Page 20 - World Journal of Laparoscopic Surgery

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

Fig. 12: Technique of anastomosis using a Flex-A device
Fig. 11: Positioning daVinci robotic patient cart to 30° with the collapsed right lung. Four trocars to be inserted. A
30° telescope to be introduced through a 10-mm port into seventh/
arm with the patient’s left shoulder. Another 8-mm left arm port eighth intercostal space along the mid-AL; two 5-mm working ports
is inserted into the seventh intercostal space 3 cm proximal to the to be placed in third/fourth and fifth/sixth intercostal space along
camera port. This arrangement provides the triangle principle that the anterior AL. One 10-mm working port to be placed in sixth/
is vital for minimal access procedure. seventh intercostal space on the subscapular angle line (Fig. 13).

Graft Anastomosis The Second Stage: Abdominal Phase
Time taken to perform the anastomosis is usually 35–45 minutes Laparoscopic Gastric Mobilization and Lymph Nodes Dissection:
using the daVinci robot. The number of graft for endoscopic During the laparoscopic phase, patient to be placed in the supine
coronary revascularization has to be performed depending on position. Five ports to be inserted. A 10-mm camera port to be
number of lesion, patient clinical status, and comorbidities. The placed below the umbilicus. Pneumoperitoneum established
patency of robotic totally endoscopic left internal mammary artery with CO insufflation pressure set at 10–12 cm of H O. One 10-mm
2
2
to left anterior descending artery (LIMA-LAD) anastomosis is similar laparoscope to be used for intra-abdominal inspection. Another
to traditional open procedures. 33–35 Several studies have found 10-mm operating port to be placed at 4 cm above the umbilicus
34
35
the long-term patency is between 92% and 98%. The use of an beside the right border of the rectus muscle. A 5-mm operating
automated coronary connector like the “Flex-A” stapling device port to be inserted 2 cm below the right costal margin along
surely reduces endoscopic anastomosis construction time during the mid-clavicular line. A 10-mm working port to be placed 2
closed chest off-pump robotic coronary artery bypass grafting cm above the umbilicus along the left mid-clavicular line. Last, a
(CABG) (Fig. 12).
5-mm working port to be inserted at the left costal margin along
Esophagectomy the anterior AL.
Esophageal cancer is currently the eighth commonest cancer
worldwide and also the sixth common reason behind death from The Third Stage: Cervical Anastomosis
36
cancer. Global incidence of esophageal cancer has increased by Gastric Conduit Formation and Anastomosis: A 3–5 cm incision to
37
50% within the past two decades. Squamous cell carcinoma is the be given on the left neck in front of the left sternocleidomastoid
foremost common esophageal malignancy worldwide; however, and cervical esophagus to be isolated and divided. The dissected
the incidence of adenocarcinoma has been increasing rapidly in the tissue then expelled from the thorax outside of the abdomen
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Western world. Esophagectomy is the foremost invasive surgery through subxiphoid incision. A 28–40 cm gastric conduit with
that includes two- or three-compartment dissection, radical lymph 3–4 cm diameter is created using multiple applications of a linear
adenectomy, and upper gastrointestinal tract reconstruction. As a stapler along the lesser curvature starting from right gastric vessels
result, conventional open esophagectomy is related to considerable to the stomach fundus. Pulling up the gastric conduit through the
morbidity and mortality, with complication rates starting from 26 to posterior mediastinum anastomosis to be done by joining a 24-mm
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41% and perioperative mortality rate is about 4–10%. To overcome anvil with the end-to-end anastomosis stapler (Figs 14 and 15).
these, minimal access techniques came in practice.
Three-stage Mie mAterIAls And methods
The combined thoracolaparoscopic esophagectomy along with This study is a prospective experimental animal study and was
cervical anastomosis is a standardized surgical technique to treat conducted at the World Laparoscopy Hospital (WLH) at Gurugram,
esophageal carcinoma through minimal access surgery for better India
outcome.
Sample Size Determination
The First Stage: Thoracic Phase The sample size was calculated using the formula, n = Z pq/d .
2
2
VATS Esophageal Mobilization and Lymph Nodes Dissection: The Where n = sample size, z = constant at 95% confidence
14
patient is placed in the left lateral prone position leaning forward interval = 1.96, p = prevalence = 0.019, q = 1 − p complementary
106 World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019)