Vision is everything: usage of Karl Storz endoscopy device during pulmonary endarterectomy surgery
AbstractChronic thromboembolic pulmonary hypertension (CTEPH) is a distinct type of pulmonary hypertensive disease, characterized by incomplete or abnormal resolution of acute pulmonary embolism such that residual emboli become organized and fibrotic. Pulmonary endarterectomy (PEA) is the treatment of choice for many patients with chronic thromboembolic pulmonary hypertension. Karl Storz Endoscopy is a useful tool used in our department to improve the quality of pulmonary endarterectomy surgery while removing the thrombus lying on the segmental and subsegmental branches of right and left pulmonary arteries.
Material and methods. From 16.12.2021–15.08.2023 14 cases of pulmonary endarterectomy were performed also using Karl Storz Endoscopy with these parameters: rigid, 0º angled, straight, 30 cm length and 2 mm width. It has an HD camera attached on the distal part of it which is connected to a monitor and at the same time magnifies the image and provides visualization with a high quality. Vision, quality of surgery and teaching potential were evaluated during this period. Overall impressions and feedback were generated by the surgical team.
Results. All 14 PEA surgeries were completed without any complication. Overall impressions and feedback were positive on the usage of Karl Storz Endoscopy as a useful tool on pulmonary endarterectomy operations. This tool provides a better view of the thrombus that lies on the segmental arteries of right and left pulmonary arteries using an HD camera attached to its distal end and its connection with a monitor. Surgical team agreed that Karl Storz Endoscopy is crucial on the removal of thrombus lying on segmental and subsegmental branches of right and left pulmonary arteries. It also has an important impact as a teaching potential of PEA technique to the trainees.
Conclusion. Karl Storz Endoscopy is a useful part of the surgical tools used in our clinic during pulmonary endarterectomy operations. It provides excellent visualization of segmental and subsegmental branches of right and left pulmonary artery during the removal of thrombus. Secondarily, we found this tool to be important in teaching trainees pulmonary endarterectomy operation technique.
Keywords: CTEPH; Karl Storz Endoscopy; thrombus; PEA
Funding. The study had no financial support.
Conflict of interest. The authors declare no conflicts of interest.
For citation: Akay H.T., Balla E., Karslıoğlu A.O., Koni A., Akpınar D., Yamaç E.T., Mansımzada E., Beyazpinar D.S., Gultekin B., Sezgin A. Vision is everything: Usage of Karl Storz Endoscopy device during pulmonary endarterectomy surgery. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2024; 30 (3): 20–2. DOI: https://doi.org/10.33029/1027-6661-2024-30-3-20-22
Introduction
The comprehensive exploration of Karl Storz Endoscopy’s integration into Pulmonary Endarterectomy (PEA) surgeries for Chronic Thromboembolic Pulmonary Hypertension (CTEPH) unfolds against the backdrop of a nuanced understanding of this distinct subtype of pulmonary hypertensive disorders. Characterized by the incomplete or aberrant resolution of acute pulmonary embolism, CTEPH presents a multifaceted clinical challenge, necessitating innovative approaches to diagnosis and management. Within this context, PEA emerges as the treatment modality of choice for a select cohort of CTEPH patients, offering the potential for a curative outcome in those presenting with surgically accessible disease [1–5].
Surgical Technique
Against this backdrop, the utilization of Karl Storz Endoscopy (Fig. 1, 2) represents a paradigm shift in the realm of pulmonary vascular surgery, heralding a new era of enhanced visualization, surgical precision, and educational opportunities. Over a meticulously documented period spanning from December 16, 2021, to August 15, 2023, a series of 14 PEA procedures were undertaken, with Karl Storz Endoscopy serving as a linchpin in optimizing procedural outcomes. This innovative device, boasting a rigid, 0º angled, straight configuration with a length of 30 cm and a width of 2 mm, is equipped with an advanced HD camera positioned at its distal end, seamlessly connected to a high – resolution monitor (Fig. 3B). This integration affords surgeons (Fig. 4) unparalleled insights into the operative landscape, enabling real-time visualization of thrombus deposits within segmental and subsegmental branches of the pulmonary arteries. Central to the success of PEA surgeries is the attainment of a comprehensive understanding of the operative landscape, necessitating meticulous attention to detail during the identification of the appropriate dissection planes within segmental and subsegmental branches of the pulmonary artery. The procedural nuances inherent to PEA, compounded by its status as a relatively uncommon procedure, underscore the exigent need for innovative tools capable of enhancing visualization, optimizing surgical precision, and enriching educational opportunities.
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The commencement of PEA procedures entails a median sternotomy to facilitate cardiopulmonary bypass (CPB) and access to both lungs, followed by the encirclement of the inferior vena cava (IVC) and superior vena cava (SVC). Subsequent establishment of CPB entails standard aorta-bicaval cannulation and left ventricular venting, culminating in the induction of deep hypothermic circulatory arrest (DHCA) to facilitate the creation of a bloodless operative field conducive to surgical precision. Against this intricate backdrop, Karl Storz Endoscopy emerges as a game-changing adjunct, enabling seamless integration into the operative workflow to facilitate optimal visualization of thrombus deposits and enhance surgical precision during PEA procedures.
Post-arteriotomy, Karl Storz Endoscopy is introduced into the pulmonary artery (Fig. 2), extending access to segmental branches and empowering surgeons with real-time insights into thrombus removal efficacy. Meticulously managed by a second or third assistant (Fig. 3A), Karl Storz Endoscopy operates in harmony with the primary surgeon’s efforts, ensuring minimal disruption to the procedural flow. The culmination of PEA surgeries hinges upon the meticulous removal of thrombus material without residue, particularly in distal regions, where meticulous dissection assumes paramount importance in mitigating the risk of residual pulmonary hypertension.
Karl Storz Endoscopy serves as a beacon of guidance (Fig. 4) in this critical phase, enabling surgeons to conduct thorough endarterectomy and conduct real-time assessments of thrombus removal efficacy. Upon completion of the procedure, meticulous closure of the arteriotomy is undertaken, typically employing 5-0 or 6-0 Prolene in a double-running fashion to optimize patient outcomes.
Discussions
The resounding success of Karl Storz Endoscopy in enhancing surgical precision and optimizing patient outcomes is reflected in the unanimous agreement among the surgical team regarding its ease of use and superior image quality. Furthermore, trainees unanimously underscored the pivotal role of Karl Storz Endoscopy in augmenting their understanding of surgical techniques, thereby fostering a conducive learning environment. While objective comparisons with non-utilization cases were not conducted, the overwhelmingly positive subjective feedback reaffirms the indispensable nature of Karl Storz Endoscopy in the context of PEA surgeries.
Looking ahead, the focus is on further elucidating the multifaceted benefits of Karl Storz Endoscopy and establishing its status as a standard component of PEA procedures at the clinic. Continued evaluation and refinement of its application are essential to optimizing surgical outcomes and advancing patient care in the management of CTEPH. Ongoing efforts are underway to explore the broader implications of Karl Storz Endoscopy in the realm of pulmonary vascular surgery, with a view towards enhancing patient outcomes and enriching educational opportunities for the surgical community at large. Through a steadfast commitment to innovation and excellence, Karl Storz Endoscopy promises to redefine the landscape of pulmonary vascular surgery, ushering in a new era of enhanced visualization, surgical precision, and educational opportunities for clinicians and patients alike.
References
1. Frykman P.K., Duel B.P., Gangi A., et al. Evaluation of a video telescopic operating microscope (VITOM) for pediatric surgery and urology: a preliminary report. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2013; 23 (7): 639–643. DOI: https://doi.org/10.1089/lap.2013.0125
2. Mullin C.J., Klinger J.R. Chronic Thromboembolic Pulmonary Hypertension. Heart Failure Clinics. 2018; 14 (3): 339–351. DOI: https://doi.org/10.1016/j.hfc.2018.02.009
3. Roscoe A., Klein A. Pulmonary endarterectomy. Current Opinion in Anesthesiology. 2008; 21 (1): 16–20. DOI: https://doi.org/10.1097/ACO.0b013e3282f2bb52
4. Akay T., Kaymaz C., Akar R.A., et al. Raising the bar to ultradisciplinary collaborations in management of chronic thromboembolic pulmonary hypertension. Türk Göğüs Kalp Damar Cerrahisi Dergisi. 2021; 29 (3): 417–431. DOI: https://doi.org/10.5606/tgkdc.dergisi.2021.21284
5. Madani M.M. Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension: state-of-the-art 2020. Pulmonary Circulation. 2021; 11 (2): 20458940211007372. DOI: https://doi.org/10.1177/20458940211007372
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