The training in thoracoscopic surgery: a comparative study and bibliometric analysis

Introduction

Thoracoscopic surgery, also known as video-assisted thoracic surgery (VATS), is a minimally invasive surgical technique that allows surgeons to perform procedures within the chest cavity using small incisions and specialized instruments (1,2). This technique is widely used for both diagnostic and therapeutic purposes. Its applications include the treatment of lung cancer, pleural diseases, and mediastinal tumors, as well as procedures such as lung biopsies, lobectomies, and pleurodesis (3,4). This minimally invasive approach has been shown to be as effective as traditional open surgery, with the added benefits of reduced postoperative pain, shorter hospital stays, and quicker return to normal activities (3,5). Thoracoscopic surgery, despite being minimally invasive, occasionally requires conversion to open surgery due to various complications or challenges encountered during the procedure. Uncontrolled bleeding, particularly from major blood vessels, is one of the most common reasons for conversion (6). The potential need for conversion to open surgery underscores the importance of comprehensive training in thoracoscopic surgery.

The demand for thoracoscopic surgery training has grown significantly as more medical professionals seek to acquire the skills necessary to perform these complex procedures (1,7). A study on a high-volume intensive training course demonstrated significant improvements in surgical skills among participants, with reduced operation times and lower conversion rates compared to open surgery (8). One study on uniport VATS lobectomy demonstrated a learning curve plateauing after 25 cases, with improved operative times and fewer complications observed in later cases. Overall, the procedure was deemed safe and feasible, underscoring the importance of adequate training and experience for optimal outcomes (9). Furthermore, simulation-based training has also been shown to be effective, allowing trainees to overcome initial learning curves in a controlled environment, thereby reducing the risk of complications in real clinical settings (10). Petersen et al. evaluated the outcomes of a training program for VATS lobectomy, showing that with careful patient selection, outcomes for the training consultant were comparable to those of an experienced consultant, despite longer operative times (11). The growing body of research on thoracoscopic surgery training highlights the value of comprehensive reviews and analyses for synthesizing findings and forecasting future trends in the field.

Bibliometrics is a quantitative analysis method that applies mathematical and statistical techniques to study publications and other forms of written communication (12). It is widely used to evaluate the impact and influence of research, track the development of scientific fields, and assess the productivity of researchers and institutions (13). Commonly used bibliometric software including VOSviewer and CiteSpace, which help visualize data such as citation networks, coauthorship relationships, and keyword trends (14). Bibliometric analysis has been applied in various surgical fields including plastic and reconstructive surgery, spontaneous pneumothorax, and mixed-reality applications in surgery (15-17). These analyses can reveal patterns in academic publishing, such as the most influential papers, emerging research areas, and collaboration networks, providing valuable insights for researchers. Based on our knowledge, there is currently no bibliometric analysis focused specifically on thoracoscopic surgery training. Therefore, this study aimed retrospectively analyze the effects of two training methods for new students in actual thoracoscopic surgery, and explore the development and trends in thoracoscopic surgery training research through a bibliometric analysis of relevant academic literature.

Methods

Materials and methods of the retrospective analysis

General information

This observation included 72 trainees from the Department of Thoracic Surgery of The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital). These trainees were all medical graduate/undergraduate students in standardized residency training, physicians in continuing clinical education, graduate students, and new thoracic surgeons between June 2022 and May 2024. Among them, the participants from June 2022 to May 2023 were the control group (n=36; including 24 males and 12 females) and the participants from June 2023 to May 2024 were the observation group (n=36; consisting of 23 males and 13 females). They underwent 1-month training sessions (see Table 1). The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics committee of The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital). Individual consent for this retrospective analysis was waived. The average age of the observational group and control group were 23.0±2.396 and 22.69±2.095 years, respectively. There was no significant difference in the gender, age, and identities of the two groups (P>0.05). The entirety training was executed by the teaching team composed of thoracic surgeons with the same level of senior academic titles.

Inclusion and exclusion criteria

The trainees included in the study were as follows: (I) nonthoracic surgery residents undergoing standardized residency training in our department, including professional master’s degree candidates (with four certificates after graduation); (II) physicians from The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital); (III) those recruited from the community or assigned by outside organizations; (IV) physicians receiving continuing clinical education; and (V) postgraduates and new thoracic surgeons. The training sessions lasted for 1 month, and all trainees should be in good compliance and observe the training schedule.

The exclusion criteria were as follows: (I) trainees whose training duration was less than 1 month or who were unable to comply with the training schedule designed by our department; and (II) those who voluntarily terminated the training program for any reason.

Definition of the camera holder

A camera holder was defined as the ancillary assistant supporting the thoracoscope during the procedure.

Training method

Initially, the advisor described the structure and components of the thoracoscope to all trainees and demonstrated the use of the device. The trainees in the observational group were then instructed on interpretation of the chest computed tomography (CT) 3D reconstruction, which was combined with the viewing of previous surgical videos of similar surgical procedures, and the videos of the surgery at the time were reviewed after operation. Before surgery, the trainees were required to participate in assessing the physical state of the patient through analyzing his/her conditions. The surgical devices used in the surgery and the surgical modality were determined 1 day before operation in accordance with the preoperative consultation of the physicians involved in the surgery. Subsequently, the trainees were expected to closely examine the chest CT 3D reconstruction in order to identify the bronchi at the lung lobes and segmental bronchi, pulmonary arteries, and pulmonary veins as well as the location of the nodule(s) and reviewed the previous similar surgical videos. The tutor was responsible for elaborating the key points and important skills related to positioning the lens in the surgical videos. During the operation, the trainees acted as the camera holder or the first assistant to progressively rehearse the skills for supporting the lens under the instructions of a tutor, especially the anchoring of the thoracoscopic lens, movement of the camera, control of the space, and distance of the lens. In addition, the instructor explained the knowledge the relevant diseases, the pleural and thoracic anatomy, provision of a clear surgical field of view, and the basic operations, which was completed via interactive questions and response. The related knowledge and techniques were reviewed and consolidated through oral question and answer in the postoperative check-up and through repeated viewing of the surgical video; in this way, the trainees could comprehensively understand the operation techniques, the related precautions, and the expertise required in supporting the endoscope.

The trainees in the control group only received traditional teaching by explanation of related knowledge based on the textbook and were asked to develop a preoperative plan and conduct an assessment of the patient for determining the surgical modality. After operation, the trainees were required to review the surgical processes based on a PowerPoint presentation (Microsoft Corp., Redmond, WA, USA) and questions and answers during postoperative checkup.

Observation indicators—intraoperative performance of the trainees in the observational and control groups in supporting the lens

After practicing supporting the lens in 10–15 cases of single-hole thoracoscopic lobectomy or segmental resection, the camera holders were assessed by the dedicated operator through scoring on each of the following components (full marks: 100 for each): correct and accurate position of the thoracoscope and its direction, incidence of interference with other devices, ability of timely conversion of the near and far view, correct orientation of the lens, the secure display of the operation point at the center of the monitor, tacit cooperation with the operator (for instance, whether the trainee could predict the next maneuver of the operator), clarity of the images, video stability, the angle of the video camera lens and correct adjustment of viewing angle of the lens (fiber optic rotation adjustment).

Statistical analysis

SPSS 20 statistical software (IBM Corp., Armonk, NY, USA) for Windows (Microsoft Corp.) was used to analyze the data. The statistical data are expressed as the number and percentage and were analyzed via χ² test; meanwhile, the measurement data are expressed as x ± s and were analyzed via the t-test. P<0.05 was considered to indicate a statistical difference.

Materials and methods of the bibliometric analysis

Search strategies and data collection

A literature search was performed using the Web of Science Core Collection (WoSCC). The formula for the search strategy was as follows: (TS=(Thoracoscop* OR thoracoscop* surger* OR thoracoscop* surger* procedure* OR thoracoscop* operative surgical procedures)) AND TS=(Training* OR education* OR trained OR course*). Publications included in this study were limited to those in the English language. Only articles were included among various document types. To prevent discrepancies due to database updates, literature retrieval was conducted on a single day (May 27, 2024), covering studies published from January 1992 to May 2024. All data were collected in textual format, using the “full record and cited references” and “plain text” export options in WoSCC. The number of publications, citations, titles, author affiliations, institutions, countries/regions, keywords, and journals were gathered for bibliometric analysis. A total of 1,219 studies were initially identified, and after exclusion of 128 reviews, 42 editorial materials, 2 letters, 78 meeting abstracts, and 11 non-English language articles, 958 studies were included in the bibliometric analysis. The data-screening process is depicted in Figure 1.

Figure 1 Flowchart of data collection.

Statistical analysis

Data related to citations were extracted from the retrieved literature and analyzed using Excel (Microsoft Corp.) to determine bibliometric indicators. These indicators encompassed critical aspects of publications, such as the annual number of publications, citation frequency, average citation frequency, journal names, journal impact factors (IF), publishing countries/regions, publishing institutions, and authors. Microsoft Excel allows researchers to systematically organize and analyze bibliometric data with efficiency. In the visualization analysis process, three powerful bibliometric analysis tools were employed for comprehensive analysis of academic data including VOSviewer (version 1.6.20), CiteSpace (version 6.3. R1), and an online bibliometric analysis tool (https://bibliometric.com/). VOSviewer is a multifunctional software tool essential for mapping institutional collaboration, author collaboration, coauthorship, citation, and cocitation data (18). VOSviewer enables the visualization and exploration of complex relationships within academic networks, providing insights into connections between authors, institutions, and publications. To gain a deeper understanding of emerging trends and research hotspots, VOSviewer was used for keyword co-occurrence analysis, while CiteSpace was employed for detecting keyword emergence.

CiteSpace 6.1.R3 was employed for keyword co-occurrence analysis with time slicing set from January 1992 to May 2024, corresponding to the initial publication year of the research. The time slice interval was set to 1 year. The node types selected were keywords. For the keyword nodes, the threshold before each fragment was set to 5, and clipping (pruning) was completed using the pathfinder and clip merge network methods. Based on these parameter settings, a visualization analysis was conducted to produce a time graph of keywords related to thoracoscopic surgery training research. The online bibliometric tool was employed to map and visualize international collaboration networks among countries, with the node size denoting the number of publications, line thickness indicating the strength of connections, and the node color representing clusters or time periods.

The h-index was used to quantify the academic impact of both individuals and journals. The h-index serves as a crucial indicator for assessing researchers’ academic contributions and predicting their future scientific achievements. The G-index extends the h-index by giving more weight to highly cited articles, reflecting an author’s most influential work. The m-index, calculated as the h-index divided by the number of years since a researcher’s first publication, normalizes the h-index for career length, allowing for comparisons across different career stages. The IF measures the average number of citations received per paper in a specific journal during a given year, indicating the journal’s influence. Finally, the Journal Citation Reports (JCRs) quartile ranking categorizes journals into four quartiles based on their IFs, with Q1 representing the top 25% of journals in a category, highlighting the prestige of the publications. In this study, the h-index for each author was sourced from WoSCC.

Results

Results of the retrospective analysis

The results of intraoperative performance in supporting the lens showed that the trainees in the observational group scored significantly higher than those in the control group in terms of correct and accurate position of the thoracoscope and its direction, incidence of interference with other devices, ability of timely conversion of the near and far view, correct orientation of the lens, display of the operation point at the center of the monitor, tacit cooperation with the operator, clear images, video stability, the angle of the video camera lens and right adjustment of the viewing angle of the lens (all P values <0.05; see Figure 2 and Table 2).

Figure 2 Practical intraoperative performance. (A) The correct position of the cavity mirror rod is the upper end of the incision and parallel to the longitudinal axis of the body. (B) The cavity mirror rod is incorrectly positioned in the center of the incision and crosses the longitudinal axis of the body. (C) Each instrument crosses on another and does not interfere with other instruments. (D) Each instrument is parallel to one another and can easily interfere with other instruments. (E) A close range is needed to separate blood vessels. (F) A incorrect perspective for separating blood vessels. (G) The lens direction is correct, and the superior vena cava is vertical. (H) The orientation of the lens is not correct, and the superior vena cava is skewed. (I) The operation point is located in the center of the visual field. (J) The operating point is located at the edge of the visual field. (K) The image is clear. (L) The image is blurred. (M) Correct angle of the video camera lens: the lens is facing the segment door, and you can see the stump of the posterior segment bronchus. (N) Wrong angle of the video camera lens: after the lens direction is skewed, the posterior apical bronchial stump is not visible.

Results of the bibliometric analysis

An overview of publications in thoracoscopic surgery training research

As illustrated in Figure 3, this study included 956 publications, all of which were articles. The investigation revealed that 5,217 authors from 2,603 institutions across 289 countries contributed to the production of these 956 manuscripts. These articles were published in 310 journals and cited 16,713 references.

Figure 3 An overview of thoracoscopic surgery training research publications and key trends. (A) Overview of key bibliometric indicators for thoracoscopic surgery training research from 1992 to 2024. (B) Annual number of publications on thoracoscopic surgery training from 2000 to 2024.

The article titled “Management of spontaneous pneumothorax: an American College of Chest Physicians Delphi consensus statement” was published in the Chest journal (IF =10.1) in 2001 and has accumulated 781 citations thus far (19). The second most cited article, “Video-assisted thoracoscopic surgery is more favorable than thoracotomy for resection of clinical stage I non-small cell lung cancer”, was published in the Annals of Thoracic Surgery (IF =4.6) in 2007, accumulating 231 citations (20). The third most cited article, “First experiences with the da Vinci operating robot in thoracic surgery”, was published in the Annals of Thoracic Surgery (IF =3.4) in 2007, accumulating 223 citations (21).

The search strategy yielded resulted in 956 studies from 1992 to 2024 being included in the bibliometric analysis. As shown in the Figure 3, the total number of publications concerning the research theme of thoracoscopy training published between 2000 and 2024 indicates a significant growing trend in global literature over time. The initial number of publications in 2000 was 17. Over the years, this field of study has progressively gained more attention from researchers. Notably, from 2016 to 2023, there was a linear increase in the number of articles published in this field, and the overall trend suggests a consistent increase in scholarly interest and contributions.

Analysis of journals

Table S1 provides a comprehensive overview of the top 20 most productive journals in the field of thoracoscopic surgery training, highlighting their respective h-index, IF, JCR quartile, total publications (TPs), total citations (TCs), and other relevant metrics. The Annals of Thoracic Surgery emerged as a leading journal with an h-index of 29, an IF of 4.6, and 51 TPs, ranking second in TP but first in TCs [1,886], reflecting its high citation impact and prominence in the field.

The journals featured in the research co-occurrence network diagram related to thoracoscopy training are depicted in Figure 4A. Journal link strength in co-occurrence networks measures the frequency with which two journals are cited together within the same articles or references, reflecting their thematic or topical connection through frequent tandem citations. The three key journals with the highest total link strength were the International Journal of European Journal of Cardio-thoracic Surgery (total link strength =127), Annals of Thoracic Surgery (total link strength =107), and Surgical Endoscopy and Other Interventional Techniques (total link strength =107) (Figure 4A).

Figure 4 Network analyses of journals in thoracoscopic surgery training. (A) Journal co-occurrence network diagram. (B) Journal bibliography coupling network diagram.

The coupling network diagram of journals is presented in Figure 4B. Journal link strength in coupling networks assesses the extent to which journals are linked based on the common references cited in their articles, capturing the degree to which the research published in two different journals relies on the same body of prior work. The three key journals with the highest total link strength in the coupling network diagram were the Journal of Thoracic Disease (total link strength =1,895), Annals of Thoracic Surgery (total link strength =1,894), and European Journal of Cardio-thoracic Surgery (total link strength =1,794) (Figure 4B).

Analysis of countries

A total of 67 countries/regions articles were published in the field of thoracoscopic surgery training. The top 20 most productive countries generated 871 articles, accounting for a significant portion of the papers worldwide (Figure 5A and Table S2). The United States lead the field with 184 articles, the highest TP (TP =570) and TC (TC =6,060), resulting in an impressive average of 32.9 citations per publication. This dominant position underscored the United States’ pivotal role in advancing thoracoscopic surgery training research. Japan followed with 152 articles and ranked third in TP (TP =327) and fourth in TC (TC =1,230). Despite having a lower average citation rate of 8.1, Japan’s substantial contribution to the field was evident. China also showed strong performance with 146 articles, ranking second TP (TP =419) and second in TC (TC =1,433). China’s research in this field had an average citation rate of 9.8, reflecting its growing influence (Table S2).

Figure 5 Global distribution and collaboration in thoracoscopic surgery training. (A) Distribution of corresponding author’s publications by country (R bibliometrics). (B) Visualization map depicting the collaboration among different countries. SCP, single-country publication; MCP, multiple-country publication.

Figure 5B provides a visualization map depicting the collaboration among different countries. The nodes represent countries, with size indicating publication count, and links represent coauthorships, with thickness showing collaboration strength. The United Kingdom, although producing fewer articles (n=57), had a substantial number of citations (n=1,452) and the highest total link strength (n=96), highlighting its extensive collaborative network. Spain and Italy followed, with Spain having 32 articles and 666 citations, and Italy leading in European contributions with 77 articles and 1,583 citations (Figure 5B). These collaborative efforts are crucial for advancing research, sharing knowledge, and fostering innovation in thoracoscopic surgery training.

Analysis of the authors

The top 20 most productive authors in the field of thoracoscopic surgery training are listed in Table S3. Hansen Henrik Jessen published the most papers (n=16), with an h-index of 12, indicating that his research results were widely cited and had considerable academic influence. His work garnered a total of 428 citations, ranking him first in this regard. Konge Lars also published 16 papers, sharing the highest publication count with Hansen Henrik Jessen. He held an h-index of 12 and accumulated 391 citations, placing him third in terms of total citations. His m-index of 0.92 reflected a strong and consistent research output over time. Petersen Rene Horsleben had 15 publications, an h-index of 12, and shared the highest total citation count of 428 with Hansen Henrik Jessen, highlighting his significant impact in the field. His research productivity was also notable, with an m-index of 0.80 (Table S3). This analysis underscored the important academic contributions and influence of these leading authors in thoracoscopic surgery training, showcasing their roles in advancing research and fostering international collaborations.

Figure 6 provides a visualization map depicting the collaboration among different authors. The map highlights various clusters of collaboration, with each color representing a distinct group of closely interacting authors. The size of the nodes corresponds to the number of publications, while the thickness of the connecting lines indicates the strength of the collaborative ties between authors. Konge Lars stood out in the network, with a total link strength of 65, reflecting his core position in the scientific collaboration network. He published 16 documents and received 391 citations, underscoring his significant academic influence (Figure 6). Hansen Henrik Jessen and Petersen Rene Horsleben also played crucial roles in international research cooperation, each with a total link strength of 62. Both had 428 citations, highlighting their impactful contributions to the field. Their extensive collaboration networks were indicative of their active engagement in global research efforts. This collaborative network was essential for advancing the field, sharing expertise, and driving innovation.

Figure 6 Visualization map depicting the collaboration among different authors.

Analysis of institutions

A total of 207 institutions were involved in the field of thoracoscopic surgery training. The top 10 institutions in article count and rank in the field are listed in Figure 7A. The size of the circles in the figure represents the article count, with darker shades indicating higher ranks, providing a visual differentiation of the institutions’ productivity. The University of Copenhagen led with the highest number of published articles, totaling 33, showcasing its prominent role in advancing research in this area. Aix-Marseille Université and Assistance Publique-Hôpitaux de Marseille followed closely with 31 and 30 articles, respectively, reflecting their significant contributions to the field.

Figure 7 Institutional contributions and collaborations in thoracoscopic surgery training. (A) Top ten institutions in terms of article count and rank (R bibliometrix). The circle size indicates the article count. A darker shade indicates a higher rank. (B) Visualization map depicting the collaboration among different institutions.

Figure 7B provides the collaboration network among different institutions, illustrating the interconnections and the strength of these collaborations. The University of Copenhagen, which published 17 articles and received 490 citations, had the highest total link strength of 36, reflecting its central role in the global research network. Northwestern University, with 15 articles and 354 citations, had a total link strength of 23, indicating significant but fewer collaborations compared to the University of Copenhagen. Tongji University, with 13 articles and 110 citations, had a total link strength of 13, showing a developing but impactful network.

Analysis of keywords

A comprehensive keyword analysis on the selected 956 articles related to thoracoscopic surgery training was performed using “Author Keywords” from the Biblioshiny application and “Keywords Plus” from the VOSviewer application. In total, 1,689 keywords were identified. However, upon comparing the results from these two sources, we observed “Keywords Plus” provided more accurate results, making it the primary data source for the analysis. The top 20 keywords in the field of thoracoscopic surgery training is presented in Table S4. Figure S1 visually depicts the keyword co-occurrence network in thoracoscopic surgery training, with node size indicating keyword frequency, link thickness indicating co-occurrence strength, and color gradient indicating the evolution of research topics over time.

The keyword “experience” was the most frequently occurring term, with 101 occurrences and a total link strength of 350, indicating its central role in the literature (Figure S1 and Table S4). This suggests that clinical experience and the sharing of such experiences have been crucial components of research in this field. “Resection”, with 80 occurrences and a total link strength of 295, and “management”, with 106 occurrences and a total link strength of 293, were also prominent, emphasizing the importance of surgical techniques and patient management strategies in thoracoscopic surgery. Other significant keywords included “thoracotomy” (64 occurrences; total link strength, 261), “surgery” (99 occurrences; total link strength, 232), and “outcomes” (59 occurrences; total link strength, 224). These terms reflect the core areas of interest, suggesting a focus on surgical approaches and the results of these interventions. “Lobectomy” and “thoracic-surgery”, with 59 and 57 occurrences respectively, along with “lung-cancer” (52 occurrences) and “cancer” (55 occurrences), highlight a focus on specific surgical procedures and their relevance in oncological contexts. These keywords underscore the critical role of thoracoscopic techniques in treating lung cancer and other thoracic conditions.

Analysis of keyword bursts

Bibliometric analysis was used to identify research hotspots and trends via an analysis of academic literature. The burst analysis of keywords from 1994 to 2024 was conducted to reveal the evolution of research trends in thoracoscopic surgery training (Figure S2). In Figure S2, blue lines indicate the time span, while red lines indicate periods of citation bursts for specific keywords. The strength of the top 20 keywords with the strongest citation bursts varied, reflecting shifts in research focus over time. The burst intensity of “cell lung cancer” was particularly high from 2014 to 2018, reflecting significant interest and citation activity during that period. Similarly, “survival” also showed a notable burst from 2015 to 2018, suggesting active research and significant contributions to the literature. “Learning curve” demonstrated a burst from 2016 to 2020, indicating growing interest in optimizing training and educational methodologies in thoracoscopic surgery. Since 2015, keywords including “assisted thoracoscopic surgery”, “learning curve”, “thoracoscopic repair”, “complications”, “outcome”, “esophageal atresia”, and “lobectomy” were more prominently concentrated, indicating promising developments and sustained research interest in these topics (Figure S2). This analysis helped to map the evolution of the field, highlighting key areas of academic and clinical focus that were likely to shape future research directions.

Discussion

General information

In this study, we assessed the value of preoperative interpretation of chest CT 3D reconstruction combined with review of previous similar surgical videos for the training of the camera holders in thoracic surgery. The scientificity, safety, and effectiveness of in the training profile of the trainees prior to the completion of training was evaluated. An operator must undergo a considerable amount of practice in real surgical settings before becoming competent in proficiently performing thoracoscopy. However, the traditional training of the camera holders simply depends on the description of the chest anatomy based on textbooks and PowerPoint presentation. This training modality has certain limitations because simple lecturing can be abstract and may result in the trainees feeling bored and having difficulty understanding the content.

Traditional medical teaching focuses on classroom lectures on theories, textbooks, experimental performance, and clinical internships instead of hands-on practice. Teaching surgery generally requires the learners to observe the operation on site in the operating theater. However, not all learners can watch the operation due to the limited environment of the operating room, much less gain hands-on practice. Although animal experiments can increase the practical operation of trainers, it is difficult to obtain the ethics of each experiment, and trainers do not have enough training time to complete these experiments, so our training does not include animal experiments. Our design of the training sing preoperative interpretation of the chest CT 3D reconstruction combined with review of previous similar surgical videos can fulfill this need by providing a visualization of the surgical procedure.

Therefore, preoperative interpretation of the chest CT 3D reconstruction plus review of previous similar surgical videos can allow the trainees to fully understand this surgical procedure, thus greatly improving training efficiency and the satisfaction of the trainees with the training. Trainees can also watch the thoracoscopic videos and imaging materials repeatedly for retrospective learning at any time after operation, which may aid in improving the learning effect and skills of the trainees (22).

In summary, application of the preoperative interpretation of the chest CT 3D reconstruction combined with review of the surgical videos in thoracic surgery in training of the camera holders may have prospects and far-reaching significance. This training mode can not only raise the quality of teaching of the required techniques but can also heighten the trainee’s motivation to learn and increase their satisfaction with the training and is thus worthy of wider application.

Our bibliometric analysis of research into thoracoscopic surgery training highlighted the dynamic growth and evolving trends within this field from 1992 to 2024. The comprehensive analysis indicated that a total of 956 publications, authored by 5,217 individuals from 2,603 institutions across 289 countries, constituted this burgeoning field. The notable surge in articles from 2016 to 2023 indicates intensified scholarly engagement, driven by innovations in surgical techniques and training methodologies. The study identified the pivotal role of leading journals such as the Annals of Thoracic Surgery. Analysis of countries showed the United States leading in both publication and citation counts. Key authors in the field such as Hansen Henrik Jessen made significant academic contributions. Additionally, institutional analysis identified the University of Copenhagen and Aix-Marseille Université as leading institutions. Initiatives of European experts in surgical education revealed a series of variations and disparities among thoracic surgery training programs in Europe (23). Keyword analysis revealed that “experience”, “resection”, and “management” were central themes in the literature. The evolution of research trends indicates a shift toward specific areas such as “assisted thoracoscopic surgery”, reflecting a growing interest in improving training methods and surgical outcomes.

Among the top 20 most prolific journals in thoracoscopic surgery training, only 3 had an IF greater than 5, indicating that while several high-impact journals contribute to the field, publishing in these prestigious outlets remains challenging. The Annals of Thoracic Surgery stood out with a remarkable h-index of 29 and an IF of 4.6, leading in TC (TC =1,886) despite ranking second in TP (TP =51). This suggests that articles published in this journal are highly influential and frequently cited, reflecting its prominence within the field. This Annals of Thoracic Surgery is especially relevant for studies that introduce new surgical techniques, evaluate clinical outcomes, or discuss advancements in thoracoscopic surgery training (24). Given its leading position in total citations, it is an excellent choice for researchers aiming to publish impactful work in thoracoscopic surgery training that resonates widely within the surgical community.

From 1992 to 2024, the United States emerged as the most productive country in the field of thoracoscopic surgery training, with 184 articles, the TP. This dominant position underscores the United States’ pivotal role in advancing research and setting benchmarks in thoracoscopic surgery training. In a recent US review, Odeh et al. confirmed the effectiveness of robotic surgery in managing complex thoracic operations, suggesting it offers better patient outcomes compared to traditional methods. This underscores the need for enhanced thoracoscopic surgery training to support the broader adoption of robotic technology in thoracic procedures (25).

The United Kingdom, despite producing fewer articles, had a substantial number of citations and the highest total link strength, indicating an extensive collaborative network. Gandhi et al. in the United Kingdom reported on the increasing use of robotic-assisted thoracic surgery (RATS) among European thoracic surgeons and the importance of robust training in both RATS and VATS. Although robotic surgery is gaining popularity, the study revealed a notable gap in training programs, with many surgeons calling for its integration to improve proficiency in minimally invasive thoracic procedures (26). China, with 146 articles, demonstrated a strong performance, ranking second in TP and second in total citations, with an average citation rate of 9.8. This highlights China’s growing influence in thoracoscopic surgery training, although there is room for improvement in research impact.

A Chinese study demonstrated that HuaXi thoracoscopic anatomical lesion resection (HX-TALR) is a safe and feasible procedure but also a technically challenging procedure that requires specialized training, emphasizing the importance of thoracoscopic surgery training to ensure successful outcomes (27). Although China has made significant strides in thoracoscopic surgery training research, ranking second in TP and second in TC, there remains a need for enhanced collaboration and investment in research quality. By fostering stronger international partnerships and focusing on impactful research, Chinese scholars and institutions can further elevate their contributions to the global field.

The University of Copenhagen, located in Denmark, stood out as the most productive institution in the field of thoracoscopic surgery training, with a total of 33 published articles, indicated its significant role in advancing research in this area. The collaboration network analysis revealed that the University of Copenhagen not only led in article count but also occupied a central position in global research networks, with the highest total link strength of 36. This strong collaborative presence suggests that the University of Copenhagen is a key player in fostering international research partnerships, which are crucial for the continued advancement of thoracoscopic surgery training. Building strong, collaborative networks will be essential for institutions worldwide to improve the quality and impact of their research. A consensus published by the University of Copenhagen emphasizes the necessity of integrating simulation-based training for key thoracic surgical procedures, including VATS and robotic-assisted techniques, into the curriculum to ensure that newly qualified surgeons achieve proficiency, which also points to the institution’s leadership in advancing thoracoscopic surgery training globally (28). However, despite this leading position at the institutional level, Denmark as a whole ranked seventh in TP in this field. This disparity suggests that the University of Copenhagen plays a disproportionately significant role in Denmark’s research output. One possible reason for Denmark’s overall lower ranking could be the relatively smaller size of its academic and research community compared to larger countries such as the United States or China.

Hansen Henrik Jessen, Konge Lars and Petersen Rene Horsleben are colleagues, all affiliated with the University of Copenhagen. Hansen Henrik Jessen emerged as the most prolific author in the field of thoracoscopic surgery training, with 16 publications and an h-index of 12, reflecting the significant academic influence of his work. His research garnered a total of 428 citations, placing him at the forefront of scholarly impact in this field. A study coauthored by Hansen Henrik Jessen and his colleagues demonstrated the successful rapid implementation of video-assisted thoracoscopic lobectomy for non-small cell lung cancer in a low-volume center, highlighting the importance of specialized thoracoscopic surgery training in achieving outcomes comparable to larger high-volume institutions (29). Their study validated the use of a virtual reality (VR) simulator-based test for assessing VATS lobectomy operator competence, confirming its importance in thoracoscopic surgery training to ensure surgeons achieve essential skills before performing the procedure on patients (30). They are key contributors to advancements in thoracoscopic surgery, particularly in the areas of VATS and RATS, with their work significantly influencing surgical techniques and training programs. Collaborators interested in working with them should focus on innovative minimally invasive surgical methods and simulation-based training, ensuring proposals align with their expertise and contribute meaningfully to the field. Their institution also ranks as the most productive university in this field. This highlights the importance of fostering a supportive academic environment that encourages collaboration and high-impact research, which in turn drives innovation and advances the field on a global scale.

The bibliometric analysis can systematically identify knowledge gaps and research deficiencies in the current field of thoracoscopic surgery training. This provides a basis for future research directions and helps researchers focus on topics that have not been fully explored. Understanding publication trends, major contributors, and literature gaps can inform future research directions. Analyzing the research results of different training methods can help clinicians and educators to better evaluate the effectiveness of existing training systems, so as to optimize teaching strategies and improve training quality. Bibliometric analysis can promote cross-disciplinary communication and cooperation, and promote in-depth research in the field of thoracoscopic surgery training.

Emerging topics

In recent years, researchers have increasingly focused on the learning curve associated with thoracoscopic surgery (31,32). The keyword “children” demonstrated significant citation strength in the field, particularly from 2006 to 2015, indicating a strong research focus and influence on pediatric thoracoscopic surgery during this period. Fung et al. found that using live rabbit models significantly improves the procedural confidence of pediatric surgeons in neonatal thoracoscopic surgery, suggesting that this realistic training method effectively enhances surgical skills (33). Additionally, the keyword “learning curve” constituted a significant burst from 2016 to 2020, which indicated that there was a notable increase in the number of studies or publications focusing on learning curves thoracoscopic surgery. Gonfiotti et al. demonstrated that significant improvements in surgical outcomes are achieved after surgeons have completed their learning curves, underscoring the importance of adequate training and experience in VATS (34). Similarly, Hernandez-Arenas et al. attested to the steep initial learning curve for uniportal VATS, noting that surgeons in a high-volume training center achieved better operative efficiency and patient outcomes after the initial phase of learning (35). Li et al. further examined the demanding nature of uniportal VATS anatomical segmentectomy, emphasizing the necessity for continuous practice to master this technique and reduce operative times (36). Martin-Ucar et al. indicated that prior experience with multiport VATS can ease the transition to single-port methods, suggesting that foundational skills in multiport techniques are advantageous (37). Nachira et al. provided evidence of the dynamic nature of the learning process in uniportal VATS lobectomy, with surgical outcomes and complication rates improving as experience accumulates. This progression indicates the presence of a learning curve that can be effectively navigated with continued practice and experience (9). In the context of thoracoscopic radical esophagectomy, Ninomiya et al. emphasized structured training and simulation as key strategies to flatten and shorten the learning curve, thus enhancing skill acquisition and improving surgical outcomes (38). Oshikiri et al. studied thoracoscopic esophagectomy with the patient in the prone position, noting that experience leads to better operative efficiency and patient outcomes, indicating the benefits and challenges associated with this technique (39). Imperatori et al. believe that in video-assisted thoracic surgery simulation training, haptic feedback training is helpful to improve the training effect (40). Collectively, these studies underscore the significance of experience, structured training, and continuous practice in mastering thoracoscopic surgical techniques, which will ultimately lead to improved patient outcomes and surgical efficiency.

The goal of training in thoracoscopic surgery and other minimally invasive techniques is to reduce the learning curve, minimize complications, and ultimately provide effective and safe patient care (41). The burst keywords analysis also revealed that the keyword “complications” surged notably from 2017 to 2021, indicating an intensified focus on the adverse effects. Additionally, the burst of the keyword “outcome” from 2019 to 2024 indicated a growing emphasis on evaluating the effectiveness of thoracoscopic surgery and their impact on patient quality of life. Whitson et al. compared VATS with thoracotomy for patients with clinical stage I non–small cell lung cancer and reported that VATS offers several advantages, including fewer postoperative complications and shorter hospital stays while maintaining similar survival rates. This underscores the need for training in VATS to maximize its benefits, as proficiency in these minimally invasive techniques can lead to improved patient outcomes and reduced healthcare costs (20). Kohno et al. observed that despite the minimally invasive nature of thoracoscopic surgery, there are inherent risks, such as prolonged air leaks, bleeding, and infections. These complications can be effectively managed and minimized through meticulous surgical techniques and comprehensive postoperative care. This highlights the value of thorough training in these areas to ensure that surgeons can handle potential complications adeptly (6).

The effectiveness of thoracoscopic surgery, particularly in reducing complications and improving patient outcomes, is closely linked to the training and experience of the surgical team. Future research should focus on advanced training methods and simulation-based learning to accelerate skill acquisition and proficiency. Emerging areas such as the integration of VR and augmented reality (AR) in surgical training, as well as the use of artificial intelligence to personalize learning experiences, warrant further exploration (42,43). Jensen et al. demonstrated the practical application of VR in thoracoscopic surgery through the development of a VR simulator tailored for VATS lobectomy. Their work supports the simulator’s effectiveness in mimicking the thoracoscopic environment, which is essential for skill acquisition in minimally invasive procedures (44). Ujiie et al. explored the application of VR in preoperative planning for RATS, which showcased how VR can enhance surgical precision and confidence, potentially improving patient outcomes by reducing intraoperative uncertainties (45). In addition to these applications, Qin et al. investigated the effectiveness of various simulation modalities, including VR, AR, and mixed reality, in training for VATS. Their findings point to the unique advantages of each modality: VR for its immersive experience, AR for blending real and virtual elements, and MR for integrating the benefits of both (46). Grossi et al. reported that intensive, twice-weekly virtual simulator training significantly enhances basic surgical skills in thoracic and general surgery residents, demonstrating greater precision in surgical maneuvers compared to less frequent training (47). Oya et al. demonstrated that a self-supervised offline learning framework for 2D/3D deformable registration significantly improves the accuracy of shape registration in thoracoscopic surgery by using synthetic images to enhance predictions from limited real endoscopic data (48). These technologies hold promise for enhancing the precision of surgical skills and decision-making processes, thus improving overall patient care (45). Additionally, there is a need to explore the development and implementation of standardized assessment tools to measure the effectiveness of training programs, ensuring that all surgical teams meet high competency standards.

Strengths and limitations

This study has several strengths. First, the use of advanced bibliometric tools allowed for detailed visualization of research collaborations and emerging topics. Second, the analysis of keyword bursts and citation metrics offers valuable insights into the evolving areas of focus and influential studies within thoracoscopic surgery training. However, there were several limitations associated with the bibliometric analysis. First, the reliance on citation counts as a measure of research impact might not fully capture an article’s clinical relevance or practical application, which may not accurately reflect the true value of the research. Second, the reliance on indexed databases might have resulted in the exclusion of relevant publications, particularly those not in English or from less prominent journals, potentially skewing the analysis of global research contributions. Additionally, most of the studies in the literature analyzed were factual reports and retrospective analyses, while there were few studies on randomized controlled trials (RCTs) and propensity score matching large sample size analyses. Future studies at a higher level need to be carried out. Finally, the analysis of trends over time, including burst keywords, might not fully capture the nuances of research evolution, which could be influenced by external factors such as technological advancements, funding availability, and changes in clinical practice guidelines.

Conclusions

Preoperative interpretation of chest CT 3D reconstruction combined with the review of surgical videos in training the camera holders in thoracic surgery can greatly improve and accelerate the quality of the assistant’s performance during the procedure. Moreover, the bibliometric analysis offers a detailed overview of the research landscape in thoracoscopic surgery training. The findings highlight the importance of clinical experience and the integration of new surgical techniques and training methods. Future research should continue to explore these areas, with a particular focus on the identified research frontiers, to advance the field and improve patient outcomes. Ongoing bibliometric analyses are essential for monitoring research progress and guiding future studies.

Acknowledgments

Funding: This research was funded by the 2023 Provincial quality project of New era Education of Anhui Provincial Department of Education (No. 2023szsfkc110), the Anhui Provincial “Four New” Research and Reform Practice Project (No. 2022sx169), the Provincial Model Curriculum Reform Program (No. 2020szsfkc0894), the 2024 Management and Service Innovation Project of the Affiliated Yijishan Hospital of Wannan Medical College (No. CX2023038), and the 289 Project of Anhui Provincial Healthcare Commission.

Footnote

Data Sharing Statement: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1913/dss

Peer Review File: Available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1913/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-1913/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 study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study was approved by the institutional ethics committee of The First Affiliated Hospital of Wannan Medical College (Yijishan Hospital). Individual consent for this retrospective analysis was waived.

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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