Keywords
VATS - instrument - surgical technique
Introduction
Surgeons apply grasping forceps and suction in minimally invasive surgical environments
to cooperate with the energy device that handled in right hand.[1] However, unlike in minithoracotomy or even multiport video-assisted thoracoscopic
surgery (VATS), where access is readily available or instrument motion is relatively
unrestricted, the use of these instruments in uniport VATS has been limited by the
single surgical corridors. The two devices possibly interact with each other when
they are maneuvered, and must be temporarily removed and replaced during surgery ([Fig. 1]).
Fig. 1 The drawing represents the major manipulated pattern of current uniportal video-assisted
thoracoscopic surgery. It is a standard two-handed surgery, and the surgeon is limited
to using only one additional surgical tool when using a dedicated energy device in
right hand for dissection. Primary surgical instruments in left hand—including suction
devices (A) and grasping forceps (B)—must be switched frequently in response to situation.
Such frequent instrument exchange during endoscopic surgery has several shortcomings:
(1) it is time-consuming; (2) it disrupts the flow of the procedure, and can break
the concentration of the surgeon; (3) it poses a safety risk to the patient. Due to
the limited view obtained with most endoscopes, there may be instances during an insertion
or removal when the instrument cannot be seen while it is still inside the patient.
These “blind” episodes are potential causes of trauma that can be minimized by reducing
the frequency of instrument exchanges.[2]
[3]
With the aim of solving this problem, we developed a novel instrument of grasping
forceps support suction. It minimized the requirement to exchange surgical devices
when performing uniportal VATS, and allowed for new maneuvers that optimized surgical
workflow, such as the ability to ensure continuous suction during surgery, maintaining
a dry surgical field and an improved endoscopic visibility.
Technique
Structure of the Grasping Forceps Support Suction
Our device ([Fig. 2]) was adapted from standard grasping forceps originally developed for target tissue
holding that were augmented to co-function as lymph node grippers. The suction tube,
which is taken from a disposal vein infusion set, accompanied the shaft of the instrument,
and then the aspiration system is connected to the handle. As such the instrument
tip does additionally function as an aspirator while it still serves its original
function as gripper.
Fig. 2 A panoramic view of the grasping forceps support suction (A). (B) Distal tip of the forceps connected with suction tube (solid arrow). The pliers
had serrations to improve the grip (dashed arrow). When the instrument grasps or handles
the target tissue, its suction is still working to clear smoke and blood, thereby
keeping the surgical field dry and clean. (C) Please note the handle manner of the instrument.
This device works identically to both a standard clamp forceps and a dedicated suction.
When the clamp grasps or handles the target tissue, the continuous suction permits
an improved endoscopic visualization via blood, smoke, and other cautery by-products
synchronized cleaning.
Clinical Experience
After its 6 months clinical application, our experience demonstrated that the combinations
of two instruments provided maximal efficiency in workflow and reduced the requirements
to remove and reinsert surgical devices when suction was intermittently needed.
Discussion
Improved efficiency in the performance of a procedure is one of the primary goals
of instrument design.[2] Multifunctionality clearly plays a role in making an instrument more effective and
hence more popular among surgeons.[2]
[3] Solely improving the primary function of an instrument at the detriment of secondary
and tertiary uses decreases its flexibility and could therefore limit its clinical
popularizing.[2] By somehow combining the function of two of the main devices, the number of device
changes necessary to complete the procedure could be reduced. This would potentially
heighten the surgical effectiveness, shorten the operative duration, and lessen the
underlying trauma to the patient during an instrument exchange. This is more important
in uniportal VATS due to its very limited access.
Attending to the combination of a grasping forceps and a suction device, our newly
developed instrument works as of dual-function, it offers several advantages compared
with what they currently are. Namely, it potentially increases surgical efficiency
and enhances workflow by expanding the functions of standard clamping forceps to dually
serve as suction apparatus. It allows a simultaneous clearing of smoke and blood resulting
from electrocautery during surgery. Meanwhile, it also allows an increased surgical
efficiency by minimizing the repetitive removal/insertion of instruments, thereby
reducing the risk of interfering with each other, and potentially reducing operative
duration. Finally, it reduces the reliance on assistant(s) and increases surgical
proficiency. These advantages render this novel, dual-functional, minimal-access device
has the potential to make a substantial contribution to uniportal VATS, minimally
invasive or traditional open surgery.
