Step 1 Laparoscopic Entry

TT approach is performed using four valveless, 12 mm ports (Fig. 3). A 1.5 cm transverse incision is made directly over the underlying seventh rib and the initial port is inserted in the intercostal space at the junction of the posterior axillary line and seventh rib. The incision is bluntly deepened using a Kelly clamp until the rib surface is reached. In the same blunt manner, dissection is then continued immediately along the superior edge of the rib, and blunt entry into the pleural cavity is gained. Careful blunt dissection prevents iatro-genic injury to the intercostal neurovascular bundle or lung. A 10 mm 30° laparoscope inserted through the 10 to 12 mm blunt tipped port is used to inspect the thoracic cavity. Ample working space in the ipsilateral hemithorax is achieved using the double lumen endotracheal tube, which allows the collapse of the ipsilateral lung (Fig. 4A). Active

FIGURE 3 ■ Port placement. Source: From Ref. 16.

FIGURE2 ■ Patient positioning. Source: From Ref. 16.

FIGURE2 ■ Patient positioning. Source: From Ref. 16.

retraction, creation of pneumothorax, or CO2 insufflation is not necessary because the ipsilateral lung falls out of view spontaneously due to lung deflation and the prone position of the patient.

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