Perioperative outcomes of uniportal video-assisted thoracoscopic lobectomy in scope operation performed by a clinical engineer

Introduction

Similar to other countries, Japan is experiencing a severe shortage of surgeons (1). One of the reasons for this issue is the diverse range of responsibilities assigned to surgeons in Japan (2). To address problems such as long working hours and to ensure the health and well-being of physicians, more advanced task shifting strategies have been proposed. Consequently, based on a discussion on the promotion of the work style reforms of physicians, a clinical engineer (CE) has been allowed to operate endoscopic video cameras in endoscopic surgery since October 2021 (3). The use of uniportal video-assisted thoracoscopic surgery (UVATS), a minimally invasive surgery for respiratory surgical diseases, is increasing (4). However, UVATS is challenging to implement. Further, the quality and safety of UVATS in scope operation conducted by a CE remains unclear. Therefore, the safety of UVATS lobectomy in scope operation performed by CEs should be evaluated. The current study aimed to assess the usefulness and safety of UVATS lobectomy in scope operation conducted by a CE. We present this article in accordance with the STROBE reporting checklist (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-73/rc).

Methods

Study design

The current study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments and was approved by the Research Ethics Committee of Saitama Hospital (approval number: R2022-06). The need for informed consent was waived due to the retrospective nature of this study.

Consecutive patients who underwent lobectomy at the Department of General Thoracic Surgery from January 2020 to December 2024 were retrospectively reviewed. In this department, UVATS for lobectomy was introduced in January 2020. Until February 2021, even if UVATS was recommended, patients sometimes preferred to undergo multiportal video-assisted thoracoscopic surgery (MVATS). At the Department of General Thoracic Surgery, the surgical indications in patients with primary lung cancer were small-cell lung cancer up to clinical stage I and non-small-cell lung cancer up to clinical stage I–IIIB single station N2. However, in patients aged ≥80 years or those with major comorbidities, the omission of node dissection 2a was considered. According to National Hospital Organization, Saitama Hospital’s policy, preoperative chemotherapy is not considered for the management of patients. Patients who required resection of the chest wall combined with other structures, such as the ribs, were excluded from this study because of transition to thoracotomy.

For UVATS lobectomy, the procedure was performed by three people: the surgeon, assistant, and scope operator. The procedures in scope operation conducted by surgeons [the doctor (DR) group] were compared with those in scope operation performed by CEs (the CE group). Two senior or midcareer respiratory surgeons conducted UVATS lobectomy. In the DR group, a scope operator was assigned with the previous midcareer respiratory surgeon and two other respiratory surgeons. The staff of the respiratory surgery department was decreased to two senior or midcareer respiratory surgery specialists from fiscal 2022. As a result, CEs have taken on the role of scope operators since March 2022 to compensate for the shortage of surgeons. For UVATS lobectomy, the aforementioned surgeons participated in the surgeries by dividing the roles of primary surgeon and assistant. In total, 12 CEs with a clinical experience of 3–12 years were assigned as scope operators. CEs and professionals in other departments did not have experience in performing scope operation. Thus, a scope operator workshop and dry laboratory training were conducted by the department before performing the surgeries. The anatomical structures and surgical procedures were explained to the CE using photographs and illustrations. During dry laboratory training, the CE practiced basic scope manipulation and had the opportunity to perform surgical maneuvers from the surgeon’s perspective. This approach allowed the CE to understand the effects of scope movements on the visual field and surgical maneuver impact.

Characteristics of the patients

Data on the characteristics of patients that could potentially influence perioperative outcomes were collected. The clinical data included age at surgery, sex, diagnosis, affected lobes, tumor size, American Society of Anesthesiologists physical status score (5), body mass index, smoking history, forced expiratory volume in 1 second, node dissection extent, and presence or absence of diagnostic wedge resection or simultaneous resection of other lobes. Propensity-score matching was used to adjust for potential confounding factors between the CE and DR groups. Perioperative outcomes including surgical duration, blood loss volume, conversion rate, postoperative complications, chest drain duration, and length of postoperative hospital stay were compared between the two matched groups. In this study, data related to all postoperative complications during the postoperative hospitalization or within 1 month after surgery were extracted. Greater than or equal to grade II postoperative complications based on the Clavien-Dindo classification system were recorded (6). Prolonged air leakage was defined as leakage that persisted for >7 days or the need for intervention such as chest tube reinsertion and re-surgery.

Devices

UVATS was performed using a 5-mm 30° or 45° rigid mirror (Precision IE 4K, STRYKER, Tokyo, Japan) as the surgical endoscope.

Surgery

The patients were placed in the lateral position under general anesthesia with a double-lumen tube. In UVATS, to perform mediastinal lymph node dissection (Figure 1A-1D), a 4-cm skin incision was made between the middle and posterior axillary lines at the 6^th or 7^th intercostal space. Then, the main port was created using a soft retractor (7). Two monitors, with a look-up monitor setting that reflected the same image, were placed on the patient’s head side. The operator stood on the right side of the patient regardless of the surgical side (dorsal for right-sided surgery, ventral for left-sided surgery). The scope operator stood on the opposite side. The camera insertion position was not fixed. However, it was basically inserted from the scope operator side of the port. The CE concentrated on holding and operating the scope and shifted approximately every 2 h during surgery. The CE is responsible for operating the scope when converted to thoracotomy to ensure optimal surgical field observation. All decisions and judgments regarding the surgical procedure are made by the surgeon, who is responsible for the team-based medical care.

Figure 1 Surgical findings after mediastinal lymphadenectomy in confronting uniportal video-assisted thoracoscopic surgery. Right upper zone (A), left upper zone (B), right subcarinal zone (C), and left subcarinal zone (D). AV, azygos vein; BCA, brachiocephalic artery; BR, bronchus; DAO, descending aorta; ES, esophagus; Lt, left; PA, pulmonary artery; RLN, recurrent laryngeal nerve; Rt, right; SVC, superior vena cava; VN, vagus nerve.

Statistical analysis

Continuous data were compared using the Student’s t-test and categorical data with the Pearson’s Chi-squared test. Propensity scores were measured using the logistic regression model that included baseline factors. Thereafter, the nearest-neighbor 1:1 matching method was used with a caliper of 0.2 standard deviations of the logit of the estimated propensity scores at a 1:1 ratio without replacement. To assess the balance of the matched cohort, the standardized difference between the two groups was calculated, and an absolute value of standardized difference >0.2 indicated a significance imbalance. EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is the graphical user interface for R (The R Foundation for Statistical Computing, Vienna, Austria) (8), was used to perform all statistical analyses.

Results

Figure 2 presents the flowchart of the patient selection process. Tables 1,2 depict the characteristics of the patients in the DR and CE groups before and after propensity-score matching. Table 3 shows the pathological N factors of patients with primary lung cancer in both groups. Based on the clinical data, the CE group had a higher number of female patients, a lower frequency of smoking history, and a greater proportion of left lower-lobe lesions compared with the DR group. After propensity-score matching, 46 patients were selected from each group. All standardized differences in confounding factors were eliminated. Table 4 shows the perioperative outcomes of the two groups. There was no significant difference in terms of surgical duration or volume of intraoperative blood loss between the CE and DR groups. Further, the CE and DR groups did not significantly differ in terms of the rate of conversion to MVATS or thoracotomy (4.3% vs. 4.3%, P=0.51). Thoracotomy was indicated for pulmonary artery injury in the CE and DR groups (4.3% vs. 2.2%). Pulmonary vein injury (n=1, 2.2%) was the cause of conversion to MVATS (2.2%) in the DR group. The CE and DR groups did not significantly differ in terms of the incidence of postoperative complications, duration of drain placement, and length of postoperative hospital stay. None of the patients in the two groups died.

Figure 2 Flow diagram of patient selection. CE, clinical engineer; DR, doctor; MVATS, multiportal video-assisted thoracoscopic surgery; UVATS, uniportal video-assisted thoracoscopic surgery.

Discussion

This study showed that the perioperative outcomes of UVATS lobectomy in scope operation performed by CEs were comparable with those of UVATS lobectomy in scope operation conducted by surgeons. The CE camerawork may provide the same field visualization as surgeons in UVATS lobectomy.

In respiratory surgery, UVATS is widely used as it is a minimally invasive procedure that can reduce patient burden (6). Moreover, it is associated with low cost, good cosmetic outcomes, low pain level, and short length of hospitalization (9). UVATS lobectomy is an effective surgical procedure against lung cancer. However, it interferes with the instruments and cameras used to deploy the surgical field. Thus, it is more challenging to perform (10).

Despite the abovementioned data, UVATS is now commonly used. In lung cancer, the placement of the UVATS port is based on the location and size of the lesions (11). A single 2–4-cm incision is usually made in the five intercostal spaces between the anterior and middle axillary lines (12). The surgeon and the assistant surgeon stand on the ventral side of the patient. Then, they perform the surgery on the same side while looking at the same monitor on the opposite side. To provide space for the operator, the assistant holds the camera with one hand and assists with the other instrument as required. However, due to the location of this port, mediastinal lymph node dissection can be insufficient. Thus, the port should be repositioned dorsally, or special instruments must be used (13). The port was positioned more caudodorsally than usual for mediastinal lymph node dissection (7). To improve operability, the operator and scope operator are positioned face-to-face. Meanwhile, the CE concentrates on operating the scope, and the assistant helps with the surgery.

Compared with physicians, CEs could have a lower field visibility with camera work due to lack of anatomical knowledge and respiratory surgical expertise (14). The surgical duration between the CE and surgeon camera work-based MVATS did not significantly differ. However, the CE camera work-based MVATS tended to take slightly longer than the surgeon camera work-based MVATS.

In addition, in UVATS, the two hands of the surgeon must coaxially handle the instruments via the same incision to prevent collision between the instruments (10). Thus, the operator can be burdened. If the surgical duration is longer, the scope operator becomes more fatigued (15). In the current study, the surgical duration between the CE and DR groups did not significantly differ. Nevertheless, the CE group was more likely to have a higher rate of diagnostic partial resection than the DR group. This finding could be attributed to several factors. First, a caudal-to-cephalic look-up setting was used for the monitors. According to a previous report (14), in thoracoscopic surgery where in the operator and scope operator are positioned face-to-face, the look-up method, which allows sharing of the same image, is advantageous in terms of education and communication compared with the confronting setting (16) in which the monitor is viewed horizontally as in thoracotomy. Even if the operator has poor anatomical knowledge, the same image can be shared. Hence, the surgeon can project the intended visual field by providing simple instructions. In this study, 12 CEs were rotated approximately every 2 h, and they could take over the camera operation even if they were not proficient in dissecting or grasping the condition during rotation. Notably, the surgeon or assistant may assist the CE in operating the scope if the CE is unable to operate the scope under verbal instructions. In addition, scope manipulation techniques and anatomical education were provided to the CE as needed. As a result, CE’s improved proficiency in scope operation and understanding of surgical progression facilitated active participation in the surgery, likely contributing to smoother surgical procedures.

Second, there may have been differences in the proficiency levels of the surgeons who performed UVATS lobectomy between the DR and CE groups. Because this study was retrospective in nature, the DR group included patients from the initial phase of UVATS implementation, which may have influenced the comparison with the CE group. The study results might not be applicable to the perioperative outcomes of UVATS lobotomy performed by operators not skilled in UVATS.

Intraoperative injuries caused by increased operator burden can lead to conversion from UVATS to MVATS or thoracotomy, thereby resulting in increased morbidity rates and longer surgical duration and length of postoperative hospital stay (17). The conversion rate in patients undergoing VATS lobectomy is 9.6%, and the associated risk factors are lymph node metastasis, tumor size, and neoadjuvant therapy. The common causes of conversion are vascular injury, difficult lymph node dissection, and adhesions (18). The range of conversion rates may be primarily attributed to the learning curve (19), with a decreasing trend in conversion with increasing surgical experience (20). The UVATS approach has a lower stereo-visual acuity than MVATS or thoracotomy and has a limited surgical surface. Moreover, it is associated with an increased risk of pulmonary artery hemorrhage and may lead to unplanned conversion to thoracotomy (21). In a previous study, the conversion rates of UVATS and 2- and 3-port VATS were 5.6%, 3.5%, and 4.0%, respectively (22). Thus, our results were not inferior to those of previous studies.

Our findings can be useful for surgeons. The shortage of surgeons has become a major issue in several countries (1,2). Notably surgeons are often assigned duties in medical oncology, emergency medicine, and end-of-life care due to shortages of emergency physicians and medical oncologists (2). Being a surgeon is a physically, psychologically, and mentally demanding profession (23), and the number of residents participating in surgical training programs in Japan has not increased (2). To assist the few surgeons, residents are allowed to perform these tasks as part of their training, including serving as scope operators. However, this is only feasible in hospitals with a sufficient number of residents each year. In smaller hospitals, task shifting with the contribution of healthcare professionals other than surgeons can reduce surgeon burden.

In response to chronic physician shortages, aging population, and the increasing number of patients with complex, long-term conditions, several countries have already introduced healthcare associate professions, including physician associates, anesthetic physician assistants, advanced emergency medical practitioners, and surgical care practitioners (24,25). Nurse surgeons, including nurse practitioners who perform surgeries independently (26), have helped alleviate the global surgical burden via cancer diagnostic surgeries, emergency surgeries, and minor surgeries (27). A previous study has revealed that the addition of nurse practitioners and physician associates to surgical and trauma services has reduced the workload of resident physicians, increased their sleep time, and improved surgical efficiency without affecting patient morbidity or mortality rates (28).

However, these services generally involve minor procedures such as chest tube placement, percutaneous endoscopic gastrostomy, and tracheostomy (29). Endoscopic diagnostic services, such as colonoscopy, are available. Nevertheless, there are extremely few reports on these professionals actively performing scope operations during endoscopic surgeries. According to the available literature, this is the first study to compare and evaluate the perioperative outcomes of UVATS lobectomy based on scope operations performed by CEs—healthcare professionals other than surgeons—versus those performed by surgeons.

The roles of CEs in countries outside Japan include adjusting and managing endoscopic equipment, as well as recording and fine-tuning endoscopic images during surgeries. Hence, they do not typically perform scope insertion or operation during endoscopic surgeries.

Therefore, using CEs as scope operators could be a viable solution to addressing the persistent physician shortage, as observed in the Department of General Thoracic Surgery. Furthermore, this approach can be an effective strategy for mitigating surgeon shortage and supporting the healthcare system.

Conclusions

The perioperative outcomes of UVATS lobectomy in scope operation performed by CEs were comparable with those of UVATS lobectomy in scope operation conducted by surgeons. Thus, CEs could be scope operators.

Acknowledgments

We gratefully acknowledge the hard work of all the clinical engineers present in our operating room.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-73/rc

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-73/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-73/prf

Funding: None.

Conflicts of Interest: Both authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-2025-73/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The current study was conducted in accordance with the Declaration of Helsinki and its subsequent amendments and was approved by the Research Ethics Committee of Saitama Hospital (approval number: R2022-06). The need for informed consent was waived due to the retrospective nature of this study.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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