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Eur J Cardiothorac Surg 2005;28:657
© 2005 Elsevier Science NL
Letter to the Editor |
Department of Thoracic and Cardiovascular Surgery, Mie University Graduate School of Medicine, 2-174 Edobashi, Tsu, Mie 514-8507, Japan
Received 13 May 2005; accepted 27 June 2005.
* Corresponding author. Tel.: +81 59 2315116; fax: +81 59 2315145. (Email: takao{at}clin.medic.mie-u.ac.jp).
Key Words: Video-assisted thoracic surgery (VATS) • Trocar placement
We read with interest Sasaki and colleagues' article [1] on a logical strategy to decide trocar placement and approach based on the target location in the thoracic cavity for video-assisted thoracoscopic wedge resection. We also prefer a trocar placement close to the target location, because we use Kuniyoshi P.N.CATCH (Takasago Medical Industry Co., Ltd; Tokyo, Japan. http://www.takasagoika.co.jp/index.html) to grasp it in lung parenchyma. Therefore, our trocar placement has been similar to Sasaki's triangle principle, and invariably depends on the target location as a result. However, we have changed it to a fixed style; following learning several principles in video-assisted thoracic surgery (VATS) from Drs Kohno and Mun at the Toranomon Hospital, Tokyo, Japan. They usually perform lobectomy using three access ports (7-, 10-, and 11.5mm diameters) without minithoracotomy [2]. This is feasible through a 30° thoracoscope, and an articulating endoscopic linear cutter and several tips that stand well in wedge resection. As well, (1) two monitors are essential, one for the operator is set up normally and another for the assistant on the opposite side who operates the thoracoscope is set up in upside-down manner to prevent mirror image problems. (2) The operator always stands on the right side of patient to maintain a wide working space for his right hand in the patient's caudal direction. Thus, manipulation is performed with a backward approach for the right lung and with a forward approach for the left one. (3) For the right lung, trocar ports are placed at the anterior axillary line in the fourth intercostal space for the scope, at the midaxillary line in the sixth intercostal space for the right hand and at the posterior axillary line in the sixth intercostal space for the left hand. For the left lung, trocar ports are placed at the posterior axillary line in the sixth intercostal space for the scope, at the midaxillary line in the sixth intercostal space for the right hand and at the anterior axillary line in the fourth intercostal space for the left hand. In cases where the target lesion is located in the upper or lower part in the thoracic cavity, these trocar ports may be shifted one intercostal space up or downward. Because this approach makes it possible for a 30° thoracoscope to monitor everywhere in the thoracic cavity from a single fixed port, and the longitudinal direction of the image on the monitors is identical with that of the patient and is unchangeable during operation; it is particularly advantageous in cases of multiple lesions that need to be resected or in TTP type III, which the authors noted needed to be refined. Finally, although VATS is an evolving technique, and preferred approaches differ somewhat among operators [2–4], the core concept and its rationale have practical importance [5]. The author's work is excellent and has been most informative for us.
References
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