Mastering Port Selection
VATS trainer is initially equipped with for wound retractors installed at predefined spots.
- Ports. Ports provide access for VATS instruments, such as endoscopes, graspers, staplers, and other tools.
- Utility Incision. A utility incision is a slightly larger incision, designed to provide direct access. It is versatile and can accommodate multiple instruments simultaneously, facilitating complex procedures with improved efficiency and ergonomics.
VATS can be performed using various approaches depending on the number of ports utilized. Each approach offers distinct advantages, and surgeons should be proficient in all of them to adapt to different surgical scenarios and patient needs.
Four-port VATS
Four-port VATS is a traditional approach that balances accessibility, visualization, and minimal invasiveness. The key feature of this technique is the use of a single instrument per port, ensuring simplicity and reducing the risk of instrument clashing.
- Endoscope Port. The endoscope is usually inserted through the smaller white port (located in the lower left of the picture) to provide optimal visualization of the operative field.
- Instrument Ports. Ports for instruments such as graspers, energy devices, and endocutters are positioned to maintain a roughly 60-90° angle between them.
Wider instrument angle...
A wider instrument angle, achieved through the use of the red port and the access incision, generally enhances ergonomic handling and provides more effective triangulation.
To perform any major surgical procedure, including thoracic surgery, three instrument ports are required to simultaneously accommodate the three essential instruments:
- Retraction Instrument. Typically controlled by the assistant, this instrument is used to hold or retract tissue, providing a clear view and adequate space for surgical tasks.
- Two Dissection Instruments. Controlled by the surgeon in a two-handed manner, these instruments are used together to perform precise dissection, enabling meticulous tissue handling and separation.
Four Robotic Arms...
Traditional surgical robots are equipped with four arms: one holds the camera, and three arms are used to control surgical instruments.
Three-port VATS
In three-port VATS, the retraction instrument and the endoscope are placed in dedicated ports to prevent instrument crowding. The two dissection instruments are typically inserted simultaneously through the utility incision, enhancing the two-handed ergonomics of the dissection.
However, introducing more than one instrument through a single incision introduces several challenges.
- Crowding. Instruments crowded in a small incision can clash with each other, reducing maneuverability and precision. This is further detailed in the next section on two-port VATS
- Triangulation. The optimal triangulation angle (60°) is lost when instruments are inserted
through the same incision.
However, in VATS, triangulation can be partially restored by utilizing the curvature of curved VATS instruments. - Exchange. Switching instruments becomes more cumbersome when sharing a single incision.
Two-port VATS
Two-port VATS is an evolution of three-port VATS, where the retraction instrument is also moved into the 3-5cm utility incision, which can comfortably accommodate three or more instruments.
Vertical order of Instruments
Proper vertical ordering of instruments within the incision is crucial to prevent clashing.
General Rule. The order of the instruments in the utility incision should match their vertical order inside the chest.
Trial and Error...
When the surgeon encounters instrument clashing, the instrument should be removed from the chest and reinserted at a different vertical position.
To prevent instrument clashing, curved instruments are typically used in two-port and uniportal VATS.
Straight Instruments...
At most one straight instrument can be used at a time to avoid interference.
Uniportal VATS
Uniportal VATS reduces the number of ports to a bare minimum, utilizing only the utility incision.
Inserting the endoscope and instruments through the same incision offers several advantages:
- More Intuitive. The surgeon's visual axis is aligned with the operative field, mirroring traditional open surgery, providing a more intuitive working environment.
- Improved Ergonomics. The single-incision approach allows the surgeon to work with less lateral hand movement, reducing arm fatigue and physical strain.
30° Endoscope
The endoscope should always be positioned above all other instruments, maintaining ergonomic alignment where the eyes are above the hands and tools, reflecting the natural setup of human work.
While the standard surgical endoscope is straight, a 30° endoscope can function effectively as a curved instrument when used efficiently.