Page 15 - World Journal of Laparoscopic Surgery

ORIGINAL ARTICLE
Evaluation of Various Port Positions for Minimal Access

Cardiovascular and Thoracic Procedures

1
Anwarul Islam , Rajneesh K Mishra 2

AbstrAct
Background: Video-assisted thoracoscopic surgery (VATS) is used to diagnose or treat diseases of the chest. Most of those procedures traditionally
performed with open thoracotomy can be done using smaller incisions with video assistance. Robot-assisted thoracic surgery (RATS) is a
technologically upgraded system that uses computers to help surgeons for precise tremor-less instrument control in a confined space with
utmost accuracy. For access to the chest minimally, two principles are followed: the baseball diamond principle (BDP) and the triangle target
principle (TTP) of port position. Both can be used for minimal access cardiovascular and thoracic surgery. Different manipulation angles (30°,
60°, and 90°) are used to perform the task and find out time, errors, and surgeon’s discomfort during the surgery.
Objectives: To evaluate and compare task performance at different port positions during minimal access cardiovascular and thoracic procedures
in a swine.
Materials and methods: A prospective experimental animal study was granted and conducted at the World Laparoscopy Hospital, Gurugram,
Delhi, India. Three thoracic and two cardiac procedures were selected for this study conducted on 30 swines over 11 months from January 15,
2018, to November 15, 2018. At the end, euthanasia was conducted humanly and carcasses disposed appropriately as per the regulation under
the provisions of the Prevention of Cruelty to Animals Act, 1960, and the Acts of 1998 and 2001.
Results: A total of 30 procedures were conducted in this study using TTP of port placement. The procedures are lung resection-6, thymectomy-6,
closure of atrial septal defect (ASD)-6, internal mammary artery (IMA) harvesting for totally endoscopic coronary artery grafting (TECABG)-6, and
esophagectomy-6. It is to evaluate the execution time (sum of the ports access time and the actual procedure time), error rates, and the surgeon’s
discomfort for each of the three angles of manipulation. Average timing of all tasks was shorter with 60° manipulation and all were reproducible. All
the tasks were difficult at 30° and 90° angle. Closer manipulation of angle to 90° and above takes longer operative time. It may be due to fatigue from
shoulder overstretching for increased elevation angle. It was demonstrated that the surgeon’s discomfort level was least at the 60° port position.
Conclusion: There is no fixed position for port placement in the cardiovascular and thoracic procedures. The average timing of all tasks was
shorter, there were less errors, and surgeon’s discomfort was less operating at 60° manipulation angle.
Keywords: Internal mammary artery, Minimal access cardiovascular, Robotic-assisted thoracic surgery.
World Journal of Laparoscopic Surgery (2019): 10.5005/jp-journals-10033-1387

IntroductIon 1 Department of Cardiac Surgery, Bangabandhu Sheikh Mujib Medical

Most major procedures traditionally performed with open University, Dhaka, Bangladesh
2
thoracotomy can be done using smaller incisions with video- Department of Minimal Access Surgery, World Laparoscopy Hospital,
assisted thoracoscopic surgery (VATS) or robot-assisted thoracic Gurugram, Delhi, India
surgery (RATS). In minimal access surgery, the access of entering Corresponding Author: Anwarul Islam, Department of Cardiac Surgery,
the body can be minimal but inside the invasiveness does not Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh,
remain minimal at all. Things we do, like opening the chest, can Phone: +8801716529337, e-mail: sagarsurgery@gmail.com
be done with limited access. The basic principles used in open How to cite this article: Islam A, Mishra RK. Evaluation of Various Port
surgery like exposure, dissection, traction, countertraction, and Positions for Minimal Access Cardiovascular and Thoracic Procedures.
apposition are followed here too but hand of a surgeon remains World J Lap Surg 2019;12(3):101–115.

outside of body or, in robotic surgery, at a separate console to Source of support: Nil
manipulate the instruments. 1–3 The concept of VATS that greatly Conflict of interest: None
reduces the trauma of chest was initiated over two decades ago
and has undergone a series of modifications and improvement. the minimal access technique provides safe, effective, and
A Swedish Hans Christian Jacobeus (1879–1937) is considered as successful surgery with equivalent or improved outcomes having
the father of thoracoscopy since he explored and established less perioperative morbidity and equivalent oncologic results
the practice of thoracoscopy in 1910. Lewis et al. reported 100 compared with open surgery. Outcomes may be better in frail and
3,5
4
consecutive thoracoscopic surgeries in 1992. Since then, VATS older patients. Minimal access thoracic surgeries remove the
has shown significant advancements and currently entered into need for thoracotomy that involves spreading of the ribs or long
the era of robotic surgery. 5,6 sternotomy incision, large scar mark, and prolonged postoperative
In VATS, surgeons hold the instruments while operating, analgesia. Usually, operative costs for minimal access procedures
but during RATS, surgeons control the instruments from a are higher because of costly equipments, although overall costs
dedicated console using a computer for instrumental movement may be lower due to the shorter length of hospital stay and faster
1,2
with utmost precision. In an appropriately selected patient, recovery. 7
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