =0.077, Pr 1 =0.044). Instead, there was a very strong probability of difference of group 4 compared to the first three groups (first 90 lobectomies): lower conversion rate (Pr 1>4 =0.992, Pr 3>4 =0.996, Pr 2>4 =0.995), lower duration of the operation (Pr 1>4 =0.946, Pr 2>4 =0.901, Pr 3>4 =0.932), less air leak (Pr 1>4 =0.936, Pr 2>4 =0.97) and shorter chest tube drainage (Pr 1>4 =0.94, Pr 2>4 =0.94, Pr 3>4 =0.937), as well as shorter hospital stay (Pr 2>4 =0.94, Pr 3>4 =0.937). Conclusions: The learning curve was bimodal. After the initial 30 lobectomies, oncologic quality of the procedure improved and stabilized. The surgeon became less selective and accepted to proceed with more complex cases (incomplete fissures, pleural adhesions). Efficiency was obtained after 90 lobectomies (shorter operative time and lower conversion rate).

Chest trauma has been described in the literature since 3000 bc. This trauma is usually not isolated and associated with high mortality and morbidity. The majority of the patients with thoracic trauma are not operated, being reported emergent thoracotomies between 1–12% of all chest traumas and of this only 1% to 2% of thoracic trauma patients need a pneumonectomy with mortality rates from 50% to 100%, with a slight improvement tendency, having worst results those with blunt trauma. In a war scenario around 25% of the casualties have thoracic trauma associated, but there is no data available related to the pneumonectomy itself. Has been shown that victim stabilization, eventually with hilar control and quick referral to the central hospital improved patient survival and outcomes. Outcomes in war victims have been improving over time and Medicine has evolved much to the learnings during war times. The presence of a cardiothoracic surgeon in an emergency scenario improves the outcome not only due to their technical skills but also to their soft skills. It is written that the presence of these professional can induce a sense of confidence and security.

Survival analysis refers to the statistical methods used for the analyzing of data where the outcome variable is the time until the occurrence of the event of interest. Survival analysis is also known as time to event analysis. Survival analysis applications are very large: For instance, they can be used for determining the survival rate of a population, or comparing the survival of two or more groups.

In the present article, Dr Bott and associates (1) seek to address the absorbing question of the safety and utility of pulmonary resection in the setting of patients with residual disease following immune checkpoint inhibitors.

Pain control after minimally invasive thoracic surgery is a contemporary question, which still raises passionate debates. The study published by Ghee and colleagues (1) evaluated continuous subpleural bupivacaine in a prospective randomized trial and concluded to no benefit. Eighty-six patients admitted for VATS lobectomy or wedge resection were randomly assigned either to continuous subpleural bupivacaine or to intraoperative incision site injection, associated with standard oral or intravenous painkillers as per request.