Team Training for Nonintubated Thoracic Surgery

Nonintubated thoracic surgery arose as supplemental evolution of minimally invasive surgery and is gaining popularity. A proper nonintubated thoracic surgery unit is mandatory and should involve surgeons, anesthesiologists, intensive care physicians, physiotherapists, psychologists, and scrub and ward nurses. Surgical training should involve experienced and young surgeons. It deserves a step-by-step approach and consolidated experience on video-assisted thoracic surgery. Due to difficulty in reproducing lung and diaphragm movements, training with simulation systems may be of scant value; instead, preceptorships and invited proctorships are useful. Preoperatively, patients must be fully informed. Effective intraoperative communication with patients and among the surgical team is pivotal.

Key points

  • Nonintubated thoracic surgery needs a specific formation of a well-trained and close-knit staff, including surgeons, anesthesiologists, scrub nurses, operating room, and floor assistants.

  • Operation requires advanced surgical skill compared with normal video-assisted thoracic surgery due to the presence of breathing or cough, patient anxiety, intolerance, or hypercapnia.

  • Dry laboratory and wet laboratory training may be of scant value due to the impossibility of reproducing lung movements, whereas visiting a high-volume center or hosting an experienced team would be of greater value.

  • Communication with patients, preoperatively and intraoperatively, and among the surgical team is pivotal and should follow a precise plan, reassuring the subjects, inciting them when necessary, with avoiding of impatience and anxiety.


Nonintubated thoracic surgery consists of an operative modality where patients receive operations without orotracheal intubation and mechanical ventilation. The term, awake thoracic surgery was used in the past to indicated the same procedures, but this is not a synonym for nonintubated thoracic surgery. Indeed a vast majority of nonintubated thoracic procedures are usually performed with some degree of sedation, while preserving spontaneous breathing. The spectrum of benefits of nonintubated thoracic surgery is multifaceted. It causes a global reduction in both inflammatory and metabolic stress compared with standard operations. This would translate into fewer postoperative complications and, more in general, faster recovery. In addition, the authors have speculated on the intriguing possibility of the immune-depressive effect provoked by mechanical ventilation and profound anesthesia that might have a short-term impact on postoperative morbidity as well as a long-term influence on oncologic outcomes.

The authors instituted the awake thoracic surgery program at the Tor Vergata University of Rome in 2000 and operations were first performed 1 year later. To the best of their knowledge, this program was the first in the world to address this specific target. This program was aimed at creating a dedicated multidisciplinary unit, understanding physiologic effects of the procedures, refining surgical and anesthesiologic techniques, selecting patients most suitable for these procedures, and training a crescent number of specialists and nurses.

The authors’ group included surgeons, anesthesiologists, intensive care physicians, physiotherapists, and both scrub and ward nurses. The authors also created a network involving external physicians, general practitioners, mass media providers, university center operators, and national health system organizations in order to popularize the progress of the program and receive adequate and reliable feedback.

All data were progressively stored in a computerized medical database in order to have readily available all demographic data, laboratory work-ups, imaging, informed consents, details of surgery, pathology, and follow-up data. At present, more than 1,000 cases of nonintubated video-assisted thoracic surgery (VATS) have been successfully carried out.

The Department of Thoracic Surgery at Tor Vergata University is intimately attached to the Tor Vergata University School of Medicine and, at the same time, it represents the main institution of the Postgraduate School in Thoracic Surgery. Therefore, the problem of teaching the new techniques of nonintubated thoracic surgery was immediately acknowledged as critical for the institution.

The learning process

Before dealing with the practical method of teaching nonintubated surgery, the current accepted ideas about the learning process are discussed. In summary, the learning process in the humans can be classified into 2 main phases: explicit learning, where the student has the consciousness of being trained, and implicit learning, where the student has not. Sequences of explicit learning are variously classified but they usually include problem-actions and effect-memories. On the contrary, implicit learning can derive from motor, temporal, and associative sequences. The knowledge can be represented as decomposition into simple information and reorganization of single fragments into a hierarchical sequence.

At present, the investigators of the learning process have individuated 4 different stages of competence that depict a pupil’s pathway from unawareness to proficiency: unconscious incompetence, conscious incompetence, conscious competence, and finally unconscious competence ( Fig. 1 ). It is a well-known Socratic quotation that the first step to acquire new skill is to become aware that there are things one does not know. Inevitably, this discovery can generate a state of anxiety and unsatisfaction. Furthermore, gaining competence is not only a matter of acquiring information but also applying what has learned through testing attempts. Depending on a pupil’s character, this step can also produce refusal to learn, fear to challenge, and even anger twoard the topics or against the teachers.

Fig. 1

The 4 different stages of competence that depict a pupil’s pathway from unawareness to proficiency: unconscious incompetence, conscious incompetence, conscious competence, and finally unconscious competence.

Acceptance and openness of the personal status are the keys to any further improvement. After enough practice and repetitions, with adequate effort and study, the pupil acquires proficiency. At the final stage, the ability is automatic and the actions come instinctively without aware forethought. To maintain this condition, however, continuous relearning is required, avoiding self-complacency; otherwise, the scholar might regress. Some investigators define this new status as “reflective competence level,” that is, a mature recognition of personal limits paralleled by the continuous incentive toward updating. Conversely, one can fall into the Dunning-Kruger effect, where the incompetent cannot recognize their own incompetence. An opposite effect, the lack of self-confidence, can cause nervousness and uncertainty, affecting the performance even in a skilled individual.

There are many learning styles: verbal, visual, aural, physical, logical, social, and solitary. Among these, 3 are particularly important in surgery. Verbal learning style is the most common teaching/learning style. The message is based on speech, but it is more incisive when integrated with acronyms and mnemonics and reinforced with small group conversations. Visual learning style is currently often used in surgery, especially with the introduction of videothoracoscopy popularized through materials available online. Physical learning style is effective when it comes to teach a practical topic, such as surgery. In this field, there are different patterns, discussed later. There are also, however, theoretic topics can get benefit associating movements to concepts.

The training process

Surgical training is intimately connected to the training process. Every time a new practical process is successfully developed, the difficulty of transferring it to both authoritative senior colleagues being the same age as the teacher and to junior doctors under training should be taken into account as well. Practice needs to address weakness, and these 2 counterparts depict 2 different kind of weakness. In mature staff, there is an initial and firm hostility toward new techniques paralleled with a greater difficulty in apprenticing new movements. This burden is much more significant and scientifically proved after the age of 50 years. Conversely, it is self-evident that young fellows are more keen to learn new techniques whereas they have to face their own inexperience, which becomes evident from the less brilliant surgical outcomes. This simple and intuitive statement has been recently reaffirmed by a trustworthy scientific publication.

The training process in surgery has been the object of many investigations and also presents many legal and ethical issues. During a learning process, different phases are crossed that can be summarized as panic zone, learning zone, and control zone. These 3 phases must be invariably passed through, taking into mind that without feeling uncomfortable, there probably is not learning. The extent of these 3 areas changes from individual to individual, according to talent and background.


Due to the historical common origin from barbers, the most common form of training, if any, for surgeons was the apprenticeship. Students learned surgery through direct observation and imitation of a master’s actions in the operating theater or, most of the time, at a patient’s home. During the nineteenth century, under the stimulus of European school, the surgeon’s formation became progressively more formal and structured. On this basis, more than 1 century ago, William Stewart Halsted established the 3 main principles ( Box 1 ) for training surgeons. This method produced a pyramidal-shaped selection, where from the large number of pupils starting, just a few terminated. After World War II, especially in the United States, this system has been progressively reconsidered, with a definite number of pupils appointed each year, structured rotating program, precise number of years for training, and completion of the course for all applicants, outlined as a rectangular-shaped program.

Box 1

Halsted’s principles of surgical training

From Polavarapu HV, Kulaylat AN, Sun S, et al. 100 years of surgical education: the past, present, and future. Bull Am Coll Surg. 2013;98(7):22–7; with permission.

  • The resident must

    • Have intense and repetitive opportunities to take care of surgical patients under the supervision of a skilled surgical teacher

    • Acquire an understanding of the scientific basis of the surgical disease

    • Acquire skills in patient management and technical operations of increasing complexity with graded enhanced responsibility and independence

At the end of the millennium, the accreditation model shifted all over the world to a new one based more on interpersonal and communication skills and on outcomes evaluation ( Box 2 ). Contemporaneously, there was increased sensitivity about the amount of resident work hours, aiming at restricting and optimizing them.

Box 2

Core Accreditation Council for Graduate Medical Education competencies

From Rose SH, Long TR, Elliott BA, et al. A historical perspective on resident evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education duty hour requirement. Anesth Analg. 2009;109(1)191; with permission.

  • 1.

    Patient care

    • Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to

      • a.

        Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families

      • b.

        Gather essential and accurate information about their patients

      • c.

        Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment

      • d.

        Develop and carry out patient management plans

      • e.

        Counsel and educate patients and their families

      • f.

        Use information technology to support patient care decisions and patient education

      • g.

        Perform competently all medical and invasive procedures considered essential for the area of practice

      • h.

        Provide health care services aimed at preventing health problems or maintaining health

      • i.

        Work with health care professionals, including those from other disciplines, to provide patient-focused care

  • 2.

    Medical knowledge

    • Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g., epidemiological and social-behavioral) sciences and the application of this knowledge to patient care. Residents are expected to

      • a.

        Demonstrate an investigatory and analytic thinking approach to clinical situations

      • b.

        Know and apply the basic and clinically supportive sciences that are appropriate to their discipline

  • 3.

    Practice-based learning and improvement

    • Residents must be able to investigate and evaluate their patient care practices; appraise and assimilate scientific evidence; and improve their patient care practices. Residents are expected to

      • a.

        Analyze practice experience and perform practice-based improvement activities using a systematic methodology

      • b.

        Locate, appraise, and assimilate evidence from scientific studies related to their patients’ health problems

      • c.

        Obtain and use information about their own population of patients and the larger population from which their patients are drawn

      • d.

        Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness

      • e.

        Use information technology to manage information, access on-line medical information, and support their own education

      • f.

        Facilitate the learning of students and other health care professionals

  • 4.

    Interpersonal and communication skills

    • Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients’ families, and professional associates. Residents are expected to

      • a.

        Create and sustain a therapeutic and ethically sound relationship with patients

      • b.

        Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills

      • c.

        Work effectively with others as members or leaders of a health care team or other professional group

  • 5.


    • Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to

      • a.

        Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and continuing professional development

      • b.

        Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices

      • c.

        Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

  • 6.

    Systems-based practice

    • Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to

      • a.

        Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice

      • b.

        Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources

      • c.

        Practice cost-effective health care and resource allocation that does not compromise quality of care

      • d.

        Advocate for quality patient care and assist patients in dealing with system complexities

      • e.

        Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

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Aug 16, 2020 | Posted by in CARDIAC SURGERY | Comments Off on Team Training for Nonintubated Thoracic Surgery
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