Conventional Anterior Approach Research Articles

Application of Lateral Approach for the Removal of Migrated Interbody Cage: Taphole and Fixing Technique.

When a revision surgery related with removal of failed interbody cage is required, going through the previous passage can lead to a higher risk of neurological deficits or incidental dural injuries. Recently, the lateral approach has become a popular method instead of the conventional anterior or posterior approaches. The lateral approach is also useful method to remove failed interbody cage previously placed and re-do interbody fusion with lower risks compared to revision surgery via previous passage. However, there is still some difficulty in retrieving the interbody cage from the intervertebral space because of no spacious passage, subsidence, and uncontrolled movable cage. In this study, we introduce our experience that we removed failed interbody cage more easily with only the simple additional steps of making a taphole and fixing the cage using a thread-tipped stick.

Optimization Correction Strength Using Contra Bending Technique without Anterior Release Procedure to Achieve Maximum Correction on Severe Adult Idiopathic Scoliosis.

Adult scoliosis is defined as a spinal deformity in a skeletally mature patient with a Cobb angle of more than 10 degrees in the coronal plain. Posterior-only approach with rod and screw corrective manipulation to add strength of contra bending manipulation has correction achievement similar to that obtained by conventional combined anterior release and posterior approach. It also avoids the complications related to the thoracic approach. We reported a case of 25-year-old male adult idiopathic scoliosis with double curve. It consists of main thoracic curve of 150 degrees and lumbar curve of 89 degrees. His curve underwent direct contra bending posterior approach using rod and screw corrective manipulation technique to achieve optimal correction. After surgery the main thoracic Cobb angle becomes 83 degrees and lumbar Cobb angle becomes 40 degrees, with 5 days length of stay and less than 800 mL blood loss during surgery. There is no complaint at two months after surgery; he has already come back to normal activity with good functional activity.

Anterior transarticular screw fixation as a conventional operation for rigid stabilization.

Background:Anterior transarticular screw (ATS) fixation is a useful surgical option for atlantoaxial (AA) stabilization. This report presents a revised ATS method for AA fusion.Methods:A 79-year-old male presented with AA instability attributed both to an old odontoid fracture and severe degeneration of the lateral atlantoaxial joints (LAAJs). ATS fixation was performed through the conventional anterior cervical approach. The longest screw trajectories were planned preoperatively using multiplanar reconstruction computed tomography (CT) scans, with entry points of the screws situated at the midpoint on the inferior border of the axial body. The surgical exposure was limited to opening at the entry points alone. Our retractor of choice was the Cusco speculum; it sufficiently secured space for utilizing the required instruments for screw placement while offering sufficient protection of soft tissues. Cannulated full-threaded bicortical screws stabilized the LAAJs. Screw insertion required a significant amount of coronal angulation up to the superior articular process of the atlas under open-mouth and lateral fluoroscopy image guidance. After ATS fixation, bone grafting was performed between the posterior laminae of the axis and the atlas through a conventional posterior approach.Results:Bony fusion between the atlas and the axis was confirmed radiographically. Arthrodesis of the LAAJs occurred despite no bone grafting.Conclusions:Rigid fixation of the LAAJs was obtained by our ATS technique, indicating that it is an alternative method for AA fixation when posterior rigid internal fixation is not applicable.

Posterior trans-septum portal approach versus anterior approach for posterior cruciate ligament reconstruction

Objective To compare the posterior trans-septum portal approach and the anterior approach for anatomic single-bundle reconstruction of the posterior cruciate ligament (PCL).Methods We reviewed 60 patients who had undergone anatomic single-bundle reconstruction of PCL from January 2008 to January 2012.They were divided into 2 groups according to surgical approaches used.In the conventional group,28 patients received early PCL reconstruction via the anterior approach.They were 17 males and 11 females,with a mean age of 33.0 ± 9.4 years.In the trans-septum group,32 patients received late PCL reconstruction via the posterior trans-septum portal approach.They were 22 males and 10 females,with a mean age of 32.2 ± 8.0 years.The 2 groups were compared in terms of tibial tunnel site distance,KT-2000 value,posterior drawer test result,neurovascular lesion,and Lysholm knee function and IKDC (International Knee Documentation Committee) scores at the last follow-up.Results The conventional and the trans-septum groups were followed up for 15.9 ± 2.2 and 15.6 ± 2.0 months respectively,with no significant difference (P ＞ 0.05).The conventional group yielded significantly better results than the trans-septum group regarding tibial tunnel site distance,KT-2000 value,negative rate of posterior drawer test [90.6％ (29/32) versus 75.0％ (21/28)],Lysholm knee function and IKDC scores (90.9 ± 3.0 and 88.3 ± 3.5 points versus 87.8 ± 2.9 and 85.4 ± 3.7 points) (P ＜ 0.05).Two patients in the conventional group had neurovascular symptoms which responded to the treatment.Conclusion In the anatomic single-bundle reconstruction of PCL,the posterior trans-septum portal approach may result in better outcomes than the conventional anterior approach in terms of facilitating recovery of knee joint stability. Key words: Posterior cruciate ligament; Arthroscopy; Approach

Alterations in axial curvature of the cervical spine with a combination of rotation and extension in the conventional anterior cervical approach

Alterations of three-dimensional cervical curvature in conventional anterior cervical approach position are not well understood. The purpose of this study was to evaluate alignment changes of the cervical spine in the position. In addition, simulated corpectomy was evaluated with regard to sufficiency of decompression and perforation of the vertebral artery canal. Fifty patients with cervical spinal disorders participated. Cervical CT scanning was performed in the neutral and supine position (N-position) and in extension and right rotation simulating the conventional anterior approach position (ER-position). Rotation at each vertebral level was measured. With simulation of anterior corpectomy in a vertical direction with a width of 17 mm, decompression width at the posterior wall of the vertebrae and the distance from each foramen of the vertebral artery (VA) were measured. In the ER-position, the cervical spine was rotated rightward by 37.2° ± 6.2° between the occipital bone and C7. While the cervical spine was mainly rotated at C1/2, the subaxial vertebrae were also rotated by several degrees. Due to the subaxial rotation, the simulated corpectomy resulted in smaller decompression width on the left side and came closer to the VA canal on the right side. In the ER-position, the degrees of right rotation of subaxial vertebrae were small but significant. Therefore, preoperative understanding of this alteration of cervical alignment is essential for performing safe and sufficient anterior corpectomy of the cervical spine.

Surgical approach for high-energy posterior tibial plateau fractures

Background:High-energy fractures of posterior tibial plateau always need surgical treatment. Generally, posterior fragments of these fractures could not be exposed and reduced well in conventional anterior approaches. Although a posterolateral/posteromedial approach to manage posterior tibial plateau fractures can achieve satisfactory results, there are few presentations concerning the treatment of these high-energy injuries based on posterior approaches combined with anterior approach if necessary.Materials and Methods:Ten cases of posterior tibial plateau fractures from high-energy injuries were retrospectively reviewed and followed up for mean 26.5 months (range 14–45 months). A posterolateral/posteromedial approach was adopted primarily to fix main fragment in posterior tibial plateau, and intraoperative assessment of the stability of knee was done. An anterior approach was added if required.Results:Posterolateral approach was employed in seven cases, posteromedial in three, and additional anteromedial in three, and anterolateral in two cases. The average time to union of all 10 fractures was 3.7 months (range 3–5.5 months). Nine patients had satisfactory articular reduction. The range of motion of the knee averaged 2° of extension to 110.5° of flexion. No patient complained of knee instability. The average postoperative HSS score at the final followup was 92.70.Conclusions:High-energy fractures of posterior tibial plateau could be well treated based on posterior approaches combined with necessary anterior approach if required.

Fluoroscopically-Guided Posterior Approach for Shoulder Magnetic Resonance Arthrography: Comparison with Conventional Anterior Approach

Copyrights © 2011 The Korean Society of Radiology Purpose: To prospectively evaluate the usefulness of the fluoroscopically-guided posterior approach compared with the anterior approach for shoulder magnetic resonance (MR) arthrography. Materials and Methods: Institutional review board approval and informed consent were obtained. Among 60 shoulder MR arthrographies performed on 59 patients with symptomatic shoulders, an intra-articular injection was performed (30 cases using the anterior approach and 30 using the posterior approach). Procedurerelated pain was assessed by using a 5 score visual analogue scale (VAS). Depth of the puncture and standardized depth of puncture by body mass index (BMI) were recorded. The contrast leakage along the course of the puncture was evaluated by reviewing the MR. The statistical analyses included the Mann-Whitney U and Kruskal-Wallis test. Results: There was no significant difference in VAS scores between the anterior and posterior groups (1.77 ± 1.10 vs. 1.80 ± 0.96). Depth of puncture and standardized depth of puncture by BMI were significantly shorter in the posterior group than those in the anterior group (4.4 ± 0.8 cm and 1.8 ± 0.3 cm vs. 6.6 ± 0.9 cm and 2.8 ± 0.4 cm, p < 0.001), respectively. The incidence of contrast leakage was more frequent in the posterior group (p = 0.003). Conclusion: The posterior approach will be useful in shoulder MR arthrography with a suspected anterior pathology, a postoperative follow-up study or obese patient. Index terms Shoulder Magnetic Resonance Arthrography Anterior Approach Posterior Approach Fluoroscopically-Guided Posterior Approach for Shoulder Magnetic Resonance Arthrography: Comparison with Conventional Anterior Approach 견관절 자기공명 관절조영술에서 고식적 전방 접근법과 비교한 투시유도하 후방 접근법

Transmandibular approach for excision of maxillary sinus tumors extending to pterygopalatine and infratemporal fossae

En bloc resection of maxillary sinus tumors that extend through the posterior wall necessitates resection of maxilla along with pterygopalatine and infratemporal fossae contents. This cannot be readily performed by conventional anterior maxillectomy approaches. The objective of this study is to evaluate the effectiveness of transmandibular approach for the excision of maxillary sinus tumors extending to pterygopalatine and infratemporal fossae. This is a retrospective review of 15 consecutive patients who underwent maxillectomy with transmandibular approach for tumors with posterior extension, between January 2004 and February 2008. The principal outcome parameter was the margin status on final histopathology report. In addition, evaluable patients were reviewed to assess the morbidity of the procedure using pre-defined parameters. All the patients had negative margins at the infratemporal fossa region. Varying degree of trismus was present in all patients. The cosmetic outcome of the procedure was excellent. Other anterior and transcranial approaches could be combined with this procedure when indicated. We conclude that transmandibular approach is an effective technique for resection of maxillary tumors with posterior extension to the pterygopalatine and infratemporal fossae. The procedure has acceptable morbidity and the aesthetic and functional results are satisfactory.

Long-Term Follow-Up Results in Patients With Cervical Disk Disease Treated by Cervical Anterior Fusion Using Titanium Cage Implants

This study is a retrospective analysis of 146 patients, 85 males and 61 females aged 21-80 years (mean 52 years), with cervical disk disease who underwent anterior fusion and titanium cage implantation with follow-up periods of no less than 72 months after surgery. All patients underwent the conventional anterior cervical approach. After removing the protruded disk and osteophyte, cylindrical titanium cages were placed. Single, two, and three level fusion was performed in 76 (52%), 64 (44%), and 6 (4%) patients, respectively. Functional assessment used the Neurosurgical Cervical Spine Scale (NCSS). The curvature index and range of motion were evaluated pre- and postoperatively. The clinical outcomes were satisfactory and there were no significant complications. The mean NCSS was 9.7 before and 12.7 at 1 year after the operation, and 12.1 at final examination. No postoperative cage extrusion or pseudoarthrosis occurred, but the cages descended in 10 patients (7%) although alignment was satisfactory. At 5 years after the operation, 140 of the 146 patients (96%) had solid fusion. The long-term results of anterior fusion with titanium cage implantation in patients with cervical disk disease were satisfactory. Titanium cage placement is a highly useful alternative to the conventional treatment method in these patients.

分化型甲状腺癌縦隔転移症例に対する縦隔郭清：ｓｔｅｒｎｏｔｏｍｙ ＶＳ ＶＡＴＳ（ｖｉｄｅｏ ａｓｓｉｓｔｅｄ ｔｈｏｒａｃｏｓｃｏｐｉｃ ｓｕｒｇｅｒｙ）

We here present two cases of differentiated thyroid carcinoma with mediastinal lymph nodes metastases below level 106 according to the classification of the Guidelines for the Clinical and Pathologic Studies for Carcinoma of the Esophagus (9 th edition) edited by the Japanese Society for Esophageal Diseases. For Case 1, we adopted a conventional anterior approach with resection of the right half of the manubrium and sternum to the level of the second intercostal space and medial half of the right clavicule. Case 2 underwent a combined cervical approach and video-assisted thoracoscopic surgery (VATS). In Case 1, the lymph nodes around the subclavian vein, 105R, 106pre and 106recR were successfully dissected under clear view. However, through this case, the difficulty in the dissection of 106tbR was recognized, because it is quite challenging to gain an adequate surgical view in this small compartment by this approach. Conversely, in Case 2, in which mediastinal lymph nodes extended to level 107, the lymph nodes were relatively easily dissected by VATS under excellent surgical views of 106tbR and 107. Although VATS is associated with difficulty in en bloc resection, requirements of a thoracotomy, changes of body position and an intubation tube during the surgery, this approach is of great use for the dissection of 106tbR and 107.

Robot-assisted radical cystectomy and urinary diversion in female patients: technique with preservation of the uterus and vagina.

After performing more than 500 robotic radical prostatectomy and robotic radical cystoprostatectomy in men, we attempted to develop the technique of robot-assisted radical cystectomy in women. This article describes two techniques of robot-assisted radical cystectomy for women, conventional and with preservation of the uterus and vagina. To the best of our knowledge, this is the first case series of robot-assisted radical cystectomy and urinary diversion in women. Robot-assisted radical cystectomy was undertaken in three female patients with transitional cell carcinoma of the urinary bladder. The operation was performed with the conventional anterior approach in one patient and with a new technique in two patients, which allows preservation of urethra, uterus, vagina, and both ovaries. As planned, the radical cystectomy was done robotically, using the da Vinci Surgical System (Intuitive Surgical). The bladder was entrapped in an Endocatch bag and removed through a small subumbilical incision. Urinary reconstruction was performed extracorporeally after exteriorizing the bowel through the incision used for retrieving the specimen. In two patients, the reconstructed pouch was placed in the pelvis and the abdominal incision was closed. Urethroneovesical anastomosis was done robotically, using a technique described previously for men. The average operating time for the robotic radical cystectomy was 160 minutes and the mean operating times for ileal conduit and orthotopic neobladder were 130 minutes and 180 minutes, respectively. The mean blood loss was less than 100 mL. The mean number of lymph nodes removed was 12 (range 3 to 21). Surgical margins were free of tumor in all three patients. This approach incorporates advantages of minimally invasive and open surgery. Performing the radical cystectomy with the robot allows precise and rapid removal of the bladder with minimal blood loss. Extracorporeal reconstruction of the urinary tract reduces operative time at this stage of evolution of laparoscopic and robotic instrumentation. In the future, with the development of technology, instrumentation, and with additional refinement of our technique, the entire procedure may be done completely intracorporeally with equal efficiency.

Microsurgical Anterior Approaches to the Lumbar Spine for Interbody Fusion and Total Disc Replacement

Anterior approaches to the lumbar spine for the treatment of various degenerative or postoperative abnormalities associated with low back pain have always been a matter of debate. They are known to be associated with considerable surgical trauma, high postoperative morbidity, and, occasionally, unacceptably high complication rates. In 1997, we inaugurated two new microsurgical modifications of conventional anterior approach techniques, which have been applied in anterior lumbar interbody fusion and more recently in total disc replacement. This article describes the results of microsurgical anterior interbody fusion in a consecutive series of 171 patients as well as preliminary results of these techniques for total disc replacement in 26 patients. The approaches are performed with the use of a surgical microscope. Lumbar segments L2-L5 are exposed through a lateral retroperitoneal approach. L5-S1 can be reached through a midline retroperitoneal or transperitoneal approach. Both approaches can be performed through a limited skin incision of 4 cm. An independent observer evaluated results of anterior lumbar interbody fusion in 171 patients during a 2-year follow-up period. The clinical follow-up demonstrated low perioperative and postoperative morbidity with an average blood loss of less than 100 ml at the fusion site. Pseudoarthrosis rates were less than 5%, and clinical results, as evaluated in accordance with the scoring system developed by Prolo et al., did not differ significantly from conventional open techniques. Total disc replacement through a microsurgical anterior approach seems to be a promising alternative to fusion procedures with even less intraoperative and perioperative morbidity. Microsurgical anterior approaches to the lumbar spine provide a reasonable surgical alternative to conventional approaches for anterior interbody fusion and total disc replacement.

Nerve irritation after laparoscopic hernia repair.

Between October 1992 and May 1996, 893 hernia repairs were performed at the Surgical Clinic in Mannheim: 448 (50%) using laparoscopy (TAPP-method) and 445 (50%) using the conventional anterior approach (Shouldice). For this study, 723 (81%) of these repairs were followed up in a prospective trial of postoperative nerve irritations. The rate of nerve entrapment in the laparoscopic group was 4.2% (n = 19), and in the group that underwent conventional surgery 1.8% (n = 8). The genitofemoral nerve was affected with particularly high frequency (2%), and the ilioinguinal nerve and lateral cutaneous nerve of the thigh (LCNT) each was affected in 1.1% of the cases. Reduction in the number of clips used and careful attention to the anatomic nerve course during preparation and placement of mesh led to a significant reduction in the occurrence of nerve irritations. In the last 100 patients who underwent laparoscopic hernia repair, only one nerve lesion was seen.

上位胸髄症に対する胸骨柄縦割前方進入法の経験

In this report, we discuss two cases of upper thoracic myelopathy, treated successfully with anterior decompression and fusion utilizing sternum manubrium splitting approach. When considering surgical approach to lesions around the spinal canal, lesions existing in the anterior of spinal canal can basically be treated more effectively from the anterior approach. This is especially true at the thoracic level, because of physiological kyposis of the thoracic spine. Since the conventional anterior approach is difficult for the upper thoracic spine, this approach proves very useful for the treatment of intracanal lesions at the upper thoracic level localized at the anterior of the spinal canal.

Laparoscopic right and left adrenalectomies. Surgical procedures.

Laparoscopic approach for adrenalectomy was recently described and the operative technique is not yet well defined. Twenty-seven laparoscopic adrenalectomies were performed between 1992 and 1995. There were 18 women and nine men ranging in age from 31 to 70 years (mean, 50.8 years). The surgical procedure was a lateral decubitus transperitoneal flank approach in 26 patients, and a retroperitoneal approach in one. Twelve right and 15 left glands were removed. Adrenal diseases were primary aldosteronism in 20 patients, nonfunctional adenoma in four patients, Cushing adenoma in two, and an adrenal cyst in one. Median adrenal gland size was 2.0 cm (range 0.5-8 cm). Five patients were converted to laparotomy (18%)-for dissection problems in four and for an unrecognized gland in one. The median anesthesia time was 200 min and the median surgical time was 140 min. Operative morbidity was one adrenal vein injury sectioned close to the vena cava. The hemorrhage was controlled by laparoscopic suturing without conversion. This patient required a three-unit blood transfusion. No mortality occurred and postoperative morbidity was one minor chest infection. The median postoperative in-hospital stay was 4.6 days (range 2-8) for nonconverted patients. Laparoscopic adrenal gland removal is safe and offers fast recovery and short in-hospital stay. Laparoscopic adrenalectomy combines the advantages of both the conventional anterior and posterior approach.

Prosthetic Inguinal Hernia Repair Using a Laparoscopic Extraperitoneal Approach

The preperitoneal technique offers several advantages over conventional anterior approaches in the surgical repair of inguinal hernias: direct access to the posterior inguinal anatomy, clear visibility of all possible hernial defects, ability to circumvent scar tissue and intra-abdominal adhesions, and ease of effecting difficult repairs. A preperitoneal prosthetic procedure has been successfully used, performed laparoscopically, to repair 163 indirect, 163 direct, and one femoral inguinal defects. In the approach used, a piece of polypropylene mesh, placed extraperitoneally, is used to reinforce or replace the transversalis fascia. In only one of 197 patients (0.5%) was it necessary to convert to an open procedure; this patient had a severely incarcerated hernia. Almost all patients were discharged on the day of surgery, and all returned to normal activities within 7 days. There were few complications, and the recurrence rate in the series of 300 repairs was only 0.3%. One patient required a second procedure because of a retained indirect hernia. Based upon these results and the experience of others using a similar approach, the laparoscopic extraperitoneal prosthetic repair is advocated for patients with recurrent, as well as bilateral and complicated inguinal defects.

Preperitoneal approach in the repair of inguinal hernias

T HE SEARCH for the elusive solution to the problem of inguinal hernia has stimulated surgeons since the days of Sir Astley Cooper [I ] to devise new and more effective technics for the permanent repair of this anatomic defect. The scholarly studies of McVay and Anson [2,3] in the early 1940’s has undoubtedly exerted a most powerful influence on the thinking of the surgical community in this matter. Their compelling logic in insisting upon the use of the transversus layers and Cooper’s ligament in the repair of posterior inguinal wall defects cannot be denied. Volumes have been written by hosts of surgeons attesting to the efficacy of this method since McVay’s initial report on the clinical application of the anatomic study by himself and Anson. Happily, it is now the rare surgeon who persists in suturing the conjoined tendon to the inguinal ligament to repair a direct hernia. The respectably low recurrence rate after inguinal herniorrhaphy when the transversus layers and Cooper’s ligament have been utilized has unfortunately led to some degree of complacency in calculating this problem. The high incidence of small indirect hernia, effectively treated by high ligation of the sac and minimal repair of the posterior inguinal wall, has contributed to the general feeling of well-being. The patient with recurrence is too often relegated to the scrap pile of causes such as poor tissues, faulty suture material, or the “elsewhere” surgeon. Recurrence rates are in fact hard to measure since the patient may actually be unaware of a small recurrent hernia, he may not report a recurrent hernia of any size, or he may seek another surgeon. Thus, both the cause and incidence of recurrent hernia remain something of a mystery. Cheatle [P] in 1920 and Henry [5] in 1936 separately reported an approach to the inguinal canal for the cure of hernia that was different from the conventional anterior approach. Both described an incision above the inguinal canal approaching the posterior inguinal wall in the preperitoneal plane. Nyhus and Harkins [6] have reported their experience with over 800 hernia repairs utilizing their own version of the Cheatle-Henry approach. More recently, Dyson and Pierce [7] have reported 192 hernia repairs using a similar route. Nyhus [8] has clearly and convincingly redescribed inguinal anatomy based on his experience in the dissection of fresh cadavers, placing particular emphasis on the anatomy of the posterior inguinal wall. His clinical application, utilizing the information gained from his dissections, and his highly respectable recurrence rates deserve our serious consideration. His anatomic reappraisal of the posterior inguinal wall vividly describes hernial defects from the preperitoneal view, and although the structures which he uses for repair are fundamentally the same structures which are used in the McVay approach from the front, they take on a curiously logical appearance. This paper is not intended to redescribe all inguinal anatomy, but in order to focus attention on the posterior inguinal wall it is necessary to point again to this layer as it relates to preperitoneal inguinal herniorrhaphy. Vital to the dis-

Changing concept of inguinal herniorrhaphy; experience with preperitoneal approach.

AFTER having repaired inguinal hernias by the conventional anterior approach for over a decade and noting the development of an occasional recurrence at the site of the internal ring or in the direct area, Dr. Dyson in 1961 was receptive to a new approach to herniorrhaphy. The report of Nyhus and associates 1 concerning their recent success with the preperitoneal herniorrhaphy provided this new approach and led to the adoption of this method for the repair of all groin hernias. It appeared worthwhile to reexamine each patient having had a groin hernia repaired by this technique over the past 3½ years. Having done this, we felt the results obtained were of sufficient interest to warrant reporting. These results have led to our modifying the method utilized for the repair of inguinal hernias. Method The technique employed over the past 3½ years was essentially that of Nyhus et al. 1 A