Page 18 - WJOLS

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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