Ebook Operative thoracic surgery (6/E): Part 2
➤ Gửi thông báo lỗi ⚠️ Báo cáo tài liệu vi phạmNội dung chi tiết: Ebook Operative thoracic surgery (6/E): Part 2
Ebook Operative thoracic surgery (6/E): Part 2
Uniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2resents an evolution of traditional VATS principles and. at the same time, a formidable return to the geometric configuration of classic open thoracotomies.i-J In a way. the uniportal concept is the center of a star system whose satellites exchange technical aspects with the other known thoracic sur Ebook Operative thoracic surgery (6/E): Part 2gical approaches (see Figure 17.1). The main feature of the unipoi tai VATS approach consists of targeting, through a caudocranial (sagittal) plane, aEbook Operative thoracic surgery (6/E): Part 2
ny aiea of surgical interest inside the chest (see Figure 17.2). Two advantages result from such a perspective: (1) the procedure allows for a similarUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2sed on the17.1 Uniportal VAĨS seen as the fulcrum of the armamentarium of the modern thoracic surgeon.17.2 Caudocranial approach (i.e.. sagittal plane) for uniportal VATS.206 Uniportal video-assisted thoracoscopic surgery (VATS)17.3 Schematic of the simultaneous insertion of the videothoracoscope an Ebook Operative thoracic surgery (6/E): Part 2d instrument ensemtne during uniportal VATS.development of a transversal latero-lateral (or anteroposterior) plane, along which the operative instrumeEbook Operative thoracic surgery (6/E): Part 2
nts are deployed to address the target area.-' With the current 2-D technology, the surgical maneuvers impede in-depth visualization through a centralUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2ort VATS demands an extent of hand-eye coordination to overcome the geometrical obstacle originating from this torsion angle isee Figure 17.4a).4 This hand-eye coordination represents an added difficulty, especially during hilar dissection during VATS lobectomy, and this has possibly undermined the Ebook Operative thoracic surgery (6/E): Part 2more universal acceptance of the procedure, which is otherwise appealing. Conversely, in the uniportal approach, the eye "accompanies" in depth the stEbook Operative thoracic surgery (6/E): Part 2
ems of the instruments, which are deployed parallel to each other along the sagittal plane, and effectively represents an extension of the surgeon's hUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2graspers can be positioned so as to avoid bite closure on the target area, which could, in turn, obstruct the in-depth view. Fur thermore. the fulcrum of the operative instruments is inside the chest—at a short distance from the actual lesion. This characteristic assimilates uniportal VATS to roboti Ebook Operative thoracic surgery (6/E): Part 2c surgery; indeed, robotic surgery is considered to be the minimally invasive surgical approach that most closely duplicates the technical features ofEbook Operative thoracic surgery (6/E): Part 2
open thoracotomy (see Figure 17.11.17.4a-b (a) The torsion angle resulting from instrument interaction along a transversal plane obstructing in-depthUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2 field.Uniportal 5The concept of using a thoracoscope and instrumentation through the same small incision dates back to a report bySinger in 1924? L’niportal VATS has since been described for sympathectomy and the diagnosis of pleural conditions?'7 The general consensus IS that the main advantage of Ebook Operative thoracic surgery (6/E): Part 2 unipor-lal VAI S is to provide a minimally invasive approach that can be used in conjunction with loco-regional anesthesia to fast track surgical canEbook Operative thoracic surgery (6/E): Part 2
didates to diagnostic or therapeutic procedures.1 In this setting, the triad one port one intercostal less pain seems justified, albeit that definitivUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2vily dependent on preoperative planning of the surgical coordinates necessary Io identify the location of the single incision. In this setting, the scapular angle line that is. longitude defines the distinction between anteriorly and posteriorly located incisions. The latitude is defined by the inte Ebook Operative thoracic surgery (6/E): Part 2rcostal space at a level that must warrant sufficient distance between the single port and target lesion to avoid videothoracoscope-instiu-ment interfEbook Operative thoracic surgery (6/E): Part 2
erence.’ Longitudinal and latitudinal coordinates usually allow for placing the incision so as to “face” the target area inside the chest. AccordinglyUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2n the apical segment of the lower lobe are best addressedfrom incisions located anterior to the scapular angle line The intercostal space selected depends on the caudocramal level where the lesion is found in the lung. As an example, if the lesion is in the apex of the right upper lobe, an incision Ebook Operative thoracic surgery (6/E): Part 2should be placed at the fourth or fifth intercostal space. Once the incision is made (see Figure 17.5a), the distribution of the surgical personnel vaEbook Operative thoracic surgery (6/E): Part 2
ries so that the first surgeon and his/ her assistant work from the same side, looking at the same monitor I see Figure 17.5b I.UNIPORTAL VATS FOR DIAUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2pacities, as well as pleural or mediastinal massesand lymph node biopsy, are all amenable to umporlal VAI S, yielding precise histological diagnosis and short hospi-talizations?6-1*'1- Interestingly, selected awake patients can be operated on under a combination of loco-regional anesthesia and sedat Ebook Operative thoracic surgery (6/E): Part 2ion.1’ Typically, an epidural catheter is positioned at theT5-6 level and a single shot of 1% Ropivacain solution (lOmg'mL diluted to 5mg mL. for a toEbook Operative thoracic surgery (6/E): Part 2
tal dose of 15mL = 75 mg) is administered.1-’” In addition, the patient is given intravenous (IV) midazolam (4 mg), fentanyl (100 mcg) and propofol (0Uniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2.l? 0(b)17.5a-b Distribution of the theater personnel before the incision (a) and after the incision (b) for a uniportal VATS procedure.208 Uniportal video-assisted thoracoscopic surgery (VATS)SURGICAL TECHNIQUE FOR UNIPORTAL VATS FOR PLEURAL CONDITIONSAs a rule, diagnostic uniportal VATS IS perform Ebook Operative thoracic surgery (6/E): Part 2ed through a single 1.0-1.5cm incision located along a virtual thoracotomy line in the fifth intercostal space, usually anterior to the scapular lineEbook Operative thoracic surgery (6/E): Part 2
if the pleural effusion occupies two-thirds or more of the chest cavity.’4 When the pleural effusion IS less significant, needle probing IS used to idUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2hrough a 10 mm trocar inserted through the single incision and the pleural fluid aspirated and routinely sent for cytology. As a rule, a 5 mm trocar is then used to introduce a 5 mm O-degree videothoracoscope to explore the posterior chest wall and the diaphragm. The trocar IS removed along the stem Ebook Operative thoracic surgery (6/E): Part 2 of the videothoracoscope to gain more operative space at the incision level. Later, the videothoracoscope is tilted toward the assistant s side, andEbook Operative thoracic surgery (6/E): Part 2
theanterior chest wall, pericardium, and diaphragm are visualized. At this point, biopsy forceps are introduced parallel to the videothoracoscope. If Uniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2tors in order to better direct talc aspersion. Talc poudrage is completed by rotating the thoracoscope and insufflator ensemble to cover all areas of the chest cavity.SURGICAL TECHNIQUE FOR UNIPORTAL VATS WEDGE RESECTIONThe perfect size for single-port VATS—in line with the extreme minimally invasiv Ebook Operative thoracic surgery (6/E): Part 2e philosophy behind this technique—is one fingerbreadth measured at the knuckle—that is. 2.5cm (see Figures 17.6 ami 17.7).’ The intercostal space isEbook Operative thoracic surgery (6/E): Part 2
opened flush to the superior border of the underlying rib17.6 Length of the incision for uniportal VATS wedge resection.17.7 The standard length of inUniportal video-assisted thoracoscopic surgery (VATS)GAETANO ROCCOINTRODUCTIONSingle-port (uniportal) video-assisted thoracoscopic surgery (VATS) repr Ebook Operative thoracic surgery (6/E): Part 2r uni17.8 The endostapler is articulated outside the chest and inserted in the same fashion as one would insert a mediastinoscope under the pre-cervical fascia.17.9 Intraoperative view of the simultaneous insertion of the videothoracoscope and instrument ensemble.so as to allow for 1 cm lateral move Ebook Operative thoracic surgery (6/E): Part 2ments on each side The following step is the introduction of a 0- or 30-degree 5 mm videothoracoscope without trocar, which is retracted along the thoEbook Operative thoracic surgery (6/E): Part 2
racoscope stem.-' Next, articulating endograspers and an endostapler are inserted to suspend and resect the pulmonary target area along a craniocaudalGọi ngay
Chat zalo
Facebook