Thoracoscopic First Assistant S.Scott Balderson PA-C Clinical Instructor, Duke Surgical Physician Assistant Residency Division of Thoracic Surgery Thoracic Oncology Program Duke Comprehensive Cancer Center Duke University Medical Center Durham, NC
Disclosures Medtronic Educational Consultant
It is all in the preparation; Keys to success! Proper equipment and instrumentation List Normal Operation Troubleshooting (take ownership!) Proper room set up Patient positioning Monitors OR Table set up (long curved sponge stick) The Team! Circulator, Scrub, Assistant, Pilot, Surgeon
Keys to success Assisting Piloting Retraction With clamps, suction, graspers, etc. Stapling Troubleshooting
Equipment and Instrumentation
Video Tower
Camera Box, light source, recorder
10mm 30 degree Thoracoscope; KNOW HOW THE BUTTONS WORK!
10mm 30 degree Thoracosope
Alternate Thoracoscopes; know their design and function
Know the difference between manufacturers.. (chip vs in-line lense)
In-line design vs chip
Know which plane you are flying
Ancillary products for operative issues, ex: Floshield
Specifically designed thoracoscopic instruments
Conventional Design
VATS Specific Instruments
VATS Specific Instruments
Almost any conventional tip is available
Most frequently used VATS Instruments
Note the different applications/trade-offs for 10mm vs 5mm suction
Thoracoscopic Staplers
Thoracoscopic Staplers
The manufacturer is not as important as it is critical to have thoracoscopic specifically designed instruments and equipment
Room Set Up
The Team Circulator Must be familiar with the conduct and steps of the case. Must know the staple cartridges and other variable supplies that will be called for during the case. Must know how to quickly locate any supplies outside of the room and anticipate their need. Be familiar with ordering for par stock etc. Pilot Surgeon
The Team Scrub Tech Must be familiar with the steps of the procedure Must know the instruments and equipment including any local nomenclature. (long curved empty) Aspire to anticipate which instruments are used for which maneuvers to facilitate hand off. Must recognize the importance of table preparation. (keeping a long curved sponge stick as the instrument closest to the field)
Patient Positioning Standard lateral decubitis position Flex the bed, reversed trendelenburg Helps keep the camera from hitting the hip which limits camera angles Slightly posteriorly rotated Makes the anterior incision a little easier to access
Patient Positioning
Patient positioning table flexed
Patient positioning
Patient positioning-locating strap
Patient positioning-strap placement
Patient positioning-check axilla
Patient Positioning- Secure Arms
Incision Placement Two incisions will allow almost any operation 10 mm camera port 7 th or 8 th intercostal space, posterior axillary line 3-4 cm anterior access incision 4 th or 5 th intercostal space, anterior axillary line
Incision Placement
Room set up- Monitor Placement
Assisting
Camera Operations Camera Pilot needs a working knowledge of the function of the camera/scope/monitors Proper use of 30 degree, flexible tip or other scope optimizes the surgeon s view In the HD world it is VERY IMPORTANT to understand how the technology functions and what the technological implications are for the surgeon. Ex. Low light = grainy picture = loss of resolution= loss of ability to visualize planes Helpful in troubleshooting
The stand-by test
Camera Pilot Poor Camera operation can make for a painfully long case When the scope has to be removed to be cleaned When the pilot has difficulty reintroducing the scope into a complex hemithorax Smudge Reproducing a consistent view in scope angle and horizon MORE IMPORTANTY, Poor Camera operation can impact the safety of a case If the surgeon cannot visualize
Camera Pilot Camera Pilot should understand the steps for the intended procedure Allows anticipation of the surgeon s next move The camera view is very much a dance, the surgeon must be allowed to move within the frame as opposed to being led. The pilot must know (or ask) what should be in the center of the screen (instrument, structure etc) Goal is for the only perception of movement on the monitor to be the maneuvers of the surgeon The Pilot must come to appreciate the value and contribution of controlling the surgeon s eyes
Thoracoscope - Design ALL Thoracoscopes are VERY fragile. 10lbs of force will break a 10mm scope The weight of the camera alone can damage the outside casing A dent in the casing means that light fibers or the inline lenses can be broken. Think of the times where you THINK the scope is in focus but it is not in certain areas of the field. 3lbs of force will snap a 5 mm scope Will bow 20 degrees before resistance can be detected
10mm vs 5mm 5mm scope is fragile and can be easily damaged 5mm port can be utilized if you are not going to need to pass a stapler, but the port is more difficult to keep clear. (cotton tipped applicator) 5mm incision can accommodate a 24fr chest tube 10mm optics are better and the port is easier to maintain (lap pad to clean) 10mm scope and camera has better stability and balance
Visual Field 5mm vs 10mm
Thoracoscope Design
What is the problem? It is easy and you can direct the staff as to which piece needs to be switched out Grainy picture = light cord One part of the picture is in focus and another is not, or there is not a perfect 360 degree circle of field, or there as specks or smudges that can t be cleaned = scope The picture is soft and the chest wall capillaries can t be focused = camera
Camera Operations There must be a clear method of communicating the visual (exposure) needs of the surgeon as: The pilot has three perspectives to maintain: the focal length, camera head rotation and the scope angle.
Camera Operations Focal Length A depth of field must be developed Facilitates depth perception Close but not too close If too close, the camera can affect the instrument angles available to the surgeon A tight focal length can be helpful during delicate dissection but hurtful for frame of reference Anticipate when to pan in and out Understanding the action being performed Adjusting retraction vs. fine dissection on the artery
Focal length- loss of reference
Focal Length reference (the power of panning out 2cm!!)
Camera Operations Camera head rotation controls: Horizon Refers to the structure on which the camera view is based.
Camera Operations Third control is the barrel of the light cord which controls the scope angle (exception: Olympus) Clock face Refers to the barrel of the light cord on the scope relative to the position of the hour hand on a clock Functionally, this reference can allow the surgeon to request a different angle without having to reach across to adjust
Scope Transition 9:00 to 3:00 (functionally from right to left)
Communication External Cues and Corrective Transitions Leaning in = tighten up the focal length Tilted head (in any direction off of neutral = I am screwing up) Hyper-extending neck = I need to do something to see over the top Head off kilter or Batman = Camera Drift= I am off of the horizon
Camera Operations Together the focal length, horizon and scope angle facilitate visual feedback to create as close to a three dimensional view as possible Optimizing these controls also minimize the incidence of intercostal nerve irritation
Camera Piloting- small hands, no problem!
Piloting Technique-One Hand (1)
Piloting Technique-One Hand (2)
Piloting Technique-Two hand (angle)
Piloting Technique-Scope Stabilization
Piloting Technique-Parallel with one hand stabilization at the scope know your pilot is in R spin
Piloting Technique-Isomer View Surgeon is in R spin (how well can you back up a trailer from your rear view mirror)
Isomer View - Difficult
Memorize the Path of Entry
No matter how complicated the Path
Resist the temptation to remove the scope- smudge or no smudge?
Intercostal Blocks
Diaphragmatic Retraction
The Durability of Lingular Retraction
Synergy of Retraction and Scope Angle
Retraction to Rotate the Hilum
Know the function and angles of your instruments!
Don t Spill Staples- Nidus for Adhesions
It Really works
Use Multiple Instruments for Maximal Advantage (2 for 1)
Always ask Anesthesia the Question!
When an endobag is not available..
Use Sterile Water to Detect Bleeding
Put it all together- R VATS MLND