Thoracoscopic First Assistant

S.Scott Balderson PA-CClinical Instructor, Duke Surgical Physician Assistant

ResidencyDivision of Thoracic SurgeryThoracic Oncology Program

Duke Comprehensive Cancer CenterDuke University Medical Center

Durham, NC

Disclosures

Medtronic– Educational Consultant

It is all in the preparation; Keys to success!

Proper equipment and instrumentation– List – Normal Operation– Troubleshooting (take ownership!)

Proper room set up– Patient positioning– Monitors– OR Table set up (long curved sponge stick)– The Team!

• Circulator, Scrub, Assistant, Pilot, Surgeon

Keys to success

Assisting– Piloting– Retraction

• With clamps, suction, graspers, etc.

– Stapling– Troubleshooting

Equipment and Instrumentation

Video Tower

Camera Box, light source, recorder

10mm 30 degree Thoracoscope; KNOW HOW THE BUTTONS WORK!

10mm 30 degree Thoracosope

Alternate Thoracoscopes; know their design and function

Know the difference between manufacturers.. (chip vs in-line lense)

In-line design vs chip

Know which plane you are flying

Ancillary products for operative issues, ex: Floshield

Specifically designed thoracoscopicinstruments

Conventional Design

VATS Specific Instruments

VATS Specific Instruments

Almost any conventional tip is available

Most frequently used VATS Instruments

Note the different applications/trade-offs for 10mm vs 5mm suction

Thoracoscopic Staplers

Thoracoscopic Staplers

The manufacturer is not as important as it is critical to have thoracoscopic specifically designed instruments and equipment

Room Set Up

The Team

Circulator– Must be familiar with the conduct and steps of the

case.– Must know the staple cartridges and other variable

supplies that will be called for during the case.– Must know how to quickly locate any supplies outside

of the room and anticipate their need.– Be familiar with ordering for par stock etc.

Pilot Surgeon

The Team

Scrub Tech– Must be familiar with the steps of the procedure– Must know the instruments and equipment including

any local nomenclature. (long curved empty)– Aspire to anticipate which instruments are used for

which maneuvers to facilitate hand off.– Must recognize the importance of table preparation.

(keeping a long curved sponge stick as the instrument closest to the field)

Patient Positioning

Standard lateral decubitis position– Flex the bed, reversed trendelenburg

• Helps keep the camera from hitting the hip which limits camera angles

– Slightly posteriorly rotated• Makes the anterior incision a little easier to access

Patient Positioning

Patient positioning table flexed

Patient positioning

Patient positioning-locating strap

Patient positioning-strap placement

Patient positioning-check axilla

Patient Positioning- Secure Arms

Incision Placement

Two incisions will allow almost any operation– 10 mm camera port

• 7th or 8th intercostal space, posterior axillary line

– 3-4 cm anterior access incision• 4th or 5th intercostal space, anterior axillary line

Incision Placement

Room set up- Monitor Placement

Assisting

Camera Operations

Camera Pilot needs a working knowledge of the function of the camera/scope/monitors– Proper use of 30 degree, flexible tip or other scope

optimizes the surgeon’s view– In the HD world it is VERY IMPORTANT to understand

how the technology functions and what the technological implications are for the surgeon.

• Ex. Low light = grainy picture = loss of resolution= loss of ability to visualize planes…

– Helpful in troubleshooting

The stand-by test

Camera Pilot

Poor Camera operation can make for a painfully long case– When the scope has to be removed to be cleaned– When the pilot has difficulty reintroducing the scope

into a complex hemithorax• Smudge• Reproducing a consistent view in scope angle and horizon

MORE IMPORTANTY, Poor Camera operation can impact the safety of a case– If the surgeon cannot visualize……

Camera Pilot

Camera Pilot should understand the steps for the intended procedure– Allows anticipation of the surgeon’s next move

The camera view is very much a dance, the surgeon must be allowed to move within the frame as opposed to being led.– The pilot must know (or ask) what should be in the center

of the screen (instrument, structure etc) Goal is for the only perception of movement on the monitor

to be the maneuvers of the surgeon The Pilot must come to appreciate the value and contribution

of controlling the surgeon’s eyes

Thoracoscope - Design

ALL Thoracoscopes are VERY fragile. 10lbs of force will break a 10mm scope

– The weight of the camera alone can damage the outside casing

– A dent in the casing means that light fibers or the in-line lenses can be broken.

– Think of the times where you THINK the scope is in focus but it is not in certain areas of the field.

3lbs of force will snap a 5 mm scope– Will bow 20 degrees before resistance can be

detected

10mm vs 5mm

5mm scope is fragile and can be easily damaged 5mm port can be utilized if you are not going to

need to pass a stapler, but the port is more difficult to keep clear. (cotton tipped applicator)

5mm incision can accommodate a 24fr chest tube

10mm optics are better and the port is easier to maintain (lap pad to clean)

10mm scope and camera has better stability and balance

Visual Field 5mm vs 10mm

Thoracoscope Design

What is the problem? It is easy and you can direct the staff as to which piece needs to be switched out Grainy picture = light cord

One part of the picture is in focus and another is not, or there is not a perfect 360 degree circle of field, or there as specks or smudges that can’t be cleaned = scope

The picture is soft and the chest wall capillaries can’t be focused = camera

Camera Operations

There must be a clear method of communicating the visual (exposure) needs of the surgeon as:

The pilot has three perspectives to maintain: the focal length, camera head rotation and the scope angle.

Camera Operations Focal Length A depth of field must be developed

– Facilitates depth perception – Close but not too close

• If too close, the camera can affect the instrument angles available to the surgeon

• A tight focal length can be helpful during delicate dissection but hurtful for frame of reference

– Anticipate when to pan in and out• Understanding the action being performed

– Adjusting retraction vs. fine dissection on the artery

Focal length- loss of reference

Focal Length – reference(the power of panning out 2cm!!)

Camera Operations

Camera head rotation controls:Horizon• Refers to the structure on which the

camera view is based.

Camera Operations

– Third control is the barrel of the light cord which controls the scope angle (exception: Olympus)

– Clock face• Refers to the barrel of the light cord on the

scope relative to the position of the hour hand on a clock

• Functionally, this reference can allow the surgeon to request a different angle without having to reach across to adjust the scope angle.

Scope Transition 9:00 to 3:00(functionally from right to left)

Communication

External Cues and Corrective Transitions– Leaning in = tighten up the focal length– Tilted head (in any direction off of neutral = I am

screwing up)– Hyper-extending neck = I need to do something to see

over the top– Head off kilter or “Batman” = Camera Drift= I am off

of the horizon

Camera Operations

Together the focal length, horizon and scope angle facilitate visual feedback to create as close to a three dimensional view as possible

Optimizing these controls also minimize the incidence of intercostal nerve irritation

Camera Piloting- small hands, no problem!

Piloting Technique-One Hand (1)

Piloting Technique-One Hand (2)

Piloting Technique-Two hand (angle)

Piloting Technique-Scope Stabilization

Piloting Technique-Parallel with one hand stabilization at the scope – know your pilot is in R spin

Piloting Technique-Isomer View Surgeon is in R spin(how well can you back up a trailer from your rear view mirror)

Isomer View - Difficult

Memorize the Path of Entry

No matter how complicated the Path

Resist the temptation to remove the scope- smudge or no smudge?

Intercostal Blocks

Diaphragmatic Retraction

The Durability of LingularRetraction

Synergy of Retraction and Scope Angle

Retraction to Rotate the Hilum

Know the function and angles of your instruments!

Don’t Spill Staples- Nidus for Adhesions

It Really works

Use Multiple Instruments for Maximal Advantage (2 for 1)

Always ask Anesthesia the Question!

When an endobag is not available..

Use Sterile Water to Detect Bleeding

Put it all together- R VATS MLND