External Incision Research Articles

Endonasal Septal Perforation Repair Using an Interpositional Porcine Dermal Collagen Implant

Objectives: Describe our novel minimally invasive technique for closure of nasal septal perforations. Methods: We describe our experience in a series of patients from 2 London teaching hospitals treated using the same surgical technique. Closure of the defect was undertaken using one inferiorly based nasal floor mucosal flap and a contra-lateral superiorly based vascularized septal mucosal flap. This was achieved by a closed endonasal approach with a porcine dermal collagen sheet interpositional graft (Permacol) placed on the more concave side of the perforation. The mucosal flaps are used to cover the repair and sutured in place. Results: Septal perforations of up to 2-cm diameter were successfully repaired in greater than 90% of cases over a 36-month follow-up period. Conclusions: Our novel technique has proved effective in closure of septal perforations. Permacol is a durable graft, utilizing acellular cross-linked collagen matrix, used commonly in abdominal hernia repair. We found Permacol to be a biocompatible graft with the ability to resist dessication if there is slow re-epithelization or partial exposure, making it a robust and easy to use interpositional graft with no morbidity from graft harvesting. The use of local intranasal mucosal advancement flaps allows a minimally invasive approach without any external incisions or scars. Potential limitations are the size of the pedicled flaps for very large perforations, or the lengths of the flaps for very anterior defects. For the majority of septal perforations the authors feel this technique offers an effective minimally invasive option with low morbidity.

The Endoscopic Modified Lothrop: Lessons Learned during a 17‐Year Experience

Objectives: Participants should be able to: (1) Recognize factors contributing to failure; (2) Describe techniques required for a safe/successful surgery; (3) Implement postsurgical medical treatment enhancing long term outcome. Methods: Results with the endoscopic Modified-Lothrop were reviewed. Although the success rate is good for revision sinus surgery (90%), factors contributing to failure such as allergy, mucosal reactivity, and scar formation were investigated. The senior author’s series of 104 endoscopic modified Lothrops completed between January 1997 and October 2013 were reviewed for patency of the frontal floor drainage, mucosal condition, and symptomatology. The Lothrop procedure was first reported in 1914 using an external incision. Draft in 1991, Close in 1994, and Gross in 1995 described the endoscopic modified Lothrop. All patients selected for this procedure had failed medical treatment of nasal saline and antiseptic irrigations, topical steroids, and appropriate antibiotics. Nearly all of these patients had also failed standard endoscopic sinus procedures at least once. Results: Image guidance has improved the precision and safety of this operation. Three of the first 5 procedures performed without image guidance failed. Of the succeeding 99 procedures performed with image guidance, 96% were successful in maintaining open frontal drainage and resolving most symptoms with a prolonged follow-up (mean 42 months). Conclusions: The endoscopic modified Lothrop is a technically difficult procedure. When performed under the supervision of an experienced endoscopic surgeon with image guidance and modern endoscopic irrigated curved drills, it can be performed safely and effectively when standard endoscopic procedures fail.

Patterns of orbital disorders

This article discusses various patterns of presentations of orbital lesions. Since this article has been authored by an otolaryngologist, the entire concept has been viewed from otolaryngologist's angle. With the advent of nasal endoscope trans nasal access to orbit is becoming the order of the day. Major advantage being that external skin incision is avoided.

Observation of curative effect of open reduction internal fixation combined with external fixation of intra-articular fractures of the distal radius

Objective To investigate the clinical effect internal fixation combined with external fixator incision in the treatment of intra-articular fractures of the distal radius.Methods 80 cases of intra-articular distal radius fracture patients underwent cut internal fixation combined with external fixator in the treatment of orthopedic were chosen,postoperative rehabilitation exercises,fracture healing after the removal of the external fixator.All patients were followed up for 8 months to 12 months,an average of 9.2 months.Results 80 patients were intraarticular fractures healed,the time required was 4 to 10 months,an average of 6.3 months.In accordance with the assessment of functional systems Dienst wrist,51 cases wrist function were excellent,21 cases were good,the good rate was 90％ (72/80).There were no clinical fractures common complication after surgery.Conclusion Open internal fixation combined with external fixator treatment of intra-articular fractures of the distal radius fractures not only makes reduction of fracture and immobilization satisfaction,but also conducive to the wrist of early postoperative functional rehabilitation exercise. Key words: Radius fractures ; Wrist joint; Fracture fixation, internal; External fixators

Transconjunctival epiblepharon repair.

To document the use of a transconjunctival approach to lower eyelid epiblepharon repair. Retrospective chart review of all patients who underwent transconjunctival lower eyelid epiblepharon repair. Nine patients underwent repair via this approach. All patients experienced the resolution of their keratitis and cilia-cornea touch by a 3-month postoperative interval, and no patient developed a postoperative complication. Furthermore, no patient developed cutaneous scarring. Conventional approaches to lower eyelid epiblepharon repair have necessitated the creation of a skin and muscle flap, thus risking the development of scarring and a cosmetically unacceptable eyelid crease. This report documents the use of a transconjunctival approach for the management of this condition that avoids external incisions and provides excellent outcomes without scarring of the anterior lamella of the eyelid.

Combined Lateral Microscopic/Endoscopic Approaches to Petrous Apex Lesions

Surgical treatment of lesions involving the temporal bone, petrous apex, or internal auditory canal is usually performed using the classical microscopic approach that necessitates wide external incisions and soft tissue dissection. At present, the main application of endoscopic surgery is in the surgical treatment of middle ear cholesteatoma, but with the natural evolution of the technique, there will be an increasing number of applications in lateral skull base surgery. This study aimed to describe the pilot clinical experiences of our institution with combined microscopic/endoscopic-assisted approaches to the lateral skull base. A retrospective chart review was performed on patients undergoing an operation between July 2005 and September 2011 for lateral skull base pathology using the endoscope-assisted technique. Nine patients (7 female, 2 male; mean age = 57.4 years) were reviewed and included in the present study. In all cases, the petrous apex lesion of each patient was unilateral: 6 cases had cholesteatoma of the petrous bone; 2 cases had cholesterinic granuloma of the petrous apex; and 1 case had a low-grade chondrosarcoma of the petrous apex. Overall, after a mean follow-up of 30.7 months, no residual disease has been found in our series up to the present time in the cholesteatoma group. In the cholesterinic granuloma group, only a partial success was obtained in the patient who underwent the infracochlear approach, since the most medial part of the pathology was not accessed and still persisted at neuroradiologic examinations made postoperatively. In our case series, lateral combined microscopic/endoscopic procedures have proved to be effective in the treatment of petrous apex lesions, allowing less destructive approaches compared to exclusive microscopic procedures.

Novel endoscopic treatment of pharyngocele: Endoscopic suture pharyngoplasty

Pharyngocele or a lateral pharyngeal diverticulum (LPD) are rare lesions, which are bulgings of the pharyngeal mucosal surface through one of the weak areas of the pharynx. The external approach has been the primary surgical treatment of pharyngoceles. The purpose of this article was for us to report an endoscopic successful treatment of pharyngocele by suture pharyngoplasty. Endoscopic suture pharyngoplasty does not require an external incision and hospitalization. After 3 months of abstinence from trumpet playing, the patient is back to his musical career. Because of the minimally invasive procedure, endoscopic suture pharyngoplasty can be performed in case of symptomatic pharyngoceles with a good result.

Midfacial degloving法を用いて切除した鼻腔化膿性肉芽腫例

Pyogenic granuloma is a benign tumor that involves the skin and mucosa. It often occurs during pregnancy and the most frequent symptoms are nasal bleeding. The author encountered a case of pyogenic granuloma of the nasal cavity which was resected via the midfacial degloving approach.A 31-year-old woman, 2 months after delivery of a baby, presented with spontaneous left-sided epistaxis and swelling of the bridge of the nose that had started 1 month previously. Physical examination demonstrated a white and dark-red mass that filled her left nasal cavity. The histological findings showed pyogenic granuloma. We determined to resect the mass because it remained 2 months after delivery without spontaneous regression.We chose the midfacial degloving approach to gain access to regions of the midface without external incisions. The entire successful resection was possible with this approach, and there has not been any recurrence for 1 year postoperatively. The cosmetic results were excellent and the patient was satisfied. No significant complications were seen.The midfacial degloving technique can be considered as a valuable procedure with low morbidity and excellent cosmetic outcome. It may be a viable procedure for pyogenic granuloma of the nasal cavity.

Surgical Treatment of Nasopharyngeal Malignancies: Role of Endoscopic Endonasal Approaches

Development of endoscopic techniques has progressed onward with the recent enrichment of anatomical knowledge and experience; as well as the development of advanced technologies. Expansion of the clinical indications for endoscopic endonasal approaches has produced a paradigm shift in the surgical management of nasopharyngeal malignancies similar to that of other areas of the ventral skull base. Endoscopic endonasal nasopharyngectomy is a feasible and minimal access technique for the resection of select recurrent and radioresistant nasopharyngeal malignancies. It bestows the advantages of lack of external incisions or scars, decreased trauma to adjacent soft tissues and bone, reduced risk of neurological damage, and superior postoperative quality of life. A comprehensive review of the available literature shows that endoscopic results are better than re-irradiation or surgery via conventional open approaches. We acknowledge that these results may be influenced by a bias in patient selection. However, they suggest that, in properly selected cases, an endoscopic endonasal nasopharyngectomy affords low morbidity rates without compromising oncologic outcomes. Nonetheless, one should be fully aware of the indications and limitations of using endoscopic endonasal approach to achieve optimal outcomes. Endoscopic endonasal approaches plays a strong role in the treatment of nasopharyngeal malignancies

Transperitoneal 3D laparoendoscopic single-site (LESS) nephrectomy: the first clinical case in China

Objective To summarize our experience on the first clinical case of transperitoneal 3Dlaparoendoscopic single-site(LESS)nephrectomy in mainland China,and to assess its safety and feasibility after obtaining the informed consents. Methods On August 5,2013,we performed a 3DLESS nephrectomy using Karl Storz 3Dendoscope and a multi-channel Quad-Port(OlympusTM)through a 3cm skin incision at our institute.The patient was a 69years old man,with a body mass index(BMI)of 27.7kg/m2 and a preoperative serum creatinine level of 81μmol/L.99mTc DTPA was used to determine the glomerular filtration rate(GFR).The preoperative unilateral renal function was 65mL/min for the left side and 9.5mL/min for the right side.And therefore he was diagnosed as"right kidney severe hydrocephalus"and received right nephrectomy.A 3cm external retus incision was made at the umbilicus level at 1cm site.After dissection of the renal pedicle blood vessels the renal blood vessels,the ureterogonadal packet was left en bloc and transected at the level when crossing the common iliac vessels. The kidney was extracted through the original incision after the skin incision was extended to 4cm.Results The procedure was smoothly completed without any extra skin incision.The operating time was 154min,with an estimated blood loss of 150mL. The gastrointestinal function recovered on the first day after operation.Postoperative serum creatinine level on the first day was 76μmol/L.Donor Visual Analog Pain Scores at postoperative day 1,2and 3were 2/10,1/10and 0/10,respectively.The recovery of the patient was uneventful and he was discharged on the 3rd postoperative day.Conclusion Transperitoneal 3D laparoendoscopic single-site nephrectomy is safe,feasible and effective.It has the clinical benefits of less pain,rapid recovery and small incision.The procedure allows for a strong stereo perception,accurate manipulation,and a decreased demand for hand-eye coordination of hand,with a promising clinical future.But more clinical experience needs to be accumulated through more cases.

Anatomical and computed tomographic analysis of the transcochlear and endoscopic transclival approaches to the petroclival region

Advances in the field of skull base surgery aim to maximize anatomical exposure while minimizing patient morbidity. The petroclival region of the skull base presents numerous challenges for surgical access due to the complex anatomy. The transcochlear approach to the region provides adequate access; however, the resection involved sacrifices hearing and results in at least a grade 3 facial palsy. An endoscopic endonasal approach could potentially avoid negative patient outcomes while providing a desirable surgical window in a select patient population. Cadaveric study. Endoscopic access to the petroclival region was achieved through an endonasal approach. For comparison, a transcochlear approach to the clivus was performed. Different facets of the dissections, such as bone removal volume and exposed surface area, were computed using computed tomography analysis. The endoscopic endonasal approach provided a sufficient corridor to the petroclival region with significantly less bone removal and nearly equivalent exposure of the surgical target, thus facilitating the identification of the relevant anatomy. The lateral approach allowed for better exposure from a posterolateral direction until the inferior petrosal sinus; however, the endonasal approach avoided labyrinthine/cochlear destruction and facial nerve manipulation while providing an anteromedial viewpoint. The endonasal approach also avoided external incisions and cosmetic deficits. The endonasal approach required significant sinonasal resection. Endoscopic access to the petroclival region is a feasible approach. It potentially avoids hearing loss, facial nerve manipulation, and cosmetic damage.

Transoral Robotic Surgery in Head and Neck Cancer: What Radiologists Need to Know about the Cutting Edge

The evolution of oncologic surgical technology has moved toward reducing patient morbidity and mortality without compromising oncologic resection or oncologic outcomes. The goals in treating head and neck cancer are to cure patients, as well as to provide quality of life by improving functional and social outcomes through organ-preservation therapies, which may include surgery, chemotherapy, and/or radiation therapy. Transoral robotic surgery (TORS) is an emerging technique that provides several benefits over existing treatment regimens and over open surgery for head and neck cancer, including reductions in operative times, blood loss, intensive care unit stays, and overall duration of patient hospitalization. Transoral robotic techniques allow wide-view, high-resolution, magnified three-dimensional optics for visualization of the mucosal surfaces of the head and neck through an endoscope, while avoiding the extensive external cervical incisions often required for open surgeries. Radiologists play an important role in the successful outcome of these procedures, both before and after TORS. Determining a cancer patient's surgical candidacy for TORS requires a thorough preoperative radiologic evaluation, coupled with clinical and intraoperative assessment. Radiologists must pay particular attention to important anatomic landmarks that are clinical blind spots for surgeons. Knowledge of the expected postoperative imaging appearances, so that they can be distinguished from recurrent disease and second primary tumors, is essential for all radiologists involved in the care of these patients.

A Modified Lacrimal Sac Implant for High-Risk Dacryocystorhinostomy

The reported 5% of patients with nasolacrimal duct obstruction who fail dacryocystorhinostomy likely include patients with severe mucosal disease or anatomical anomalies. The technique described herein avoids mucosal anastomosis and minimizes mucosal manipulation by inserting a permanent silicone conduit from the lacrimal sac into the nasal cavity. This retrospective review of 9 surgical cases was performed with institutional review board approval. Six patients underwent 9 surgeries (3 sequentially bilateral) for dacryocystitis. Two patients had Wegener granulomatosis, 1 had pemphigoid, 1 sarcoidosis, 1 Rosai-Dorfman disease, and 1 congenital choanal atresia with chronic neonatal dacryocystitis. In each case, a modified Rains sinus stent was inserted through an external lacrimal sac incision with the draining end positioned in the nasal cavity. Two patients underwent concurrent canalicular intubation with Guibor silicone stents to prevent internal punctum obstruction by the lacrimal sac implant. Recurrence of symptoms, patient comfort, and modified Rains stent stability and patency were evaluated. Mean follow up was 30 months (range 7-59 months). The modified Rains stent remained stable and patent in 7 of 9 cases, and symptoms resolved in 8 of 9 cases. In 1 patient with sarcoidosis, the modified Rains stent became repeatedly obstructed with nasal secretions and ultimately dislodged after intranasal manipulation by a physician unfamiliar with the surgery. In no other case did the patient experience recurrent infection, and in those cases, epiphora resolved entirely. In the patient with pemphigoid, one of the modified Rains stents extruded 6 months postoperatively, but his symptoms remained controlled. No adverse reaction to the implant material was seen. A Rains silicone frontal sinus stent can be modified for implantation into the lacrimal sac and can safely and effectively drain the lacrimal sac into the nose in patients with severe mucosal disease or anatomical anomalies. Additional study and a stent specifically designed for this application will likely improve outcomes.

Simplified Transoral Load-Bearing Osteosynthesis with Preformed Mandible Reconstruction Plates

Transcutaneous submandibular approaches are the preferred technique for the application of load-bearing mandibular osteosynthesis plates. However, an extraoral approach is associated with several shortcomings, like the risk of harming the facial nerve and scarring. This technical note presents a specialized mandibular reconstruction plate (MatrixMANDIBLE Preformed Reconstruction Plate [Synthes Maxillofacial, Paoli, PA]), simplifying the transoral application by its design with a preformed curvature along the lateral surface of the mandible. The application of wide-spanning plates reaching from the posterior margin of the ramus even into the contralateral body region is facilitated. Transoral application of preformed mandibular reconstruction plates seems to be a promising option to bypass external incisions and to reduce operating room time.

The Long-Term Follow-Up Results of External Dacryocystorhinostomy Skin Incision Scar with “W Incision”

Objective: To determine the effect of “W incision” instead of classical vertical incision at external DCR on scar formation.Materials and Methods: Patients with acquired nasolacrimal duct obstruction (NLDO) who were treated with external DCR with classical vertical incision, and patients who were treated with external DCR with “W incision” were included in the study. The first 39 eyes were operated with a vertical incision, and the remaining 37 eyes were operated with a “W incision”. All the skin incision scars of the patients were assessed and scored by at least the 6th month. The assessment was made by both the patients themselves, and by an ophthalmologist other than the surgeon himself, each scored the incision scar separately (single-masked study). Scores for both groups were compared, and statistical analyses were performed.Results: Self-assessment scores for the incision scar were Grade 2.28 ± 0.94 in the Vertical incision group, and Grade 1.68 ± 0.57 in the “W incision” group (p < 0.01). The “W incision” scar formation was significantly less noticable than the Vertical incision scar formation. Similarly, the assessment scores of the ophthalmologist other than the surgeon himself were significantly lower for the “W incision” group than for the Vertical incision group. The mean scar assessment scores were Grade 2.13 ± 0.95 in the Vertical incision group, and Grade 1.57 ± 0.68 in the “W incision” group (p < 0.01).Conclusion: Skin scar tissue was found to be significantly reduced with a “W incision” in external DCR operations.

Endoscope-Assisted Intraoral Removal of the Thyroid Isthmus Mass Using a Frenotomy Incision

A thyroid isthmus nodule is a relatively rare condition. A small number of patients will present with thyroid mass isolated at the thyroid isthmus, which can cause discomfort in swallowing and cosmetic problems. Thus, some patients choose to have these nodules excised. The surgical removal of the thyroid isthmus mass is usually accomplished through an external incision of the neck. However, this procedure inevitably results in a neck scar. We report a case of an 18-year-old woman with a thyroid isthmus mass. We implemented a modified approach for the removal of the thyroid isthmus mass by using a frenotomy incision of the mouth, accompanied by an endoscope system. A modified approach for the removal of the thyroid isthmus mass was used on the patient. The total operating time was 70 minutes. The patient continues to be free of any diseases 12 months after the excision. Resection of the thyroid isthmus mass can be performed by an intraoral endoscope-assisted approach through a frenotomy incision of the mouth. We described the detailed procedures for an endoscope-assisted transoral thyroid isthmus mass excision using a frenotomy incision.

Alar-Spanning Suture for Tip Contouring in Closed Approach Rhinoplasty for African-Caucasian Noses

The alar-spanning suture is one of the easiest techniques for correcting the width of the alar complex that reduces the bulbous tip of African-Caucasian patients. This conservative technique does not weaken the lateral crura and yields long- term predictable results. Rhinoplastic surgeons should keep in mind this useful and reliable tool in their options for refinement of these challenging wide tips and not create so dramatic a change that the appearance is not consonant with the patient's ethnic heritage. Despite cosmetic surgeons usually performing it through an external columellar incision approach, it is possible, in many cases, to do it in a closed access, and thus avoid the risk of hyperpigmentation or hypertrophic scarring.

Endoscopic transmaxillary transMüller's muscle approach for decompression of superior orbital fissure: A cadaveric study with illustrative case

BackgroundIn an effort to avoid the damage and inconvenience associated with transcranial approaches, we developed an endoscopic transmaxillary transMüller's muscle approach for decompression of the superior orbital fissure (SOF). MethodsThe endoscopic transmaxillary transMüller's muscle route was performed in ten cadaveric heads. We measured important anatomic landmarks, and angles radiographically. This approach was initially attempted in one patient with traumatic superior orbital fissure syndrome (tSOFS). ResultsA maxillary antrostomy was carried out with a buccal sulcus incision. The sinus ostium and the course of infraorbital nerve were used as endoscopic anatomic landmarks. Then the inferior orbital fissure was drilled out, followed by separating the Müller's muscle. The periorbita were peeled off from the lateral wall, followed by the endoscope going along the periorbital space, until the lateral aspect of the SOF could be visualized. Decompression was successfully performed in all specimens. The initial clinical application justified this approach. The patient had an uneventful postoperative course and satisfactory recovery. ConclusionThis approach offers sufficient endoscopic visualization and reliable decompression of SOF. It avoids the need for brain retraction, temporalis muscle manipulation, or any external incision, and appears to be able to deliver satisfying aesthetic results as well as favourable functional recovery.

Endoscope-Assisted Intraoral Removal of Ectopic Thyroid Tissue Using a Frenotomy Incision

Ectopic thyroid tissue is a relatively rare condition and a developmental anomaly characterized by the aggregation of thyroid tissue. Usually, it occurs along the path of descent of the developing thyroid primordium from the foramen caecum, the most common being in the anterior midline of the neck at or below the level of the hyoid bone. Surgical removal of ectopic thyroid tissue is usually accomplished through an external incision in the neck. However, this procedure inevitably results in a neck scar. We report the case of a 30-year-old woman with ectopic thyroid tissue. We implemented a modified approach to ectopic thyroid tissue removal through a frenotomy incision of the mouth using an endoscope system. A modified approach to ectopic thyroid tissue removal was used in this patient. The total operative time was 50 minutes, and the patient remains free of disease 15 months after excision. Resection of ectopic thyroid tissue can be performed by a transoral endoscope-assisted approach through a frenotomy incision of the mouth.

Robotic control of a traditional flexible endoscope for therapy.

In therapeutic flexible endoscopy a team of physician and assistant(s) is required to control all independent translations and rotations of the flexible endoscope and its instruments. As a consequence the physician lacks valuable force feedback information on tissue interaction, communication errors easily occur, and procedures are not cost-effective. Current tools are not suitable for performing therapeutic procedures in an intuitive and user-friendly way by one person. A shift from more invasive surgical procedures that require external incisions to endoluminal procedures that use the natural body openings could be expected if enabling techniques were available. This paper describes the design and evaluation of a robotic system which interacts with traditional flexible endoscopes to perform therapeutic procedures that require advanced maneuverability. The physician uses one multi-degree-of-freedom input device to control camera steering as well as shaft manipulation of the motorized flexible endoscope, while the other hand is able to manipulate instruments. We identified critical use aspects that need to be addressed in the robotic setup. A proof-of-principle setup was built and evaluated to judge the usability of our system. Results show that robotic endoscope control increases efficiency and satisfaction. Participants valued its intuitiveness, its accuracy, the feeling of being in control, and its single-person setup. Future work will concentrate on the design of a system that is fully functional and takes safety, cleanability, and easy positioning close to the patient into account.