Basic Endo-Cutter

The goal of the exercise is to position the lung within the jaws of the endo-cutter and precisely align the anvil along each of the two marked lines in both the apical and caudal triangles.

Any order of lines or triangles can be attempted, and instruments may be inserted through any combination of the remaining three ports.

Before proceeding with this exercise, it is essential to be thoroughly familiar with all functions of the endo-cutter.

• Closing and opening the jaws.
• Firing the endo-cutter.
• Understanding the rotation of the shaft and its independence from the handle.
• Articulating the tip of the endo-cutter.

Introduction

This exercise is designed to develop basic VATS skills and proficiency with an endo-cutter within the chest cavity, focusing on:

• Planning and preparation for endo-stapling.
• Introduction of the endo-cutter into the chest cavity.
• Efficient use of rotation and articulation.

The harmonic exercise serves as excellent preparation for this exercise, as it addresses similar challenges.

Planning and preparation

The endo-cutter is a bulky and heavy device, making it particularly challenging to maneuver within the confined space of the chest cavity, especially in smaller-sized patients.

Most of these challenges can be effectively mitigated through careful planning and preparation, which can be distilled into answering the following key questions:

Endo-cutter port

Which access port offers the most convenient angle to position the endo-cutter at the desired location on the lung?

What are the alternatives, particularly if the optimal access port necessitates operating the endo-cutter with the non-dominant hand?

Retraction

Similar to the grasping exercise, where efficient grasping was only achievable by properly utilizing the retraction hand, the same principles apply to feeding the lung into the endo-cutter. The following questions must be addressed:

• How can the desired part of the lung be best exposed and aligned with the selected endo-cutter port using retraction by a grasper?
• What is the optimal location to position the grasper, and which is the most efficient port through which the grasper should be introduced to maximize exposure while minimizing interference with the endo-cutter?

Opening the chest...

Performing an open surgery to achieve the same goal can often aid in planning and refining the execution of the procedure by VATS.

Once optimal exposure is attained, one of the graspers is replaced with the endo-cutter to execute the task.

Testing

Before switching from the grasper to the endo-cutter, it is highly advisable to use the grasper to verify that the angle from the port is perfectly aligned with the lung's surface and the marked line.

Retraction should be adjusted until perfect alignment is achieved to avoid unnecessary complications when switching to the endo-cutter.

Feeding the Jaws

With precise alignment, a straight (non-articulated) endo-cutter can be easily introduced and positioned along the marked line, requiring only minor adjustments for optimal placement.

Rotation. Before introduction, the endo-cutter should be rotated to align the surface of its jaws with the surface of the lung, ensuring a smooth and accurate approach.

Closed Without Locking.. When entering the chest cavity through the utility port, the endo-cutter should typically be closed but not locked, to allow for easier opening inside the chest.

Open it outside the port, then gently squeeze the handle to close the jaws, but not enough to engage the locking mechanism. This facilitates controlled opening and positioning once inside.

Struggling...

If this step cannot be achieved comfortably, it is best to restart the entire process from the beginning.

Articulation

Articulation is a feature of endo-cutters that allows the tip to bend at various angles, enabling precise alignment with the target, even in challenging and confined regions.

Swinging Tip. Similar to curved VATS instruments, which are more difficult to control compared to straight laparoscopic instruments, the same principle applies to endo-cutters.
A straight endo-cutter is much easier to manipulate into position, whereas an articulated endo-cutter can be more challenging, as the tip tends to swing significantly with the rotation of the shaft.

Articulation is often performed only when absolutely necessary. In the context of this exercise utilizing 4-port VATS, articulation is not required except for positioning on the line at number 18.

Feed the jaws before articulation...

To prevent the swinging tip, articulation is often performed at the last possible moment, such as when the lung is already fed into the jaws of the instrument.

Scoring and Feedback

The lung should be fed into the endo-cutter according to the following criteria:

• Surface Alignment. The blade must be perfectly aligned with the surface of the lung when feeding the jaws. Minor departures from alignment earn ½ point.
• Line Alignment. The anvil must fully touch the marked line, ½ point is awarded for departures not exceeding the thickness of the line.
• Deformation. Lung should not be unnecessarily stretched or twisted.
• Alignment Test. A bonus is awarded if the grasper is used to verify the angle before switching to the endo-cutter.

Camera

• Horizon. The camera horizon must be leveled within a tolerance of ±10°.
• Target. The blade of the endo-cutter must be positioned within the outer target scoring area.

Penalties

The following errors result in penalties:

• Articulation. Introducing an already articulated endo-cutter into the chest cavity.
• Reload. Aligning the reload side of the endo-cutter instead of the anvil with the marked line.
• Abuse. Requiring excessive movement of the lung or endo-cutter to achieve alignment.
• Injury. Any major injury to the lung results in immediate game over.

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