Page 18 - WJOLS
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Ahmad Jameel Ismail, RK Mishra

          by using TTP was statistically significant and reproducible  VATS Esophagocardiomyotomy
                           2
          using chi-square (c -value of 7.80 at a p-value of 11.07).   From the results the execution time for VATS esophago-
          VATS thoracic sympathectomy done using BDP takes    cardiomyotomy using BDP for ports placement was more
          longer time to be executed, although the BDP data is not   than when TTP was used with a mean difference of 326.67
          reproducible.                                       seconds. This is in contrast to the results of the errors rates
             There was one episode of major errors (intercostal vessels
          injury) recorded while using both the BDP and TTP for port   and surgeons discomfort which were more when TTP was
                                                              used.
          placement in VATS thoracic sympathectomy. Thus, VATS      One episode of esophageal perforation was recorded
          thoracic sympathectomy using BDP and TTP are comparable   when using the BDP while two major errors (esophageal
          in terms of the error rates.                        perforation and descending aortic injury) were recorded
             The surgeon’s discomfort during VATS thoracic sympa-
          thectomy using the BDP for port placement ranged from 4 to   when TTP was used. This is significant as it translates to
                                                              33.3% error rate.
          6 (mean of 4.83) and the same discomfort level was obtained      The surgeon’s discomfort using TTP was worse with an
          when the TTP was used. VATS thoracic sympathectomy   average of 7 compared to 5.83 recorded for BDP.
          between the application of BDP and TTP is comparable in      The increased error rates and surgeon’s discomfort can
          terms of the surgeon’s discomfort.
                                                              be explained by the mirror image produced when using TTP
                                                              and the flimsy nature of the pig’s tissue giving rise to injury
          DISCUSSION
                                                              to the esophagus and the surrounding structures even with
          The BDP is the conventional principle for deciding sites  minimal force.
          of port placement during VATS. 1-3,8  It is the background     The prolongation of the execution time when BDP was
          principle to which other principles are compared.   used which is in contrast to the trends of the error rates
                                                              and the surgeon’s discomfort could have been due to the
          VATS Pericardial Window                             increased error rates in TTP use. When these major errors
                                                              are encountered, the procedure do not usually proceed and
          The result showed that using the TTP for ports placement   the execution time when using TTP is recorded as shortened.
          led to longer execution time with a mean difference of     This calls for more data from larger sample size to revalidate
          93 seconds. The error rates and the surgeons discomfort
          were however similar.                               this and offer more explanations.
             The prolonged execution time may be attributable to   The BDP appears to be better than the TTP of ports
          the mirror image produced when TTP is used. The scissors   placement for VATS esophagocardiomyo tomy in terms of
                                                              the error rates and the surgeon’s discomfort, although it took
          and the grasping forceps were often alternated between the   longer time to be executed.
          working port and the target port during the procedure to
          conform to the different orientations for resecting the peri-     The TTP may have clear advantages over BDP when
          cardial segment. The mirror image distorts the visuals and   treating other esophageal diseases requiring stapling, such
          the orientation which prolongs the execution time.  as esophageal diverticulum or during esophagectomy due
                                                              to the 90° manipulation angle between the grasping forceps
             With more experience this problem may be addressed   and the stapler.
          by maintaining the grasping forceps in the target port and
          cutting the pericardial segment with a scissors or monopolar
          spatula through the working port.                   VATS Thoracic Sympathectomy
             The TTP may have a role when dealing with pericardial  The execution time for VATS thoracic sympathectomy
          lesions requiring digital palpation and stapling, such as  when using the TTP was less than when BDP was used
          pericardial cysts. The manipulation angle between the gras-  (mean difference of 194 seconds). But the execution time
          ping forceps and the stapler (through the target and working  data is not statistically significant and so not reproducible
                                                               2
          ports respectively) is then 90° which is the perfect angle  (c = 21.04 at p-value of 11.07). Thus, there may be need
          for stapling. When BDP is used in this scenario, a different  for a larger sample to reassess its reproducibility and then
          access may be required for the stapler to achieve this angle.  objectively compare it with the TTP. The BDP and the TTP
             Thus, BDP is preferred for ports placement during VATS  are comparable in terms of the error rates and the surgeons
          pericardial window but TTP may have clear advantages  discomfort.
          when dealing with pericardial lesions requiring digital pal-     It can also be seen that TTP is comparable or more
          pation and stapling.                                favorable to BDP when the instrument through the target port

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