Page 19 - World Journal of Laparoscopic Surgery

Evaluation of Various Port Positions for Minimal Access Cardiovascular and Thoracic Procedures

Fig. 7: Ports placement in video-assisted thoracoscopic surgery
thymectomy

Fig. 8: Trocars position

Fig. 10: Thoracoscopically harvested LIMA

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compared with vein grafts. Currently, closed chest coronary artery
Fig. 9: Port position for endoscopic or robotic CABG bypass grafting has become reality in several centers worldwide and
considered as a safe, secure, less traumatic, and effective alternative
a pneumothorax. A 5-mm port is inserted and 30° thoracoscope to standard open surgery with or without robotic assistance. 29
is used for inspection of potential adhesions and pathology. CO Dissection is almost similar to the open technique. In a closed
2
insufflation to be done using a pressure limit of 6–8 mm Hg. Under chest environment, instead of a diathermy the harmonic scalpel
vision, a second 5-mm port is inserted in the third intercostal space (HS) is preferable to prevent production of excessive smoke
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along the anterior AL and a third 5-mm port is inserted into sixth that obscures telescopic vision during dissection. The HS is an
or seventh intercostal space along the mid-clavicular line (Fig. 7). ultrasonically activated shaft that vibrates harmonically at 55,500 Hz
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over a distance of 80 μm. It couples with tissues and mechanically
ASD Closure denatures protein by destroying hydrogen bonds among the
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Atrial septal defect is one of the most common congenital heart protein structure. The newly formed disorganized protein creates
defects. Currently, many ASDs can be closed with septal occluder a sticky coagulum that coapts the vessel walls.
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devices through cardiac catheterization. But large ASDs may not
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be appropriate for device closure and require surgical correction. Port Placement (Thoracoscopic Approach)
Minimal access surgical approaches are applied to repair ASD to A 5-mm port at the level of fourth intercostal space for grasper. One
minimize operating trauma and early recovery with better cosmetic 5-mm port at sixth intercostal space on the medial posterior AL for
results. 27 HS. One 10-mm port for the telescope to be placed sixth intercostal
space at the level of the anterior AL (Figs 9 and 10).
Port Placement for ASD Closure
Four trocars to be placed. One 10-mm trocar at fifth intercostal For Robotic LIMA Harvesting
space in the anterior AL for needle holder or knife, one 5-m trocar Robotic assistance greatly enhances the entire harvesting process.
at third intercostal space in the mid-AL for tissue forceps, one 5-mm The patient has to be placed in the supine position with the left
trocar at the fifth intercostal space in the mid-AL for camera, and chest slightly elevated and the both arms to be tucked to the chest
one 5-mm trocar at sixth intercostal space in the mid-AL for sucker (Fig. 11).
(Fig. 8). The daVinci patient cart approaches to the patient from the
right side. Deflating the left lung, the camera port is inserted within
IMA Harvesting the fifth intercostal space along the anterior AL. Carbon dioxide is
Internal mammary artery is the conduit of choice for myocardial insufflated with a pressure limit between 6 and 8 mm of Hg. The
revascularization as a result of its higher long-term patency rate 8-mm right arm port is inserted into the third intercostal space
and lower occurrence of myocardial infarction and reoperation 3 cm anterior to the camera port to avoid conflict of the robotic

World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019) 105