Page 27 - World Journal of Laparoscopic Surgery

Evaluation of Various Port Positions for Minimal Access Cardiovascular and Thoracic Procedures
IMA (LIMA) Harvesting It may be due to fatigue from increased elevation angle and
Timing for Trimming of Anastomotic End of LIMA for LAD shoulder overstretching.
From above figures and discussion, it is obvious that a surgeon’s
Grafting discomfort level is least at the 60° port position.
Average timings (mean time) in seconds for trimming of the Fortunately, no errors during surgical procedures occurred.
anastomotic end of LIMA for LAD grafting at 30°, 60°, and 90° angle But in some other studies different errors occurred during surgical
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are 34.17, 31.83, and 40.33, respectively. χ values at those angles task performance. 8,10
are 2.42, 1.28, and 1.52. The lowest time required is at 60° angle Regarding surgeon’s discomfort, 30° and 90° angles were
manipulation. revealed as discomfortable port positions, whereas 60° angle
Readings of timing taken for trimming of the anastomotic end of of manipulation showed a more comfortable position. Though
LIMA for LAD grafting of swine at different manipulation angles are 60° angle showed some discomfort in a few cases, but it was not
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shown, which were validated by the χ test and average obtained. significant. In their article, Yunusa et al. mentioned that the BDP is
The average timings in seconds for 30°, 60°, and 90° were 34.17, 31.83, the standard principle for deciding sites of port placement during
and 40.33, respectively. Here it is observed that only the readings VATS. 8,10 It is the conventional principle to which other principles are
at 60° manipulation angle were reproducible at a p value of 30.141 compared. The TTP was discovered as an alternative principle where
at 5% level of significance, which further support any port position BDP is associated with difficulties especially in lung procedures.
that will provide working angle of 60° as the ideal. In a study of VATS pericardial window, Yunusa et al. found similar
Some other researchers found similar findings. 8,10 results. The result showed that using the TTP for ports placement led
Timing for Grafting of Harvested LIMA to LAD in TECABG to a longer execution time with a mean distinction of 93 seconds.
Average timings (mean time) in seconds grafting harvested LIMA Error rates and surgeons’ discomfort were almost similar.
They explained the prolonged execution time might be
to LAD in TECABG at 30°, 60°, and 90° angle are 2110.83, 2097.33, due to the mirror image production when TTP is employed. The
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and 2146.17, respectively. X values at those angles are 0.21, 0.11, scissors and grasping forceps were usually alternated between the
and 0.14. The lowest time required is at 60° angle manipulation. operating port and the target port during the procedure to adapt
Similar findings were explored by some other researchers. 8,10
the various orientations for resecting the pericardial segment.
Esophagectomy The mirror image distorts the visuals, so the orientation causes
prolongation of execution time.
Timing for Suturing and Tying Surgeon’s Knot in They also mentioned that with more experience this problem
Esophagectomy might be solved by maintaining the grasping forceps in the target
Average timings (mean time) in seconds for suturing and tying port and incise the pericardium with a scissor through the operating
surgeon’s knot in esophagectomy at 30°, 60°, and 90° angle are port.
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340.33, 304.50, and 359.33, respectively. χ values at those angles They discussed that TTP might have a role when dealing with
are 1.09, 0.29, and 0.48. The lowest time required is at 60° angle pericardial lesions requiring digital palpation and stapling in case
manipulation. of pericardial cysts. The manipulation angle between the grasping
Readings of timing of suturing and tying surgeon’s knot in forceps and the stapler (through the target and operating ports) is
esophagectomy of swine at different manipulation angles are then 90° that is the proper angle for stapling. When BDP is employed
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shown, which were validated by χ tests and average obtained. The in this scenario, an alternate access might be needed for the stapler
average timings in seconds for 30°, 60°, and 90° were 340.33, 304.50, to get this angle.
and 359.33, respectively. Despite the facts that the first two readings In that study, they explained that BDP is preferable for ports
were reproducible at a p value of 30.141 at 5% level of significance, placement during the VATS pericardial procedure but TTP might
it was demonstrated that the 60° angle had shorter operative time have clear advantages when dealing with pericardial lesions
than that of 30° and 90° angle. It indicates increased difficulties and requiring digital palpation and stapling.
time consumption when ports are positioned in such a way that In this present study, it was also found that the 60° angle of
will give working angle of 90° and above. manipulation is advantageous for ASD closure and some other
Similarity of these findings were found by some other procedures.
researchers. 8,10 In VATS esophagocardiomyotomy, Ismail and Mishra and
Yunusa et al. found almost similar results. From the results, the
Timing of Purse String Suture Placement for Circular Stapler in execution time for VATS esophagocardiomyotomy using BDP for
Esophagectomy ports placement was more than when TTP was used. This is in
Average timings (mean time) in seconds for purse string suture contrast to the results of the errors rates and surgeons’ discomfort
placement for a circular stapler in esophagectomy at 30°, 60°, and that were more when TTP was used.
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90° angle are 635.50, 598.50, and 659.33, respectively. X values at In the study of Yunusa et al., one episode of esophageal
those angles are 0.34, 0.18, and 0.26. The lowest time required is at perforation was recorded when using the BDP while two major
60° angle manipulation. errors (esophageal perforation and descending aortic injury) were
Similar findings were found by some other researchers. 8,10 recorded when TTP was employed. This is vital as it translates to
From above discussions, the average timings of all tasks 33.3% error rate. But fortunately, no such error occurred in the
were shorter with 60° manipulation and all were reproducible. present study.
Irrespective of the difficulty of the tasks then, it was followed by They found that the surgeon’s discomfort using TTP was worse
30° and 90° angle. The closer the manipulation angle is to the with an average of 7 compared to 5.83 recorded for BDP, which was
90° and above, the more the likely to take longer operative time. contrary with the present study.

World Journal of Laparoscopic Surgery, Volume 12 Issue 3 (September–December 2019) 113