Conversion rates during video-assisted thoracoscopic lobectomy are reported, but no previous publications have classified the cause of conversion. The aim of the study was to develop a quality assessment tool [vascular, anatomy, lymph node, technical (VALT) 'Open'] to evaluate reasons and nature of conversion during the development of a video-assisted thoracoscopic lobectomy program. Between 2006 and 2008, 237 patients with a median age of 65 years underwent video-assisted thoracoscopic lobectomy primarily for lung. The number of video-assisted thoracoscopic lobectomy cases over open cases has increased over the period. Conversion rate has dropped from 15% (2006) to 11% (2008). A total of 32 cases required conversion. The VALT 'Open' classification for reason to convert and nature of conversion was used. The average length of stay was shorter for non-converted cases. No uncontrolled conversions where the patient was unstable were required, and in the 14 cases converted following some difficulty, such as pulmonary artery injury. A pattern to the learning curve became predictable. The quality assessment tool used (VALT 'Open') will allow cause of conversion and nature of conversion to be tracked and audited during the development of a video-assisted thoracoscopic surgery lobectomy program.

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Managing a solitary fibrous tumour of the diaphragm from above and belowa ns_5282 370..371 Solitary fibrous tumours are rare spindle-cell neoplasms that usually arise from visceral and parietal pleura and peritoneum and are likely of either mesothelial cell origin or fibroblast/primitive mesenchymal cell origin.1 They are typically found in the chest and occasionally the abdominal cavity but have been reported in the parotid gland, pericardium, ovary, liver, intestine, lung, orbit, upper respiratory tract, bladder and periosteum.2 Solitary fibrous tumours involving the diaphragm arising from overlying pleura or underlying peritoneum have been occasionally described but never with such intimate involvement.A 32-year-old female smoker presented with clinical features typical for gallstones. An ultrasound of her biliary system confirmed cholelithiasis but also noted a large heterogeneous solid hypoechoic mass medial to the spleen in the left upper quadrant. Beyond issues with symptoms related to gallstones, she denied any other problems including breathlessness, atypical chest pain or referred pain. She had no night sweats or weight loss, and clinical examination was unremarkable.A chest computerized tomography (CT) demonstrated a large mass in intimate contact with the left hemidiaphragm (Fig. 1a,b). Following standard general anaesthesia and single lung ventilation, a left video-assisted thoracoscopic assessment showed the mass appearing to be within the diaphragm or pushing up from the abdomen. A laparoscopy was performed, which confirmed the mass was within the diaphragm itself (Fig. 2) and completely separate form underlying abdominal viscera. Following left thoracotomy, a full thickness excision of the hemidiaphragm with the tumour contained within its leaves was completed. The hemidiaphragm was reconstructed using Gore-Tex (Flagstaff, AZ, USA).The patient went on to make an uneventful recovery, and following discharge at one-year follow-up, was fully recovered with a chest CT showing no evidence of recurrence. Tumour inspection found grossly normal diaphragmatic tissue covering both sides of the specimen. Immunoperoxidase stains demonstrated strong diffuse cytoplasmic positivity for CD34 as well as vimentin, Bcl-2 and S100, but a lack of strong cytokeratin positivity. The morphologic and immunophenotypic features were those of a solitary fibrous tumour.