Endoscope-assisted Surgery Research Articles

Endoscopic Stapedotomy for Congenital Absence of Stapes

Objective: To describe our experience with endoscope-assisted stapedotomy in a patient with congenital absence of stapes. Patient: Female patient with bilateral congenital absence of stapes. Intervention: Endoscopic stapedotomy. Results: The patient recovered well with closure of air-bone gap on pure-tone audiogram postoperatively. Conclusion: A rare case of congenital absence of stapes managed by endoscopic-assisted surgery is presented. The aetiology of this condition and the relative benefits of using the endoscope in such cases of congenital middle ear malformation are discussed.

内視鏡下披裂軟骨内転術

内視鏡下披裂軟骨内転術

317P - Endoscopic Assisted Mastectomy with Immediate Reconstruction in Treatment of Early Breast Cancer-Experience from Taiwan

ABSTRACT Aim: Endoscopic assisted breast surgery (EABS), performed through minimal axillary and/or peri-areolar incisions, could be another option for the management breast cancer. In this study, we report our preliminary results of EABS in the National Cheng-Kung University Hospital (NCKUH), Taipei Medical University Hospital (TMUH) and Changhua Christian Hospital (CCH), Taiwan. Methods: Patients with breast cancer managed by EABS were search from 3 medical centers database. The patients' clinicopathologic characteristics, type of surgery, method of breast reconstruction, complication and recurrence were recorded. (IRB Nr 121229) Results: A total of 220 patients with breast cancer undergone EABS from the above three endoscopic breast surgery centers in Taiwan. All of them were female, and the mean age at diagnosis was 49.5 ± 10.1 years old (range 26 to 80 year). Among these 220 patients, 36(16.4%) underwent endoscopic assisted partial mastectomy (EAPM), and 184 received endoscopic assisted total mastectomy (EATM). In the 184 EATM patients, 46 (25%) received endoscopic assisted skin sparing mastectomy (E-SSM), and 138 (75%) underwent endoscopic assisted nipple sparing mastectomy (E-NSM). The mean pathologic tumor size of these 220 patients was 2.1 ± 1.6 cm (0.1 to 8.5 cm). Lymph node metastasis was found in 33 (15%) patients, 17 patients with lymph node 1-3 positive, and 16 patient with 4-9 lymph nodes metastasis. The post operative stage distribution were 70 (31.8%) ductal carcinoma in situ (DCIS), 75 (34.1%) stage 1, 36(16.4%) stage 2a, 26(11.8%) stage 2b, and 13 (5.9%) stage 3a.Among the 184 EATM patients, 147 (79.9%) received immediate breast reconstruction. Most (57.3%) of them received Gel implant reconstruction, and 42.7% received breast reconstruction with autologous pedicled transverse abdominal myocutaneous (TRAM) flap. Complications (9.6%) follow EABS were all minor, and most of them were wound related. The cosmetic result was scored by surgeons and patients. Conclusions: Endoscopic assisted breast surgery is a safe and highly acceptable operation for the management of Taiwanese women with early stage breast cancer. Disclosure: All authors have declared no conflicts of interest.

Complications of Sialendoscopy: Personal Experience, Literature Analysis, and Suggestions

This article describes our experience combined with analysis of the emerging literature, presenting suggestions of how to avoid the complications that may arise during or after endoscopic or endoscopy-assisted surgery of the salivary glands. In a retrospective study, the surgical data of 498 consecutive patients who underwent surgery for calculus removal from the parotid, submandibular, and sublingual glands from 2010 to 2012 were collected and analyzed. The analysis was concentrated on specific complications of endoscopic or endoscopy-assisted operations. The patients were operated on by various sialendoscopy-involved techniques that included intraductal endoscopy and an endoscopy-assisted extraductal approach. The total percentage of complications associated with endoscopy was 3.23% (n = 17). In 1 case (0.2%) (submandibular gland surgery), severe bleeding occurred that required immediate gland resection. At present, sialendoscopic and endoscopy-assisted techniques produce a minimal number of postsurgical endoscopy-related complications, but they are not complication-free operations. Strictures, ranulas, and lingual nerve paresthesias are the most frequent of these complications. Further reduction of the number of complications is possible with careful preprocedural imaging analysis and correct endoscopic techniques.

Primary dural closure and anterior cranial base reconstruction using pericranial and nasoseptal multi-layered flaps in endoscopic-assisted skull base surgery.

Dural and anterior cranial base reconstruction is essential in the surgical resection of a craniofacial tumor that extends from the paranasal sinuses to the subdural space. Watertight reconstruction of vascularized tissue is essential to prevent postoperative liquorrhea, especially under conditions that prevent wound healing (e.g., postoperative irradiation therapy). We successfully treated two cases of olfactory neuroblastoma by endoscopic-assisted craniotomy with primary dural closure and anterior cranial base reconstruction using a multi-layered flap technique. Dural defects were closed using temporal fascia or fascia lata in a conventional fashion, immediately after detaching the subdural tumor, in order to isolate and prevent contamination of subdural components and cerebrospinal fluid (CSF) from the tumor and nasal sinuses. Tumor removal and anterior cranial base reconstruction were performed without any concern of CSF contamination after dural closure by craniotomy and endoscopic endonasal approach (EEA). Vascularized pericranial flaps (PCF) and nasoseptal flaps (NSF) were used simultaneously as doubled-over layers for reconstruction. The tumor was completely removed macroscopically and the anterior cranial base was reconstructed in both cases. CSF leak and postoperative meningitis were absent. Postoperative and irradiation therapy courses were successful and uneventful. This multi-layered anterior cranial base reconstruction consisted of three layers: a fascia for dural plasty and double-layered PCF and NSF. This surgical reconstruction technique is suitable to treat craniofacial tumors extending into the subdural space through the anterior cranial base dura mater.

Occult risk of broken instruments for endoscopy-assisted surgery.

The influence of broken sophisticated surgical instruments on the safety of surgery has yet to be determined, in spite of an assumption that breakage of surgical instruments is not associated with critical incidents. The purpose of the present study was to delineate the risk from breakage of surgical instruments used in surgery assisted by endoscopy. A retrospective analysis was conducted to determine the frequency of breakage of instruments used in 39,817 operations from 2007 to 2011. Data of breakage were collected using incident/near-incident reports and the request forms for repair of broken instruments. During the study period, 441 instruments were reported to be broken intraoperatively, and 7,541 were found to be broken on inspection. The incidence of breakage adjusted by the number of operations and the number of uses suggested that instruments for endoscopy-assisted surgery are broken more frequently intraoperatively than are any other type of instruments (visceral surgery: 0.039 versus 0.017, P = 0.0002, RR = 2.318; obstetrics/gynecology: 0.023 versus 0.0067, P < 0.0001, RR = 3.461; thoracic surgery: 0.019 versus 0.004, P = 0.0772, RR = 5.212). Inappropriate use and wearing out were two major possible causes of breakage of instruments. The predominant adverse events were suggested to be attributable to parts falling off broken instruments because of inappropriate use. Our results demonstrated that surgery assisted by endoscopy has its own occult risk, which has not been previously highlighted. Minimally invasive surgery is not necessarily safe with respect to breakage of surgical instruments. Our data provide substantial evidence for higher risk of instrument breakage in endoscopy-assisted surgery, as well as its possible detrimental effect on patient safety.

5-ALA Endoscope-Assisted Surgery of the Anterior Skull Base

Objective: In skull base surgery endoscopic techniques gain increasing importance. In gliomas 5-ALA fluorescence-guided surgery (FGS) could increase radicality and improve PFS. We proposed to establish the proof of principle to resect anterior skull meningiomas with help of a 5-ALA endoscope (5-ALA eFGS). Material and Methods: Two patients with anterior skull base meningiomas were operated using a special endoscope equipped for 5-ALA FGS. Results: Patient number 1 was operated by a combined transnasalendoscopic and transcranial approach. Patient number 2 was operated via an endoscope-assisted transeyebrow subfrontal approach. In both the patients fluorescing tumor was well visualized by the endoscope and it helped to detect a residual tumor at the end of surgery. Conclusion: We established the proof of principle to use a 5-ALA endoscope as an additional tool in anterior skull base surgery.

Clinical analysis of sinonasal hemangiopericytoma

To investigate the clinical features, therapeutic methods and therapeutic effects of sinonasal hemangiopericytoma. Clinical data of 6 patients with sinonasal hemangiopericytoma, diagnosed by pathology and immunohistochemistry between January 1990 and December 2012 were analyzed retrospectively. There were 4 males and 2 females, with a median age of 58 years. Clinical manifestation included epistaxis and nasal obstruction. These patients were operated on by nasal endoscopic surgery or endoscope-assisted surgery, of which 2 cases of tumor located in the nasal cavity underwent nasal endoscopic surgery and 4 cases of tumor located in the nasal cavity and sinuses underwent endoscope-assisted surgery. All the patients were followed up for a period of 6 months to 7 years after operation. Two cases recurred and 4 cases didn't recurred. One case recurred 6 months after operation and underwent second operation, with no recurrence by further one year follow-up. Another case recurred 17 months after operation and underwent second operation, with recurrence by further 9 months follow-up. This patient lived with tumor over two years. Hemangiopericytomas are rarely found in the sinonasal cavity. Nasal endoscopic or endoscope-assisted surgery provides satisfactory effect.

Endoscope-Assisted Excision of Second Branchial Cleft Cysts Using a Hairline Approach in the Posterior Occipital Region

Second branchial cleft cysts have usually been resected through a prominent incision over the entire protruding zone. The resultant scar can be esthetically displeasing. We report on the endoscope-assisted excision of second branchial cleft cysts by way of a posterior occipital approach. We explored the feasibility, validity, and safety of this procedure. From November 2008 to February 2011, 8 patients with second branchial cleft cysts underwent endoscope-assisted resection by way of a posterior occipital approach using an endoscopic technique. All the procedures were successfully performed using endoscope-assisted surgery by way of a posterior occipital approach with an operative time of 70 minutes (range 60 to 110) and a bleeding volume of 10 mL (range 5 to 15). No postoperative complications, such as injury to the great auricular nerve, occurred and no operative conversions were required. The average follow-up period was 42.6 months (range 35 to 61), without any symptoms. All the patients and their families were satisfied with the cosmetic results. Endoscope-assisted excision of second branchial cleft cysts by way of a posterior occipital approach could be applied effectively, safely, and feasibly, allowing adequate exposure for dissection and providing good cosmetic results. Thus, it should be considered as an alternative surgical approach for these patients.

Modified Endoscope-Assisted Partial-Superficial Parotidectomy through a Retroauricular Incision

Objectives: The aim of this study was to evaluate the feasibility of an endoscope-assisted partial parotidectomy through a modified retroauricular incision. Patients and Methods: Thirty patients with benign parotid superficial lobe tumors with a diameter of 2.4 ± 0.5 cm, located in the anterior portion of the inferior auricular lobule, underwent an endoscope-assisted partial-superficial parotidectomy. A retrograde approach through a small skin incision was used. An additional 30 patients who underwent conventional surgeries were used as controls. The operation time, operative bleeding volume and subjective satisfaction with the incision scar were compared between the groups. Results: All operations were successfully performed. The endoscopic surgery duration (74.8 ± 15.7 min), bleeding volume (12.7 ± 3.9 ml) and incision length (4.8 ± 0.4 cm) differed between the groups (p = 0.001). The mean patient satisfaction score was 8.6 ± 1.2 in the endoscope-assisted surgery group and 5.4 ± 1.3 in the control group (p = 0.001). There were no tumor recurrences during the 9-36 months of follow-up. Conclusion: Endoscope-assisted partial-superficial parotidectomy via a modified retroauricular incision is a feasible method for the treatment of benign parotid superficial lobe tumors located in the anterior portion of the inferior auricular lobule. The main advantage of this procedure was that the small operative scars improved the cosmetic results.

Endoscopy-assisted breast-conserving surgery for breast cancer patients.

Breast-conserving surgery (BCS) combined with postoperative radiotherapy is a standard therapy for early-stage breast cancer patients. In addition, recent developments in oncoplastic surgery have improved cosmetic outcomes and patient satisfaction. Therefore, a breast surgeon's current role in BCS is not only to perform a curative resection of cancerous lesions with adequate surgical margins, but also to preserve the shape and appearance of the treated breast. Endoscopy-assisted breast-conserving surgery (EBCS), which has the advantage of a less noticeable scar, was developed more than ten years ago. Recently, some clinical studies have reported the feasibility, oncological outcomes, aesthetic outcomes, and patient satisfaction of EBCS. Herein, we will review the EBCS clinical studies that have been conducted so far and discuss current issues regarding this operative method.

Midcheek mass: 10 year of clinical experience

This is a literature review and retrospective chart review of ten years experience on the treatment of midcheek masses in our department. The purpose of this study is to provide the reader with an overview of the pathology of this complex anatomic area focusing the attention on the differential diagnosis and the recent surgical strategies.From May 2002 to December 2012 we enrolled 22 consecutive patients studied for masses located in the midcheek area. Only four studies were found in the literature describing the experience of individual centres reporting few cases of midcheek masses. Combined with the previously reported 37 cases, we describe 22 lesions for a total of 59 cases. Patients were evaluated with a head and neck clinical and instrumental examination. Apart from 4 cases treated with intramuscular infiltration of botulinum toxin for masseter hypertrophy, surgical approach to the lesions was varied: 10 patients received an external approach (standard parotidectomy approach or face-lift-type approach); 6 patients had the lesion removed through an intraoral approach; in 2 cases a direct skin incision was performed. In our series we found a significant rate (55.5%) of temporary complications in all the procedures performed (external, intraoral, direct skin approach). This study aims to emphasize the role of endoscope assisted surgery as a possible alternative to the traditional approaches for the management of well selected benign midcheek masses.It would be advisable to increase the study of the endoscopic anatomy of the midcheek area in order to standardize the procedure and better define the surgical indications.

Nasal endoscope: an armamentarium in the management of sinonasal inverted papilloma.

Sinonasal inverted papillomas (SIP) are unique group of locally aggressive benign neoplastic lesions arising from mucosa of sinonasal tract with potential for recurrences and known association with squamous cell carcinoma in 5-15% of cases. This study was conducted was to assess the efficacy and usefulness of the nasal endoscope in treating SIP. We reviewed 28 biopsy proven cases of SIPs that were treated at our hospital between June 2009 and September 2013. Average patient age was 46years. Fourteen were treated by transnasal endoscopic excision of tumor with noted recurrence of 21.43%. Thirteen were treated by endoscopic assisted open surgery which had 23% recurrence. Three patients had malignant inverted papillomas, of whom two (7%) were found to have synchronous squamous cell carcinoma and one (3.6%) had metachronous squamous cell carcinoma. No evidence of recurrence was found in rest during our follow up. The endoscopic approach is the preferred method for the treatment of the majority of inverted papillomas. Powered instrumentation is extremely useful to achieve good results. Although significant number of cases was done by external approach by lateral rhinotomy, the endoscopic assistance is required to ensure complete removal of the tumour to reduce the recurrence rates. Close follow up of the patient for a longer period of time is necessary for the early detection of recurrence and to allow for surgical salvage.

Complications in the endoscopic and endoscopic-assisted treatment of juvenile nasopharyngeal angiofibroma with intracranial extension ,

IntroductionAlthough it is a rare neoplasm, juvenile nasopharyngeal angiofibroma (JNA) is associated with high rates of morbidity and mortality, with the potential for intracranial extension. Surgical excision is the main treatment. The external approach has largely been replaced by the endoscopic approach in small lesions, and it can be used as a complement in more advanced cases. However, there is no consensus in the literature regarding the complications of surgical treatment of JNAs with intracranial extension. AimTo assess the prevalence of complications in endoscopic or endoscopic-assisted surgical treatment of JNA with minimal intracranial invasion. MethodsThis was a retrospective cohort study of all patients with JNA with intracranial extension (Radkowski grade IIIa) treated with endoscopic, endoscopic-assisted, and external surgery from January of 1996 to May of 2010. ResultsThirteen patients underwent surgery. Endoscopic surgery was performed in three patients, without postoperative complications; endoscopic-assisted surgery in three others, with two instances of complications, and external surgery in seven. ConclusionsOperative treatment of nasopharyngeal angiofibroma with intracranial extension is one of the major challenges of ENT and neurosurgical practice. The success rates and low intra- and postoperative complication rates of endoscopic surgery suggest that this route has been gaining ground in the management of Radkowski grade IIIa JNAs.© 2014 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. All rights reserved.

Delayed Synostoses of Uninvolved Sutures After Surgical Treatment of Nonsyndromic Craniosynostosis

Craniosynostosis causes significant cranial deformity in the pediatric population. Open and endoscopic-assisted surgeries have led to increasingly successful management of this condition. Following surgical reconstruction, subsequent development of postnatal synostosis of previously patent sutures have been described and noted to be most frequently associated with multisuture synostosis patients with syndromic diagnoses. Very rarely, postsurgical new sutural fusion has been identified in nonsyndromic patients who initially present with isolated single-suture synostosis. The purpose of this study was to evaluate the incidence of new synostosis among patients who had undergone craniosynostosis reconstruction with either the open or endoscopic technique. Patients undergoing open and endoscopic surgery for nonsyndromic craniosynostosis were reviewed. Preoperative and postoperative imaging and clinical information were reviewed, and cases showing progressive cranial deformity were identified. Three (2.1%) of 145 patients undergoing open craniosynostosis surgery and 2 (1.7%) of 121 patients undergoing endoscopic surgery developed delayed fusion of an additional suture during follow-up. This was identified at a median of 16.4 months after initial surgery in the open group and 15.25 months after surgery in the endoscopic group. In patients undergoing open surgery, each patient developed new sagittal synostosis after initial presentation of coronal synostosis in 1 patient and metopic synostosis in 2 patients. In patients undergoing endoscopic surgery, each patient developed new coronal synostosis after sagittal repair. Management of craniosynostosis has evolved over time with increasing availability of effective and safe treatments. During long-term follow-up, a small number of patients may develop premature closure of a different suture that did not undergo surgical manipulation. In our case, series, we identified 3 patients undergoing open surgery and 2 patients undergoing endoscopic surgery for nonsyndromic, single-suture craniosynostosis. This finding supports the necessity of long-term clinical follow-up and the utility of delayed imaging when clinical suspicion indicates.

Endoscope-assisted second branchial cleft cyst resection via an incision along skin line on lateral neck

The aim of the study is to report the feasibility of endoscope-assisted second branchial cleft cyst resection via a small incision along the skin line on the lateral neck. In total, 41 patients from the Department of Otolaryngology, Foshan Hospital of Yat-sen University were randomly assigned to conventional (20 patients) or endoscope-assisted (21 patients) second branchial cleft cyst resection. The patient clinical characteristics, operation time, operative bleeding volume, postoperative complications, and subjective satisfaction with the incision scar (measured using a visual analog scale) were compared between the groups. All 41 s branchial cleft cyst resections were successfully performed, and the wounds healed uneventfully. The bleeding volume (6.3 ± 2.5 ml) and incision length (2.7 ± 0.3 cm) differed between the groups (P < 0.00). The mean patient satisfaction score was 8.0 ± 0.8 in the endoscope-assisted surgery group and 6.4 ± 0.9 in the control group (P < 0.00). All of the patients in the endoscope-assisted surgery group were satisfied with their cosmetic results. No marginal nerve palsy occurred. No complications such as bleeding, salivary fistula, or paresis of the marginal mandibular branch occurred. All of the patients were disease free through a follow-up period of 6-24 months (median: 14 months). Endoscope-assisted second branchial cleft cyst resection via a small incision along the dermatoglyph on the lateral neck is a feasible technique. This procedure may serve as an alternative approach, allowing a minimally invasive incision and better cosmetic results.

Endoscopic-assisted surgery for pyriform sinus fistula in children: Experience of 165 cases from a single institution

BackgroundCongenital pyriform sinus fistula (PSF) is relatively rare, but often presents diagnostic and therapeutic challenges. Herein, we report our experience of endoscopic-assisted surgery of PSF in children. MethodsSince 1999, 165 children (100 males, 65 females) with PSF had been enrolled. Their clinical manifestations were recurrent lateral neck infection, cervical mass and respiratory distress. Preoperative investigations included barium swallow, ultrasound, computed tomography, and thyroid scan. After resolution of the infection, the fistulas were identified by the endoscopic-assisted technique at operation. The fistula tract was completely excised just at the apex of the pyriform sinus. More recently, the anatomic point where the fistula tract penetrated into the pharynx was specified and recorded. ResultsOf the 165 cases, the male to female ratio was 1.54:1, the median age of onset was 3.2 years (range, 1 day to 13.8 years), and median age at operation was 5.0 years (range, 17 days to 15.0 years). One hundred fifty-six (94.6%) fistulas located on the left side, 7 right, and 2 bilateral. Twelve neonates and young infants (younger than 3 months) presented with a large cervical cyst. The fistulas were completely excised in all but 2 (98.8%) with intraoperative gastroscopy successfully conducted in 160 cases (97.0%). In 77 cases the points where fistulas penetrated into the pharynx were specified intraoperatively, which were classified into 3 types according to their anatomic relationship with the inferior cornu of the thyroid cartilage (ICTC): type I (anterior to ICTC), 22 cases (28.5%); type II (inferior to ICTC), 18 cases (23.4%); and type III (posterior to ICTC), 37 cases (48.1%). Postoperatively, 160 cases recovered well without complications. PSF recurred in 5 cases, 2 of whom were cured by fistula re-excision and 3 remained asymptomatic. Esophageal perforation was found and repaired uneventfully in 1 neonate and 1 young infant. Transient postoperative hoarseness happened in 1 neonate. All the latter 3 cases had cervical cysts. ConclusionsTo our knowledge, this series is the largest report of PSF in children. Our results suggested that PSF is more common in males. With the help of endoscopy and a better understanding of the anatomic relationship between ICTC and the points where the fistulas penetrated into the pharynx, PSF excision can be done successfully with minimized complications. For neonates and young infants with a cervical cyst, however, the management of PSF continues to be a challenge.

Endoscope-assisted repair of metopic synostosis

Endoscopic treatment of nonsyndromic craniosynostosis has been used in recent decades. The aim of this study is to present the results of endoscope-assisted surgery of the patients with metopic synostosis. Nineteen patients with metopic synostosis underwent endoscope-assisted surgery between 2005 and 2012. The frontal angle was measured on CT scans pre- and postoperatively. A midline strip craniectomy was made, making sure that the removal extended inferiorly to the nasofrontal suture. Postoperatively, all patients wear a custom molding helmet. The helmet was then worn for 23 h daily and worn for the next 10-12 months. There were 15 boys and 4 girls, ranging in age from 4 to 24 weeks. Mean operative time and transfused blood volume were 43.42 min and 76.31 ml, respectively. Mean follow-up was 59.3 weeks. Good esthetic results, judged by radiological examination and photograph comparison, were obtained in all patients. Endoscope-assisted repair of metopic synostosis is safe and offers promising results in infants before the age of 6 months. Molding helmet therapy following surgery is very important in obtaining the good results. Early diagnosis and referral for surgery are crucial.

Endoscopic evaluation of the nasal cavity, pharynx and soft palate after radiotherapy and radiochemotherapy for neoplasms

developed a virtual reality (VR) systemwhich simulates a surgical step in endoscopic-assisted surgery, and evaluated the usefulness as a training system. Methods: In the first step, five students performed basic technical tasks: exfoliation and lift the blood vessel, on the monitor of the VR model. Other five students without the VR training were served as a control group. Finally, all performed the same tasks using a conventional kit for trainees. Results: Significant advances of the operation technique after VR training were noted in operation time (p< 0.05) and number of strokes of forceps (p< 0.05). Also these parameters were significantly improved in the training group in compared with the controls. Conclusions: We have developed a VR training system that faithfully reproduced to visual and sense of the touch the actual surgery. This study proved our VR training system can improve surgical skill correctly and smoothly.

Sialoendoscopy: surgical technique and treatment protocol in a series of 45 patients

developed a virtual reality (VR) systemwhich simulates a surgical step in endoscopic-assisted surgery, and evaluated the usefulness as a training system. Methods: In the first step, five students performed basic technical tasks: exfoliation and lift the blood vessel, on the monitor of the VR model. Other five students without the VR training were served as a control group. Finally, all performed the same tasks using a conventional kit for trainees. Results: Significant advances of the operation technique after VR training were noted in operation time (p< 0.05) and number of strokes of forceps (p< 0.05). Also these parameters were significantly improved in the training group in compared with the controls. Conclusions: We have developed a VR training system that faithfully reproduced to visual and sense of the touch the actual surgery. This study proved our VR training system can improve surgical skill correctly and smoothly.