Eur J Cardiothorac Surg 2005;27:307-312
© 2005 Elsevier Science NL
Triangle target principle for the placement of trocars during video-assisted thoracic surgery
Masato Sasaki*,
Seiya Hirai,
Masakazu Kawabe,
Takahiko Uesaka,
Kouichi Morioka,
Akio Ihaya,
Kuniyoshi Tanaka
Department of Surgery (II), University of Fukui, Faculty of Medical Sciences, 23-3 Shimoaizuki, Matsuoka Fukui 911-1104, Japan
Received 10 April 2004;
received in revised form 11 October 2004;
accepted 19 October 2004.
* Tel.: +81 776 61 3111x2350; fax: +81 776 61 8114. (E-mail: masato{at}fmsrsa.fukui-med.ac.jp).
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Abstract
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Objective: The baseball-diamond principle is generally used for trocar placement during video-assisted thoracic surgery; however, we are unable to treat all peripheral lung lesions using this principle. Therefore, we have developed another method for determining trocar placement based on a modification of the conventional principle. We have termed this method the triangle target principle. This report describes the instrument positioning that we now use for many video-assisted thoracic surgical procedures. Methods: We position 3 trocars in an equilateral triangle, with the target lesion at the apex. One vertex of the base becomes the site of the first trocar placement for introduction of the thoracoscopic camera. Another vertex of the base becomes the site for the second trocar for forceps or the endoscopic stapler. The third trocar is for forceps and is inserted to create the vicinity of target lesion. Four types of the triangle target principle were developed according to sites of the target lesion. Results: Between January 2000 and December 2002, we used this principle for 161 patients who underwent video-assisted thoracic surgery and all intrathoracic lesions were accessible except in 3 patients requiring intraoperative modifications. Conclusions: We conclude that video-assisted thoracic surgery by this principle is more effective and easier than the conventional principle to treat intrathoracic disease.
Key Words: Video-assisted thoracic surgery (VATS) • Trocar placement • Pneumothorax • Benign lung tumor
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1. Introduction
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Expanded indications for video-assisted thoracoscopic surgery (VATS) now necessitate access to every part of the pleural cavity. Therefore, it is very important to place trocars appropriately. The baseball-diamond principle is generally accepted as the concept guiding trocar placement [1]. This approach, however, is no longer the standard. Most thoracic surgeons have modified the trocar placement based on the individual geometry of the case and on common sense. Although there are several reports describing site of trocar placement for approaching all regions of the pleural cavity [1,2], there is no report that unifies the principle of trocar placement during VATS, except for the baseball-diamond principle. We have developed another principle for trocar placement to allow all thoracic and general surgeons to easily perform VATS. We report the effectiveness of VATS by this principle in the treatment of intrathoracic diseases.
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2. Materials and methods
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2.1. Triangle target principle (TTP)
The triangle target principle entails trocar placement in an equilateral triangle with the target lesion at the apex (Fig. 1a). One vertex of the base is the site of the first trocar placement for introduction of the thoracoscopic camera. Another vertex of the base becomes the site for the second trocar for forceps or the endoscopic stapler. The third trocar is for the forceps and is inserted to create the vicinity of target lesion. We have termed this third trocar the target trocar. The thoracoscope is inserted via the target trocar to obtain a wide view of the intrathoracic space. Trocar placement using TTP is shown in Fig. 1b. Partial resection of the lung is facilitated, because the forceps and endoscopic stapler meet at a right angle. Needle biopsy for the diagnosis of an undetermined pulmonary nodule is performed easily without touching the surrounding tissue through the target trocar, because this trocar is closest to the target of other trocars. The tumor can be palpated through the wound of the target trocar when the tumor is not visible by thoracoscopy.
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Fig. 1. (a) Basic concept behind the triangle target principle (TTP) of trocar placement during video-assisted thoracic surgery. (b) TTP. Note that the stapler and forceps meet at a right angle in TTP.
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2.2. Indication and contraindication for the VATS procedure using the TTP
The indications for a VATS procedure in our institution are as follows: spontaneous pneumothorax, benign lung tumor, mediastinal benign tumor, metastatic lung tumor, primary lung cancer (for palliative operation), hyperhidrosis, pericarditis, diagnosis of undetermined lung tumor, biopsy of idiopathic interstitial pneumonia, staging of lung cancer and biopsy of mediastinal disease.
The indications for a VATS procedure using the TTP (for lung tumors) are as follows: (1) distance from visceral pleura to center of lung tumor is <2cm; (2) diameter of lung tumor is <3cm (to permit partial resection of the lung by autostapler). Contraindications for a VATS procedure using TTP are as follows: (1) tumor located on the lateral chest wall; (2) tumor located with in the central region of the each lobe and required segmentectomy or lobectomy. We do the selection of patients who are suitable for the TTP trocar placement based on chest CT.
2.3. Classification of triangle target principle (TTP)
The method was classified into 4 types according to the location of the target (Fig. 2). TTP type I is used in cases of a target mainly in the apex of the upper lobe (Fig. 2a). Type II is used in cases of a target in the vicinity of an interlobular fissure. (Fig. 2b). Type III is used in cases of a target in a posterior and lateral basal segment in a lower lobes (Fig. 2c), and type IV is used in cases of a target in anterior mediastinal and pericardial lesion (Fig. 2d). When we cannot check a position of the target on chest CT, for example, spontaneous pneumothorax, we insert thoracoscope through trocars into the 7th or 8th ICS on the anterior axillary line and confirm a position of the target and decide type of TTP.
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Fig. 2. The four types of trocar placement in triangle target principle during video-assisted thoracic surgery. (a) Type I, (b) type II, (c) type III, and (d) type IV star mark: target lesion.
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2.3.1. Type I
TTP type I is used in cases of a target mainly in an apical and anterior segment of the upper lobe and for upper mediastinal lesions. The patient is placed in a lateral decubitus position under general anesthesia. The surgeon stands on the abdominal side, and introduces the first and second trocar into the 5th or 6th intercostal space (ICS) on the anterior axillary line and the 7th or 8th ICS on the posterior axillary line, respectively. The target trocar is placed in the 3rd ICS on the mid-axillary line (Figs. 2a and 3).
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Fig. 3. Triangle target principle type I-based trocar placement during video-assisted thoracic surgery for resection of apical bullae in a 28-year-old man with spontaneous pneumothorax. (a) Schematic diagram showing trocar placement. (b) Intraoperative photographs.
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2.3.2. Type II
TTP type II is used in cases of a target mainly in bilateral posterior segments of the upper lobes, the left lingula, the right lateral segment of the middle lobe, bilateral segment 6 and 8 of the lower lobes and an upper lesion of the posterior mediastinum. The patient is placed in a lateral decubitus position under general anesthesia. The surgeon stands on the abdominal side, and introduces the first and second trocars into the 7th or 8th ICS on the anterior axillary line and into the 8th or 9th ICS on posterior axillary line, respectively. The target trocar is placed in the 4th ICS on the mid-axillary line. When the target lesion is in right segment 4, left segment 5 or bilateral segment 8, the surgeon stands on the posterior of the patient and determines the position of each trocar based on the caudal view (Figs. 2b and 4).
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Fig. 4. Triangle target principle type II-based trocar placement during video-assisted thoracic surgery to resect pT1N0M0 Stage 1A lung cancer in a 68-year-old woman. (a) Schematic diagram showing trocar placement. (b) Intraoperative photographs. The arrow indicates the string used to mark the lesion under computed tomography guidance.
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2.3.3. Type III
TTP type III is used in cases of a target mainly in bilateral segment 9 and 10 of the lower lobes, a low lesion of posterior mediastinum and a diaphragmatic lesion. The patient is placed in a lateral decubitus position under general anesthesia. The surgeon stands on the abdominal side to obtain a caudal view, and positions the first and second trocars into the 4th or 5th ICS on the anterior or mid-axillary line and into the 7th or 8th ICS on the mid or anterior-axillary line, respectively. The third trocar is placed into the 8th or 9th ICS on the posterior axillary line (Figs. 2c and 5). It is usually difficult to excise a target lesion that is adjacent to the diaphragm by VATS. However, when TTP type III is used, it is easy to perform a partial resection of the diaphragm.
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Fig. 5. Triangle target principle type III-based trocar placement during video-assisted thoracic surgery to resect pulmonary metastasis in segment 10 of the right lung in a 69-year-old man. (a) Schematic diagram showing trocar placement. (b) Intraoperative photographs.
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2.3.4. Type IV
TTP type IV is used in cases of a target mainly in the medial segment of the middle lobe, a pericardial lesion and an anterior mediastinal lesion. The patient is placed in a semilateral decubitus position under general anesthesia. The surgeon stands on the posterior of the patient, and introduces the first and second trocars into the 6th or 7th ICS on the posterior axillary line and into the 3th or 4th ICS on the posterior axillary line, respectively. The target trocar is placed on the 3th mid-clavicular line or the 7th ICS on the anterior axillary line (Figs. 2d and 6).
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Fig. 6. Triangle target principle type IV-based trocar placement during video-assisted thoracic surgery to resect a pericardial cyst in a 68-year-old woman. (a) Schematic diagram showing trocar placement. (b) Intraoperative photographs.
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3. Results
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Between January 2000 and December 2003, 345 patients underwent surgery for non-cardiovascular intrathoracic diseases. The thoracoscope was used in 285 patients, and 161 of these patients had an indication for VATS using the TTP (Table 1). One hundred and twenty-four remaining patients enforced VATS+utility mini-thoracotomy.
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Table 1. Indication for the use of the triangle target principle in 161 patients who underwent thoracoscopic surgery for intrathoracic disease
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We showed the details of indicated patients of each type in Table 1.
One patient in whom VATS using the TTP type IV was indicated, required conversion to a mini-thoracotomy, because it was difficult to perform a pericardiectomy for recurrent pericardial effusion due to severe cardiac dilatation. Two patients in whom VATS using the TTP type III was indicated needed a fourth trocar. In the first patient, a fourth trocar was necessary to retract the lower lobe for partial resection of the lower lobe. In the second patient, the first and second trocars were so close to the target lesion that instrument manipulation was awkward, making it difficult to perform the partial resection of the lower lobe. Three of 161 patients suffered from minor complication. Prolonged air leakage was defined as lasting longer than 7 days; it occurred in two patients in TTP type II. Another complication was wound infection in a patient in TTP type III. No patients required conversion to thoracotomy due to bleeding. Thus, 158 of the 161 patients had successful VATS procedures using the TTP and were managed successfully without operative mortality.
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4. Discussion
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The indication for VATS now includes peripheral benign tumors of the lung, bullae causing pneumothorax, malignant tumor of the lung [3] and mediastinal disease [4,5]. Therefore, it is necessary to access every part of the pleural cavity during VATS. The baseball-diamond principle is generally used for trocar placement. We, however, have been frustrated by the inability to access the target lesion via trocars placed using this principle. There have been several reports on trocar placement for approaching every part of the thorax [1,2]. The intercostal access strategy and the instrument positioning in a large VATS procedure were reported by Landreneau et al. [1]. This report describes the basic operative set-up for VATS based on their experience with 467 patients undergoing VATS over 18 months. This report, however, does not describe the principle of unified trocar placement during VATS. We developed the TTP to enhance access to the thoracic cavity by VATS and to place VATS within the capacity of all thoracic and general surgeons. Although we need three ports for the operation using TTP, a hand technique is easier than using the conventional method. We classified 4 types of TTP, based on the location of the target lesion. TTP type I is used most frequently of the four types. The main operative indication is spontaneous pneumothorax secondary to bullae in the apex of the upper lobe. Trocar placement and instrument manipulation is easiest using the TTP type I. The thoracoscope is inserted via the target trocar to obtain a wide view of the intrathoracic space and to prevent overlooking the bullae. TTP type II is used second most commonly and permits the partial resection of the lung when the target is located near an interlobular fissure; it is most frequently indicated for malignant tumors. TTP type III is the most difficult type for trocar placement, because the first and second trocars are positioned close to each other. However, a partial resection of segment 9 or 10 of the lower lobe, which generally is difficult to perform via VATS, can be accomplished easily using the TTP type III, though occasionally a fourth trocar is necessary to retract the lower lobe. TTP type IV is mainly used when the target is in segment 5 of the right lung, a pericardial lesion, or an anterior mediastinal lesion. For example, the indication for type IV included pericardiectomy for recurrent pericardial effusion and resection of an anterior mediastinal tumor. But we have experienced one patient in whom a mini-thoracotomy was needed to perform partial pericardial resection due to severe cardiac dilatation. Recently, we perform VATS after having done puncture of pericardial effusion from target trocar in transesophageal cardiac echocardiography for a secure view field. The four main advantages of this principle are as follows: (1) it is possible to grasp the lung tissue near the target lesion with the forceps through the third trocar; (2) partial resection is easy because the forceps and endoscopic stapler meet at a right angle; (3) the tumor can be palpated through the wound of the target trocar when the tumor is not visible by thoracoscopy; and (4) needle biopsy is easy because the tumor is close to the third trocar to minimize risk of port site recurrence. The disadvantages of this method are as follows: (1) determination of trocar placement is sometimes difficult, for example, in TTP type III. When the site of the first and second trocar placement is too close to the target lesion, ‘fencing’ or crowding during instrument manipulation can result; and (2) the simultaneous use of forceps and the endoscopic stapler is sometimes difficult for one surgeon, especially with TTP type III, because of mirror image.
This principle provides a fast and certain technique for trocar placement during thoracoscopic surgery, because all intrathoracic lesions can be approached and treated by VATS using this principle. Furthermore, the principle makes it easy to grasp the lung near the target lesion, perform a partial resection, palpate the tumor and perform needle biopsy during video-assisted thoracic surgery. However, we need further refinement of this method about requirement of fourth trocar in TTT type III.
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References
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- Landreneau RJ, Mack MJ, Hezelrigg SR, Dowling RD, Acuff TE, Magee MJ, Ferson PF. Video-assisted thoracic surgery: basic technical concepts and intercostal approach strategies. Ann Thorac Surg 1992;54:800-807.[Abstract]
- Lewis RJ, Caccavale RJ, Sisler GE, Mackenzie JW. One hundred consecutive patients undergoing video-assisted thoracic operations. Ann Thorac Surg 1992;54:421-426.[Abstract]
- Solaini L, Bagioni P, Prusciano F, Di Francesco F, Poddie DB. Video-assisted thoracic surgery (VATS): lobectomy for typical bronchopulmonary carcinoid tumor. Surg Endosc 2000;14:1142-1145.[CrossRef][Medline]
- Demmy TL, Krasna MJ, Detterbeck FC, Kline GG, Kohman LJ, DeCamp Jr MM, Wain JC. Multicenter VATS experience with mediastinal tumors. Ann Thorac Surg 1998;66:187-192.[Abstract/Free Full Text]
- Akashi A, Hazama K, Miyoshi S, Minami M, Matsuda H, Kido T. An analysis of video-assisted thoracoscopic resection for mediastinal masses in 150 cases. Surg Endosc 2000;15:1167-1170.
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Abstract
1. Introduction
