Modified Marionette Technique for Laparoscopic Colorectal Surgery

The String Puppet Technique to Improve Exposure in Totally Endoscopic Mitral Valve Surgery

AIM

To determine the feasibility of the string puppet technique as a flexible, dynamic alternative to atrial retractors in totally endoscopic non-robotic mitral and tricuspid valve surgeries.

METHOD

Fifty-one (51) consecutive patients were operated on for totally endoscopic mitral valve repair from July 2017 to February 2018. A 3 cm peri-areolar (males) or submammary (females) incision was placed on the right chest. The thoracic cavity was accessed via the fourth intercostal space. A temporary pacing wire was placed transcutaneously as a puppeteering sling in the thoracic cavity under endoscopic vision. Multicoloured sutures were used to expose the right atrium and interatrial septum by weaving and suspending the sutures on the sling. The sling was tightened to pull up the walls of the cardia and manipulate them externally, like a puppet on a string, to improve selective exposure.

RESULTS

We were able to obtain adequate exposure of the mitral and tricuspid valves in all patients without the use of atrial retractors. No patient required conversion to sternotomy due to lack of exposure. None of our patients had postoperative mitral regurgitation of more than 1+ over a mean follow-up of 2 years.

CONCLUSIONS

The string puppet technique improves exposure of mitral and tricuspid valves in totally endoscopic cardiac surgery. It is safe, effective, easy to perform, and inexpensive.

Modified marionette technique for uniportal video-assisted thoracic surgery: a case report

Background

The current state of thoracoscopic technology allows less invasive surgical procedures and requires fewer ports and incisions. Totally video-assisted thoracic surgery with a single port has emerged as the least invasive thoracoscopic approach.

However, uniportal video-assisted thoracic surgery brings about considerable difficulties, necessitating the development of skillful techniques as well as specific surgical devices. In such situations as dense pleural adhesion and anatomical abnormality, it may be more burdensome, necessitating the conversion to conventional multiportal video-assisted thoracic surgery or even to thoracotomy. To troubleshoot these situations, we herein propose the use of additional technique which could support to sustain the confident operative field for uniportal video-assisted thoracic surgery. This procedure also provides the same cosmetic outcomes as uniportal video-assisted thoracic surgery.

Case presentation

A previously healthy, 77-year-old female was referred to our hospital, with a lung adenocarcinoma measuring 28 mm in the right upper lobe. Uniportal video-assisted thoracoscopic surgery was planned to resect the tumor. During operation, we found the incomplete interlobar fissure between the upper and the middle lobe and the abnormal lobulation of the upper lobe. Therefore, the modified marionette technique was introduced to make the procedure safer and easier. This technique proposed herein consists of employing the untethered gripping forceps to retract the lung, not requiring additional traumatic trocars. The postoperative course was uneventful and the patient `was discharged in 1 week after a modified uniportal video-assisted thoracic surgery for the right upper lobectomy.

Conclusions

The modified marionette technique produced sufficient operative views to attain uniportal video-assisted thoracic surgery safely in this case, rendering operative conversion unnecessary.