Acta Chirurgica Belgica

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Introduction of pediatric thoracoscopic lung

resections in a low-volume center – feasibility,
outcome and cost analysis

Arimatias Raitio, Vesa Vilkki & Niklas Pakkasjärvi

To cite this article: Arimatias Raitio, Vesa Vilkki & Niklas Pakkasjärvi (2022): Introduction of
pediatric thoracoscopic lung resections in a low-volume center – feasibility, outcome and cost
analysis, Acta Chirurgica Belgica, DOI: 10.1080/00015458.2022.2086394

To link to this article: https://doi.org/10.1080/00015458.2022.2086394

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Published online: 09 Jun 2022.

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ACTA CHIRURGICA BELGICA
https://doi.org/10.1080/00015458.2022.2086394

ORIGINAL PAPER

Introduction of pediatric thoracoscopic lung resections in a low-volume

center – feasibility, outcome and cost analysis
Arimatias Raitioa , Vesa Vilkkib and Niklas Pakkasj€arvia
a
Department of Paediatric Surgery, University of Turku and Turku University Hospital, Turku, Finland; bHeart Centre, Turku
University Hospital, Turku, Finland

ABSTRACT ARTICLE HISTORY

Background: Early series of pediatric thoracoscopic surgery have reported high conversion Received 31 July 2021
rates and significant complications. This study investigated the introduction of pediatric thor- Accepted 1 June 2022
acoscopic lung resections in a low-volume center with reference to corresponding open
KEYWORDS
thoracotomy procedures with regards to operative times, length of stay, cost of admission,
Lung resection; minimally
and outcomes. invasive surgical
Methods: A single surgeon series. Data from the first 10 consecutive thoracoscopic lung procedures; pediatrics;
resections were compared to a cohort of 10 consecutive open lung resections performed thoracoscopy
before the introduction of the thoracoscopic technique. All operations were performed
between December 2015 and October 2021. The median follow-up was 34 months
(range 4–65).
Results: The cohort included 14 lobectomies (8 thoracoscopic and 6 open) for congenital
pulmonary airway malformation (CPAM), and 6 resections (mainly non-anatomic) of pulmon-
ary sequestration (2 thoracoscopic and 4 open). One lobectomy required conversion to
thoracotomy, and one patient required reinsertion of a chest drain after open lobectomy
due to persistent air leak. No other complications were recorded. All patients were asymp-
tomatic at their follow-up. There was no significant difference in the mean age, mean
weight, operative times, and intraoperative blood loss between open and minimally invasive
procedures. Thoracoscopic technique was associated with significantly shorter stay at pediat-
ric intensive care unit and shorter overall inpatients stay.
Conclusion: Thoracoscopic lung resections can be safely introduced in a low-volume center
with comparable cost, operative time, and results and significantly shorter inpatient stay.

Introduction pediatric surgeons [6]. Also, a sufficient case vol-

The main benefit and aim of minimally invasive ume is required to reach a plateau of competence,
surgery (MIS) are to minimize tissue damage. which is typically challenging in pediatric surgery
Recent development of small, high-quality instru- [5]. According to the European Society of Pediatric
ments has allowed these operations to be per- Endoscopic Surgeons (ESPES), at least 30 proce-
formed even in neonates [1,2]. This has led to dures as assistant and more than 50 basic proce-
exponentially increasing popularity of thoraco- dures as primary surgeon should be included in a
scopic surgery [3]. Current evidence suggests that valid MIS training curriculum [7].
thoracoscopic surgery in pediatric population is On average, our pediatric surgery unit has less
associated with improved recovery but also longer than five lung resections annually, which makes
operative times compared to conventional open completion of validated MIS training challenging.
thoracic surgery [4]. However, there are no studies However, collaboration with adult thoracic sur-
on cost-effectiveness of thoracoscopic surgery in geons at our hospital facilitated the introduction
pediatric population. of minimally invasive lung resections regardless of
Thoracoscopy is considered technically more a low case volume.
difficult than open surgery [5], and therefore it is This study aims to analyze the introduction of
regarded as the last step in MIS training by many pediatric thoracoscopic lung resections in a low-

CONTACT Arimatias Raitio [email protected] Department of Paediatric Surgery, Turku University Hospital and University of Turku,
Turku, Finland
All authors contributed to the acquisition of data, writing, and revision of the manuscript and have approved the final version.
ß 2022 The Author(s). Published by Informa UK Limited, trading as Taylor & Francis Group.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives License (http://creativecommons.org/
licenses/by-nc-nd/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited, and is not
altered, transformed, or built upon in any way.
2 A. RAITIO ET AL.

volume center to assess the feasibility, safety, and Outcome measures and data collection
cost-effectiveness of a new technique in a teaching
Primary outcome measures were length of stay
hospital without prior experience in pediatric thor-
(LOS) at pediatric intensive care unit (PICU) and total
acoscopic surgery.
inpatient stay, time to chest drain removal, complica-
tions, readmissions, requirement for postoperative
pain medication (adjusted for patients’ weight), oper-
Materials and methods ation times, intraoperative blood loss, and costs
We performed a retrospective study on lung resec- related to surgery and total admission. Also, data on
tions performed by a single pediatric surgeon. patients’ age, weight, diagnosis, and performed
Data from first 10 thoracoscopic lung resections operation(s) were collected. Routine follow-up
were compared to a cohort of 10 consecutive included chest radiograph at 3 and 12 months post-
open lung resections performed before the intro- operatively. Complications were graded according to
duction of thoracoscopic technique. Patients were the Clavien–Dindo classification system [9].
identified in the operating theatre management
software (Centricity Opera 4.5, GE Healthcare, Statistical analysis
Barrington, IL) by searching with relevant oper-
One-way ANOVA and Wilcoxon rank test were
ation codes for lung resections: GDC00 and GDC01
used to compare continuous variables and chi-
for open and thoracoscopic lobectomy, and
square for categorical variables. A significance level
GDB96 and GDB97 for open and thoracoscopic
of p < 0.05 (two-tailed) was set. Analyses were per-
resection of lung. Performed operations are all reg-
formed using JMP Pro, version 15.1.0 for Windows
istered according to the Finnish version of
(SAS Institute Inc., Cary, NC).
NOMESCO (Nordic Medico-Statistical Committee)
Classification of Surgical Procedures (NCSP).
Results
The thoracoscopic cohort included 8 lobectomies
Surgical technique for congenital pulmonary airway malformation
(CPAM) and two resections of pulmonary seques-
All operations were performed under general anes-
tration. The open cohort consisted of 6 lobecto-
thesia at our unit of pediatric surgery. After endo-
mies for CPAM and 4 resections of pulmonary
tracheal intubation, patients were placed in lateral
sequestration. All operations were performed
decubitus position. For open procedures, a standard
between December 2015 and October 2021. The
posterolateral muscle-splitting thoracotomy was uti-
median follow-up length was 12 months (range
lized. The main vessels were divided with absorb-
3–34) and 54 months (36–69) for thoracoscopic
able sutures and non-absorbable suture was used
and thoracotomy cohort, respectively. There were
for bronchial division. For thoracoscopic procedures, no significant differences in the median age,
single lung ventilation was required and contralat- median weight, operative times, and intraoperative
eral mainstem intubation was confirmed with bron- blood loss between open and minimally invasive
choscopy by the anesthetist. Three 5-mm trocars procedures. The thoracoscopic technique was
were inserted, and CO2 insufflation was utilized to associated with a significantly shorter stay at pedi-
create pneumothorax and complete lung collapse. atric intensive care unit (PICU) and shorter overall
A 5-mm surgical stapler (JustRight Surgical, inpatients stay, as well as shorter time to chest
Louisville, CO) was the primary device for vessel drain removal postoperatively (Table 1).
and bronchial sealing as described by Dr One lobectomy required conversion to thoracot-
Rothenberg [8]. Anterior incision was extended up omy due to bleeding, which could not be man-
to 3 cm before specimen retrieval; a retrieval bag is aged thoracoscopically. Only one complication was
not required. A chest drain was left in place rou- recorded (Clavien-Dindo IIIb). This patient was ana-
tinely for both open and thoracoscopic procedures. lyzed as part of thoracoscopic cohort. A patient
As the new minimally invasive technique was intro- was readmitted for reinsertion of a chest drain
duced, an adult thoracic surgeon experienced with under general anesthesia one week after open lob-
minimally invasive lung resections was working as ectomy due to persistent air leak. All patients
the first assistant holding the camera to shorten the attended and were asymptomatic at their routine
learning curve, as recommended in literature [3]. follow-up visits at 3 and 12 months postoperatively
 ACTA CHIRURGICA BELGICA 3

Table 1. Comparison of open and thoracoscopic operations showing significant differences in length of PICU
and inpatient stay duration only.
Thoracoscopic operation (n ¼ 10) Open operation (n ¼ 10) p Value
Age (years) 0.9 (0.7–9.7) 1.0 (0.7–2.0) 0.46
Weight (kg) 9.6 (8.0–40) 9.6 (6.7–12.4) 0.46
Operative time (minutes) 107 (60–148) 95 (61–203) 0.87
Blood loss (ml) 10 (2–100) 18 (2–120) 0.22
PICU stay (days) 1 (1–2) 2 (1–3) 0.015
Inpatient stay (days) 2 (1–6) 4 (3–5) 0.005
Chest drain removal (days) 1 (1–2) 2 (1–3) 0.039
Cost of operation (e) 5447 (3212–9010) 4373 (2108–6176) 0.10
Total cost of admission (e) 8611 (7039–16,271) 9568 (7046–12,833) 0.49
Values are given as median and range.

Table 2. Comparison of postoperative main management and dosage of pain medications.

Thoracoscopic operation (n ¼ 10) Open operation (n ¼ 10) p Value
Epidural anesthesia 2/10 patients 8/10 patients 0.02
Oxycodone (mg/kg) 0.57 (0.45–1.39) 1.17 (0.51–2.09) 0.01
Dexmedetomidine (ug/kg) 16.8 (0–46.6) 37.7 (0–93.8) 0.01
Paracetamol (mg/kg/day) 71.0 (51.7–106.9) 61.1 (47.4–67.3) 0.03
Naproxen (mg/kg/day) 7.3 (0–13.4) 5.6 (0–13.3) 0.40
Values are given as median and range.

and chest radiographs revealed no signs of Discussion

complications.
We show here that thoracoscopic lung resections
For cost analysis, the hospital charges for the
can be safely introduced in a low-volume center
surgical procedure as well as the total cost of the
with comparable short- and mid-term results,
admission were analyzed and compared between
operative time, and hospital charges. The thoraco-
open and minimally invasive cohorts with all
scopic approach eases the burden on the patients
charges converted to 2021 hospital rates. For 2021,
and their families with significantly shorter
the list prices of thoracoscopic lobectomy includ-
inpatient stay and lower need for postoperative
ing operating theatre and anesthesia were 3940
epidural anesthesia, sedation, and opioids.
euros (e) and of open lobectomy 4260 e, respect-
Thoracoscopic lobectomy in infants and children
ively. The list prices are predefined for specific
is considered a technically challenging procedure
operation codes. For our patients, the operative
[8]. Hence, at least 50 cases should be included in
costs of thoracoscopic operations were higher
than in conventional open surgery; 5448 e versus a valid MIS training curriculum [7]. Fifty cases are
4373 e, including the price of special instrumenta- also considered as a cut-off point for learning
tion required for minimally invasive surgery. The curve in operative time and stable outcomes [10].
total charges of the admission were nevertheless A meta-analysis on thoracoscopic resection of
lower in the thoracoscopic cohort; 8611 e versus asymptomatic congenital lung malformation
9568 e with shorter total and PICU length of stay. reported a mean operative time of 142 min in 404
However, no statistically significant difference was minimally invasive procedures [11]. The operative
observed (Table 1). Total charges, which in our times reported here were comparable with our
country are all covered by patient’s municipality, own control group as well as the median operative
include both the price of surgery and postopera- time (100 min) reported by Park et al. after more
tive care. than 50 performed lung resections [10]. Hence, our
There was a significantly higher frequency of results would suggest that the learning curve can
postoperative epidural anesthesia after open be shortened by the assistance provided by adult
thoracotomy (8/10 versus 2/10 patients, p ¼ 0.02). thoracic surgeon.
The total amount of sedative medication One of the main disadvantages of thoracoscopic
Dexmedetomidine; DexdorV R ) as well as the total lung resections in pediatric patients is longer
requirement for opioids (Oxycodone) was signifi- operative time compared to open surgery, which
cantly lower after minimally invasive surgery. Daily has been reported in several studies [12–14],
dose of paracetamol was higher in thoracoscopic including one meta-analysis [11]. However, this
group while no difference was observed in utiliza- finding has not been confirmed in all published
tion of Naproxen (Table 2). All patients were dis- reports [15]. In our study, the operative times were
charged with Paracetamol and Naproxen or comparable between open and minimally invasive
Ibuprofen only, and no opioids were prescribed. cohorts despite recent introduction of
4 A. RAITIO ET AL.

thoracoscopic technique. This may be explained in Strengths and limitations

part by having two complicated lobectomies with
The strength of the current study is the inclusion
previous infection in open cohort compared to
of ten consecutive patients in both cohorts and no
one lobectomy for CPAM and lung abscess in min-
patients were lost to follow-up. The main limitation
imally invasive cohort. On the other hand, the
is the small sample size and heterogeneity of per-
operative times for thoracoscopic lung resections
formed operations.
reported here were comparable with those of
larger series [10], as stated above.
There is robust evidence that the length of hos- Conclusions
pital stay is significantly shorter for thoracoscopic
The findings of the current study suggest that
lung resections confirmed by two meta-analyses
introduction of pediatric thoracoscopic lung resec-
(evidence level 3a) [11,15]. Shorter time in inten-
tions in a small volume center is safe, feasible, and
sive care unit has also been reported as an advan-
economically justifiable. In our experience, the
tage of thoracoscopic surgery [16,17]. In
assistance provided by the adult thoracic surgeon
accordance with previous reports, we also
has been crucial in the introduction of this
observed significantly shorter hospital and PICU
new technique.
stay after minimally invasive surgery. Thoracoscopy
was associated with faster time to chest drain
removal, which is supported by several previous Geolocation information
studies [16–18] including one meta-analysis [15].
Finland
Early studies have reported that thoracoscopic
surgery is associated with less regional anesthesia
[19] and narcotics use [20]. These findings were Disclosure statement
supported by our results as requirement for epi- The authors report no conflict of interest.
dural anesthesia, sedatives, and opioids was lower
in thoracoscopic cohort. Thus, it seems evident
Funding
that minimally invasive surgery is associated with
significantly reduced postoperative pain compared Dr Raitio reports grants from the Finnish Paediatric
to conventional surgery. Research Foundation outside the submitted work, Grant
According to a recent systematic review, the number 200156 and Paulo Foundation.

majority of adult studies have reported lower or

similar overall costs for thoracoscopic lobectomies
compared with open surgery [21]. However, similar ORCID
studies in pediatric population are sparse. While Arimatias Raitio http://orcid.org/0000-0001-9114-2204
thoracoscopy is a safe alternative to open surgery,
the need for cost-analysis has been noted [22]. A
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