Page 18 - World Journal of Laparoscopic Surgery

Evaluation of Various Port Positions for Minimal Access Cardiovascular and Thoracic Procedures
intercostal nerve dysfunction due to tight leverage on the chest space along the mid-AL, and second operating port inserted at sixth
wall and large vessels injury, hemothorax, perforation of thoracic intercostal space along the posterior AL. For left VATS, the camera
organs, prolonged air leak, atelectasis, pneumonia, chylothorax, port is inserted at sixth intercostal space along the posterior AL,
atrial fibrillation, etc. the first operating instrument at the sixth intercostal space along
the mid-AL, and second operating port at fourth intercostal space
AnesthesIA And PosItIonIng of PAtIent along the anterior AL. Depending on the lesion, ports can be shifted
And surgeon one intercostal space below or above (Fig. 3).
In most VATS procedures, general anesthesia with a double-lumen Key technIcAl PoInts (APPlIcAble to All
endotracheal tube is employed to confirm collapse of the ipsilateral
lung that offers more space inside the thorax. vAts )
In majority of the cases, patients are placed in the lateral
decubitus position. To make the intercostal spaces wider, the OT • Insert the instruments into the chest cavity without injuring the
table is flexed. This decreases leverage of the instruments on the chest wall or lung. Division of the posterior pleural reflection
ribs with reduction in frequency of intercostal nerve compressions greatly improves the ability to perform safe dissection of desired
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and postoperative pain. It also allows better maneuverability of arterial branches.
the instruments. Some VATS procedures such as thymectomy can • There should be no traction on pulmonary artery (PA) and tissue
be done in the prone position or the supine position with slight dissected away from PA and its branches. Complications can be
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elevation of the ipsilateral shoulder. Alternatively, the supine prevented by avoiding excessive tension on PA during retraction
position with a roll under patient’s back to push him up allows and dissection. The pulmonary vein and bronchus can tolerate
access to the thorax from the anterior approach. The positions of some degree of tension, therefore developing tissue planes
the surgeon and the assistant rely on the location of pathology. between these structures. During dissection around PA, it should
The surgeon and the camera-holding assistant stand facing the site be stationary, moving the other structures away from PA.
of pathology. The surgeon, the site of pathology, and the monitor • Lymph nodes to be cleaned away to facilitate dissection of
are aligned to permit the surgeon to look straight ahead while relevant structures. Endobags to be used for retrieval of the
operating (Figs 5 and 6). excise tissue to prevent spillage of tumor cells within the thorax.

Lung Resection Thymectomy
As a standard treatment of early-stage lung cancer, minimally Thymectomy is typically indicated for myasthenia gravis (MG),
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invasive lung resection has replaced thoracotomy. Minimally thymoma, and anterior mediastinal tumors. Primary epithelial
invasive lung resection allows patients a much faster recovery tumors of the thymus are found in approximately 50% of all anterior
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with equivalent oncologic effectiveness and offers more accurate mediastinal masses, of which thymoma is foremost common.
staging that potentially improved survival. About 98% of patients Thymectomy is an appropriate therapy in the great care of MG
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are usually operated successfully using TTP without major and in the undetermined anterior mediastinal lesion. Minimal
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complications. Takao et al. reported using TTP. For right VATS, access thymectomy can be performed in all patients of thymic
the camera port is inserted at fourth intercostal space along the neoplasm who will tolerate single lung ventilation. Minimally
anterior axillary line (AL), first operating port at sixth intercostal invasive methods include transcervical, thoracoscopic, and robotic
thymectomy. They decrease postoperative morbidity and mortality
particularly in patients with MG. 23,24
Port Placement in VATS Thymectomy
Three ports are needed. The first port is made with a 5-mm skin
incision along the upper edge of sixth ICS in the mid-AL to create

Fig. 6: Standard patient position for video-assisted thoracoscopic
Fig. 5: Theater setup for video-assisted thoracoscopic surgery surgery

104 World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019)