Endoscopic Surgeon Research Articles

Anatomical Analysis of the Frontal Recess Cells in Endoscopic Sinus Surgery-An Indian Perspective

AbstractSurgery of the frontal sinus has gone a full circle from intranasal procedures to destructive and disfiguring external operations and now back to intranasal procedures but with endoscopes. Endoscopic surgery of the frontal sinus has always been a challenging experience because of the narrowness of the area, poor visibility, variable anatomy and encroachment by accessory cells such as agger nasi, frontal, intersinus septal cells on the drainage pathway. With the developments in optical aids such as endoscopes, which provide an angled view, better and brighter illumination, sophistication in the designs of instrumentation and development of imaging techniques, a renewed interest has been created in this area, but the knowledge of anatomy of this area is poor and does not meet the demands of the present day endoscopic surgeon. Moreover, no studies are available on Indian subjects.Our main interest in the present study was to study the various air cells which encroach the area of frontal recess and would need surgical removal to provide a good drainage and ventilation.

Surgical outcomes of endoscopic management of adenocarcinoma of the sinonasal cavity

To report the surgical outcomes of endoscopic resection of adenocarcinomas of the Sinonasal cavity. Retrospective chart review of patients presenting with adenocarcinoma of the anterior skull base between 1998-2008. All patients who underwent wholly endoscopic resection were included in the study. Twelve patients presented with adenocarcinoma involving the sino-nasal cavity. At diagnosis 6 patients were staged as a T2, 5 as a T3 and one as a T4. All of the patients had successful removal of the tumour entirely endoscopically. Three patients recurred: 2 locally and 1 with distant metastases. Overall, 11 patients are alive and free of disease and 1 patient dead of disease. We found an overall disease free survival rate and overall survival rate of 91.6%. The follow-up period ranged from 10 to 96 months with a median of 30 months. Endoscopic management of adenocarcinoma of the sino-nasal cavity can be a viable treatment option to craniofacial resection. With the advancement in endoscopic equipment and surgeon skill, larger tumours may be managed wholly endoscopically.

Endoscopically stapled diverticulostomy for Zenker’s diverticulum: results of a multidisciplinary team approach

A variety of open and endoscopic surgical approaches for the treatment of Zenker's diverticulum have been described. In recent years, growing evidence has shown that the endoscopic techniques are superior to the open approaches in many aspects. Among the endoscopic techniques, endoscopically stapled diverticulostomy (ESD) appears to have better efficacy and safety than the other endoscopic techniques. This study retrospectively reviewed the medical records of all the patients with Zenker's diverticulum treated surgically by the same team, which involved an ear, nose, and throat surgeon and an endoscopic surgeon. From January 2002 to March 2008, 55 consecutive patients with Zenker's diverticulum underwent 60 ESDs. The mean follow-up time was 32.6 months (range, 1-72 months). The mean operative time was 21.8 min (range, 5-45 min), and the average hospital stay was 2.24 days (range, 1-30 days). The treatment was technically feasible for 51 patients (93%), and initial symptom relief without recurrence was achieved for 46 patients (90.2%) after a single procedure. Five patients with recurrent symptoms underwent a successful revision ESD, with a 100% success rate among the patients for whom the procedure was technically feasible. Only two major postoperative complications (3.64%) occurred: one esophageal perforation and pneumomediastinum and one severe esophageal edema. Both patients had complete resolution of their complications with conservative treatment and no long-term sequela. The findings showed endoscopic stapled diverticulostomy to be both safe and effective. Compared with the historical results of open diverticulectomy and myotomy, the reported procedure has fewer complications and better outcomes and should become the procedure of choice for the treatment of most patients with a diagnosis of Zenker's diverticulum.

Feasibility of balloon dilatation in endoscopic sinus surgery simulator

Assess the feasibility of the use of a life-size model for ESS to perform balloon catheter dilatation of the paranasal sinus ostia. Four validated sinus models were enrolled in this study. One experienced endoscopic surgeon performed all the dilatations of the paranasal sinus ostia. We used the Relieva Sinus Balloon Catheter System (Acclarent, Inc, Menlo Park, CA), and its described technique for fluoroscopic guided sinuplasty. Twenty-four ostia were available. All sinuses were successfully catheterized and dilated. The total fluoroscopic time was 18 minutes and 8 seconds (mean, 45.3 seconds per sinus) and the total procedure time was 50 minutes and 56 seconds (mean, 2 minutes and 7 seconds per sinus). It was feasible to perform a successful dilatation of the 24 available sinus ostia of the models: 8 maxillary, frontal and sphenoid. No major technical difficulties were encountered. This model could help surgeons in the training of sinus ostia balloon dilatation.

Endoscopic Management of Cerebrospinal Fluid Leaks

Cerebrospinal fluid (CSF) rhinorrhea is an uncommon but important medical condition. It can result from trauma, intracranial hypertension, or be idiopathic in origin. If left untreated, significant sequelae can result including infectious meningitis. Beta-2 transferrin is a sensitive and specific protein marker for CSF. Various radiographic modalities have been used to localize defects, including computed tomography (CT), magnetic resonance imaging, and CT cisternography. In recent years, surgical management of this condition has evolved significantly, primarily being performed endoscopically. Reconstruction can be performed with fat, free mucosal, or fascial grafts, or with vascularized flaps. The endoscopic surgeon should have a thorough understanding of the pathophysiology and diagnosis of CSF rhinorrhea as well as several surgical options in his or her armamentarium available to treat the patient suffering from CSF rhinorrhea.

Comparison of complications rates in endoscopic surgery performed by a clinical assistant vs. An experienced endoscopic surgeon

Study Objectives:(a) To find out the actual incidence of complications during endoscopic surgeries. (b) Comparison of complication rate between an experienced laparoscopic surgeon (> 10 years of experience in endoscopic surgery) and a clinical assistant (> 3 years of experience in endoscopic surgery). (c) How to manage complications in endoscopic surgery. (d) Concrete suggestions to reduce the complication rate.Design:Retrospective study (Canadian Task Force classification ii-2).Setting:Tertiary gynecologic endoscopic unit.Patients:A total of 3204 cases of gynecologic endoscopic surgery out of which 2001 were laparoscopic and 1203 were hysteroscopic surgeries.Interventions:Laparoscopic and hysteroscopic gynecologic surgeries in indicated cases.Measurements and Main Results:The study was carried out between April 2003 and October 2007 at a referral center for endoscopic surgery. A total of 3204 cases of gynecologic endoscopic surgery were studied. There were five significant complications in laparoscopic surgeries and four significant complications in hysteroscopic surgeries seen in four years and six months. All the complications could be managed with no mortality. Conversion to laparotomy was needed in eight cases of laparoscopic surgeries and none in hysteroscopic surgeries.Conclusion:The risk of complication reduces with the experience in endoscopic surgery. However, the proper grooming of a novice in experienced hands, for a sufficient period of time, can minimize the complication rate in the initial learning phase. The complication may be utilized as a stepping-stone to overcome any given situation without panic, but with adequate safety.

Endoscopic Therapies for the Treatment of Reflux Disease

Endoscopic techniques for the treatment of reflux disease were first introduced in 2000 as an alternative to laparoscopic antireflux operations. Because of reports of long-term treatment failure with laparoscopic fundoplication and the fact that surgery is increasingly being reserved for the relatively small proportion of patients with complicated reflux disease, attempts to develop safe, effective, and durable endoscopic approaches to antireflux surgery continue. Techniques include radiofrequency ablation, injection therapy, and suturing/stapling techniques. Of these, the suturing/stapling techniques are most similar to the anatomic restructuring of the gastroesophageal junction provided by fundoplication. While early attempts at endoscopic suturing have been disappointing, significant advances in endoscopic instrumentation, a more complete understanding of the gastroesophageal junction anatomy, and improvements in the technical skills of the endoscopic surgeon have been realized. As a result, techniques now being tested, such as the endoluminal fundoplication, may prove more effective and durable than previous endoscopic antireflux procedures.

Thoracoscopic Repair of Tracheoesophageal Fistula and Esophageal Atresia

To evaluate the safety and efficacy of the thoracoscopic repair of esophageal atresia and tracheoesophageal fistula (EA/TEF). From August 2005 to March 2008, 23 consecutive patients (16 boys, 7 girls) weighing 1,070 to 3,390 g underwent thoracoscopic EA/TEF repair. Nine cases had associated malformations. Two 5-mm and one 2.5-mm trocars were placed. The 5-mm 25- to 30-degree telescope was preferred. A pneumothorax was maintained with 5 to 6 mm Hg. The azygos vein was never divided. The TEF was closed with 5-mm titanic clips mainly.The esophageal anastomosis was made over 6-French nasogastric tube by three to seven simple stitches of 5-0Vicryl. The 8-French chest tube was left without suction. The enteral feeding was usually started on postoperative day 3 or 4. Barium swallow was performed on postoperative day 5 or 6, then the chest tube was removed. All procedures were successfully completed without conversion. The average operative time was 131 minutes (range, 55-245 minutes) with significant improvement after gaining experience (mean, 171 minutes for first 10 cases and 98 minutes for last 13 cases). There were two cases of accidental tracheal opening. The anastomotic leak rate was 13% (three cases), and all were healed on conservative treatment. Four cases required one to three courses of anastomotic stricture dilatations. There were three deaths (13%) of causes not related with performed operation. The thoracoscopic repair of EA/TEF is effective method, and based on our experience, it is the procedure of choice if performed by an experienced endoscopic pediatric surgeon. The intraoperative complications observed if properly managed have a good prognosis.

Initial Experience with Surgical Telementoring in Pediatric Laparoscopic Surgery Using Remote Presence Technology

To evaluate the efficacy of remote presence technology in surgical mentoring. A self-propelled robot, which is controlled from a wireless remote control station (Laptop computer)and provides two-way audio and visual communication, was used to allow an experienced endoscopic surgeon to provide mentoring during three unique laparoscopic cases. This first was a laparoscopic exploration in a 9-month-old child with clinical evidence of intermittent obstruction but nondiagnostic imaging studies.The second was a 4-day-old, 3-kg infant with a congenital diaphragmatic hernia, and the third was a 1-day-old child with duodenal atresia. The robot was used to visualize the patient and radiologic studies, telestrate suggestions for trocar placement, visualize the laparoscopic procedure, and provide advice during the procedure.In the second case, another surgeon at a remote site control station watched the surgery and asked questions. The procedures were completed successfully in 90, 30, and 90 minutes. The first case included identification of the obstructing lesion (internal jejunal polyp) and intestinal resection and anastomosis. The second case involved resection of the hernia sac and repair of the congenital diaphragmatic hernia. The third consisted of identification of the site of atresia and identification of the site for the proximal and distal enterotomy. The robot allowed excellent visualization of the procedures and direct communication between the surgeon and mentor was uninterrupted throughout the case. Both surgeon and mentor felt the telementoring assisted in the case. While this is a limited series, the initial evaluation of this remote presence technology in the operating room suggests that it may be extremely usefully in adding surgical experience and expertise in minimally invasive surgery.

Basic Laparoscopic Suturing Techniques

The purpose of our video is to demonstrate basic laparoscopic suturing techniques and principles for beginning practioners. Many styles and techniques of suturing exist for laparoscopy. Our style may be an example that can be applied to a learning endoscopic surgeon's practice. We also discuss advantages and disadvantages to certain techniques developed but most importantly would like the audience to understand the basic principles of laparoscopic suturing.

Transcavum interforniceal endoscopic surgery of the third ventricle

Intraventricular anatomy has been detailed as it pertains to endoscopic surgery within the third ventricle, particularly for performing endoscopic third ventriculostomy (ETV) and endoscopic colloid cyst resection. The expanding role of endoscopic surgery warrants a careful appraisal of these techniques as they relate to frequent anatomical variants. Given the common occurrence of cavum septum pellucidum (CSP) and cavum vergae (CV), the endoscopic surgeon should be familiar with that particular anatomy especially as it pertains to surgery within the third ventricle. From a prospective database of endoscopic surgical cases were selected those cases in which the defined pathology necessitated surgery within the third ventricle and there was coexistent CSP and CV. Pertinent radiographic studies, operative notes, and archived video files were reviewed to define the relevant anatomy. Features of the intracavitary anatomy were assessed regarding their importance in approaching the third ventricle. Four cases involving endoscopic surgery within the third ventricle (2 colloid cyst resections and 2 ETVs) were identified in which the surgical objective was accomplished through a septal cavum. In each case the width of the body of the lateral ventricle was reduced and the foramen of Monro was obscured. Because of the ventricular distortion, a stereotactic transcavum route was used for approaching the third ventricle. Entry into the third ventricle was accomplished through an interforniceal fenestration immediately behind the anterior commissure. The surgical goal was met in each case without any neurological change or postoperative morbidity. During the follow-up period, there has been no recurrence of a colloid cyst and no need of a secondary cerebrospinal fluid diversionary procedure. In the presence of a CSP and CV, endoscopic navigation into the third ventricle can be problematic via a transforaminal approach. Alternatively, a transcavum interforniceal route for endoscopic surgery in the third ventricle is suggested, with the rostral lamina and the anterior commissure as important anatomical landmarks. Endoscopic third ventriculostomy and endoscopic colloid cyst resection performed via a transcavum interforniceal route in patients with a coexistent septal cavum is a feasible and safe option.

R428 – Evaluation of an Endoscope With an Ultra-wide Field of View

Problem The objective of this project is to establish if an advantage exists in using the C-View ‘trademark’ endoscope compared to a typical 0-degree Hopkins rod-lens telescope. The C-View ‘trademark’ endoscope is a novel design that provides a field of view up to ‘plus-minus’ 135-degrees about the optical axis and 360-degrees panoramically. Methods A cadaveric sheep glottis and trachea was examined using both a 4-mm Hopkins rod-lens telescope and a C-View ‘trademark’ endoscope (under development by Inter-Science, Inc., Troy, NY). At this time, the C-View ‘trademark’ endoscope prototype performs optical imaging only and does not include a means of internal illumination. Therefore, a separate external illumination source was used. Video taken during these examinations was analyzed and still images were obtained using the video editing software included with our stroboscopy tower (KayPentax Model 9295, Lincoln Park, NJ). Results The C-View ‘trademark’-based endoscope offers a sizable increase in field of view. Mucosal findings on the tracheal wall that could not be appreciated with the standard 0-degree model were readily apparent using this endoscope. Conclusion The C-View ‘trademark’ endoscope has enormous potential in the field of diagnostic endoscopy by creating a new working environment with an unmatched ultra-wide field of view. At this point, its use in living models or patients cannot be assessed without further development of the endoscope's illumination subsystem. Significance The true potential of this endoscopic system may not be fully realized until a prototype is developed which includes adequate illumination capabilities. Once perfected, this system will provide an enlarged field of view to any endoscopic surgeon or diagnostician. In the field of otolaryngology, this system has potential clinical relevance in many areas, including sinus endoscopy, laryngoscopy/tracheoscopy, esophagoscopy, and skull base surgery. Furture studies will assess manipulation of instruments in this new environment.

Surgeon's View on the Limitations of Left-Handedness During Endoscopic Surgery

The influence of endoscopic surgery on left-handedness is unclear. The aim of this study was to investigate the role of left-handedness during endoscopic surgery. A survey distributed during the 15th Congress of the Turkish Society of Surgery, held in 2006, was conducted to 194 participants. The survey was focused on hand preference and endoscopic surgery. Besides demographic data and use of endoscopy, lateral predominance, questions related to surgical performance (open and endoscopic), training support during residency, and operating room experiences during endoscopic surgery were assessed. The laterality preference in performing surgery was left in 9.3% (n = 18). Almost 50% of the left-handed surgeons believed that endoscopic surgery needs to be modified for the left-handed endoscopic surgeon, although 66% reported they had no difficulty while using endoscopic instruments and did not need any modification during surgical endoscopy. Over 86% of all surgeons reported that laterality had no importance for them if they were a patient undergoing endoscopic surgery, while 14% of surgeons refused to be operated on by a left-handed surgeon. Endoscopic surgery has impact on laterality-related comfort, and technical modifications are warranted for left-handed surgeons. Further research is needed to address questions related to hand dominance in surgical endoscopic skill performance that allows more comprehensive conclusions.

Silent sinus syndrome

Silent sinus syndrome is a clinical entity with the constellation of progressive enophthalmos and hypoglobus due to gradual collapse of the orbital floor with opacification of the maxillary sinus, in the presence of subclinical maxillary sinusitis. It occurs secondary to maxillary sinus hypoventilation due to obstruction of the ostiomeatal unit. Correction of the problem is surgical. Surgery is endoscopic with reestablishment of maxillary aeration and drainage. The orbital repair can be staged. The endoscopic surgeon must be careful of the prolapsed orbital contents in to the maxillary sinus. Silent sinus syndrome is rare and multiple findings are needed for the diagnosis. These include enophthalmos or hypoglobus in the absence of clinically evident sinonasal inflammatory disease. Treatment consists of correction of the maxillary sinus atelectasis and the orbital defects. There is evidence that a two-stage repair may eliminate the need to perform the orbital repair. Due to the lateral position of the uncinate, endoscopic maxillotomy needs to be done with care to avoid injury to the orbital contents.

Endoscopic Anatomy of the Pterygopalatine Fossa and the Transpterygoid Approach: Development of a Surgical Instruction Model

The pterygopalatine fossa (PPF) is a narrow space located between the posterior wall of the antrum and the pterygoid plates. Surgical access to the PPF is difficult because of its protected position and its complex neurovascular anatomy. Endonasal approaches using rod lens endoscopes, however, provide better visualization of this area and are associated with less morbidity than external approaches. Our aim was to develop a simple anatomical model using cadaveric specimens injected with intravascular colored silicone to demonstrate the endoscopic anatomy of the PPF. This model could be used for surgical instruction of the transpterygoid approach. We dissected six PPF in three cadaveric specimens prepared with intravascular injection of colored material using two different injection techniques. An endoscopic endonasal approach, including a wide nasoantral window and removal of the posterior antrum wall, provided access to the PPF. We produced our best anatomical model injecting colored silicone via the common carotid artery. We found that, using an endoscopic approach, a retrograde dissection of the sphenopalatine artery helped to identify the internal maxillary artery (IMA) and its branches. Neural structures were identified deeper to the vascular elements. Notable anatomical landmarks for the endoscopic surgeon are the vidian nerve and its canal that leads to the petrous portion of the internal carotid artery (ICA), and the foramen rotundum, and V2 that leads to Meckel's cave in the middle cranial fossa. These two nerves, vidian and V2, are separated by a pyramidal shaped bone and its apex marks the ICA. Our anatomical model provides the means to learn the endoscopic anatomy of the PPF and may be used for the simulation of surgical techniques. An endoscopic endonasal approach provides adequate exposure to all anatomical structures within the PPF. These structures may be used as landmarks to identify and control deeper neurovascular structures. The significance is that an anatomical model facilitates learning the surgical anatomy and the acquisition of surgical skills. A dissection superficial to the vascular structures preserves the neural elements. These nerves and their bony foramina, such as the vidian nerve and V2, are critical anatomical landmarks to identify and control the ICA at the skull base.

Teach the Teachers: An Observational Study on Mentor Traineeship in Gynecological Laparoscopic Surgery

Operative laparoscopy is a most important development in gynecological surgery, and also is a technically challenging type of surgery. In general surgery, making available an advanced endoscopic surgeon in the setting of mentor traineeship has improved the results of advanced procedures performed by residents. This study evaluated a mentor traineeship in laparoscopic surgery at a teaching hospital. Starting in 2001, an advanced endoscopic gynecologist has mentored a trainee in laparoscopic surgery. Results were reviewed for the preceding years 1997–2000 and for the training years 2001–2004. The trainee was scheduled to perform surgery 1 day a week and was mentored biweekly in the operating room. The trainee was in each instance the primary surgeon, and the mentor an assistant. The trainee has performed a significantly greater number of advanced laparoscopic procedures during mentoring. Level-1 procedures, the easiest, declined, while level-2 and level-3 procedures increased significantly. The rate of conversion to laparotomy remained stable during the entire period under review; it was 7.5% in the earlier period and 4.5% in the later years. The conversion rate declined for level-3 procedures. Complication rates did not change appreciably in the course of mentoring despite an increase in advanced cases. Operating times tended to decrease over time, but not to a significant degree. The authors believe that mentor traineeship is a most useful approach to training resident gynecologists in laparoscopic surgery without compromising patient care.

Is Training in Endoscopic Sinus Surgery Detrimental to Patient Outcome?

To identify whether training in endoscopic sinus surgery (ESS) is detrimental to patient outcome. Prospective evaluation of SinoNasal Outcome Test 22 (SNOT-22) scores for all patients undergoing ESS. Comparison between the outcome scores of patients operated on by the established endoscopic sinus surgeon with outcome scores of patient operated on by the supervised trainee. Patients operated on by the supervised trainee did not have poorer outcome scores than patients operated on by the established endoscopic surgeon. Training in endoscopic sinus surgery is not detrimental to patient outcome when assessing symptom resolution, assuming that the training is closely supervised and that the trainee complies with a structured training program.

Real-time computed tomography image update for endoscopic skull base surgery

The development of computer-aided systems for endoscopic sinus surgery has enabled surgical navigation through diseased or surgically altered sinus anatomy with increased confidence. However, conventional computer-aided systems do not provide intra-operative updated computed tomography imaging. We describe the technical aspects of the xCAT, a new intra-operative mobile volume computed tomography scanner. A patient with a malignant melanoma unwittingly removed at another hospital underwent surgery for removal of the lateral nasal wall and directed biopsies, in an attempt to identify the site of tumour origin. The procedure was performed with the GE InstaTrak 3500 Plus computer-aided system, updated with intra-operative computed tomography images. Intra-operative, updated images were integrated successfully into the InstaTrak system, and these images were consistent with the observed endoscopic anatomy. The xCAT intra-operative mobile volume computed tomography scanner is a technological advancement that can assist the endoscopic sinus surgeon when performing complex rhinological and skull base procedures.

Vidian Canal: Analysis and Relationship to the Internal Carotid Artery

The purpose of this study is to describe the anatomy and relationships of the vidian canal to known endonasal and skull base landmarks. This will allow the endoscopic skull base surgeon to safely approach the anterior genu of the petrous carotid artery during expanded endonasal approaches to the skull base. The study is a prospective cohort study. Axial, coronal, and sagittal computed tomography scans of the paranasal sinuses and skull base of 44 patients were examined. Individuals with known skull base pathology were excluded. Measurements included the length of the vidian canal, the relationship of the vidian canal to the anterior genu of the petrous carotid artery, and the type of pneumatization of the sphenoid sinus as it pertains to foramen rotundum and the vidian canal. In addition, we will focus on the relationship of the vidian canal to the sphenopalatine foramen and base of the medial pterygoid plate. The degree of pneumatization of the sphenoid sinus is highly variable. The mean length of the vidian canal is 18 mm (10-23 mm). The vidian canal is found entirely within bone in 27% to 30% of scans reviewed. The anterior genu of the petrous internal carotid artery is found superior-medial to the vidian canal in 44 of 44 of the CT scans reviewed. The vidian canal runs medial to lateral in 93% to 98% of patients studied. As a result of this study the endoscopic skull base surgeon has a number of anatomical landmarks and measurements that may be helpful in safely localizing the anterior genu of the petrous internal carotid artery during expanded endonasal approaches to the skull base.

Diagnostik und Therapie des Karpaltunnelsyndroms

Evidence-based supradisciplinary guideline that deals with the epidemiology, pathogenesis, symptoms, clinical and electrophysiological diagnosis, supplementary imaging investigations, differential diagnosis, conservative and surgical treatments, prognosis and course along with complications and revision surgery. The recommendations on investigation and treatment are based on a comprehensive literature search with critical evaluation and two consensus methods (expert group and Delphi technique) within the participating specialist societies. Besides this long version, a short version and a patient version can be viewed through the AWMF platform. The development of the guideline and the methodological foundations are documented in a method report. MAIN STATEMENTS: Apart from an accurate history and clinical neurological examination (including clinical tests), electrophysiological investigations (distal motor latency and sensory neurography) are particularly important. Radiography, MRI, high-resolution ultrasonography can be regarded as optional supplementary investigations. Among conservative treatment methods, treatment with a nocturnal splint and local infiltration of a corticosteroid preparation are effective. Oral steroids, splinting and ultrasound showed only short-term benefit. Surgical treatment is clearly superior to all other methods. Open and endoscopic procedures (when the endoscopic surgeon has sufficient experience) are equivalent. A routine epineurotomy and interfascicular neurolysis cannot be recommended. Early functional treatment postoperatively is important.