Mini-invasive Procedure Research Articles

Single-port or Classic Laparoscopy Compared With Laparotomy to Assess the Peritoneal Cancer Index in Primary Advanced Epithelial Ovarian Cancer

A thorough laparoscopic assessment of the abdominopelvic cavity is a crucial step in the workup of primary advanced epithelial ovarian cancer to decide whether up-front cytoreductive surgery or neoadjuvant chemotherapy is the best option for adequate management. The purpose of our study was to compare single-port laparoscopy (SPL), classic laparoscopy (CL), and laparotomy using the peritoneal cancer index (PCI). Patients treated for Fédération Internationale de Gynécologie et d'Obstétrique stage 3 or 4 epithelial ovarian cancer were included in our study when they underwent a PCI evaluation by laparoscopy followed by laparotomy for cytoreduction. According to the technique used for the “noninvasive” procedure (SPL vs CL), 2 groups were compared retrospectively. The individual records of all patients were reviewed and analyzed. From 2011 to 2014, 21 patients were assessed for PCI by SPL plus laparotomy versus 21 by CL plus laparotomy. The clinicopathological features were similar in both groups (not significant [NS]), except for performance status >0, which was more frequent in the SPL group (39% vs 6%, p = .04). Quotation of PCI was possible for all patients. Nonbrowsing areas marked 3 procedures in the SPL group and 2 procedures in the CL group (NS). The mean PCI score and the score of each region assessed by SPL and CL were comparable with the evaluation by laparotomy (NS). Completeness of cytoreduction was achieved in 78% of cases in both groups (NS). SPL and widely mini-invasive procedures seem to be effective tools compared with laparotomy to adequately assess the resectability of a peritoneal carcinomatosis using the PCI.

Application of intravascular interventional embolization in emergency treatment of hemodynamically unstable pelvic fracture

Objective To evaluate the value of intravascular interventional embolization in the emergency treatment of patients with hemodynamically unstable pelvic fracture. Methods The retrospective analysis was made on the medical records of 45 cases treated from October 2012 to December 2014. There were 27 male and 18 females(39.2±10.3) years (range, 28-54 years). Time from injury to admission was within 3 h. Injury severity score (ISS) was (25.3±8.1)points. The pelvic fracture included 32 cases of Type B and 13 Type C according to Tile classification system. After admission, anti-shock treatment and pelvic immobilization with the belt or external fixator were performed, and emergent intravascular interventional embolization was used to stanch bleeding after the bleeding of other organs was excluded. Vascular intervention, post-treatment vitazl signs and prognosis were evaluated. Results Time from admission to interventional therapy was 1.2-2.7 h[(1.9±0.8)h]. Time of interventional treatment was 1.6-3.2 h [(2.3±0.6)h]. Of the 45 cases, contrast extravasation was seen in 38 cases, abnormal vascular morphology in 5 cases, no obvious bleeding in 1 case, and contrast extravasation in the angiographic venous phase in 1 case. Among the 38 cases of contrast extravasation, the offending vessels involved were internal pudenda artery (26 cases), obturator artery (16 cases), superior gluteal artery (4 cases), inferior gluteal artery (4 cases), inferior epigastric artery (1 case) and external iliac artery (1 case), but 8 cases were noted to have two offending vessels and 1 case had delayed bleeding. Of the 45 cases, the hemostatic effect was good in the early stage. After the interventional embolization therapy, the heart rate was (105.2±14.8) beats/min, arterial pressure was (79.0±10.6)mmHg, central venous pressure was (5.1±0.8)cmH2O, and shock index was 1.1±0.5, showing improved vital signs postoperatively (P<0.05). Four cases died mainly due to the multiple organ failure. One case had abdominal distention aggravated 3 days after operation, which were confirmed to be bleeding in the branch of external iliac artery, and the symptom was alleviated after embolization therapy. Forty-one cases survived with ICU length of stay of (14.5±5.4) d, hospitalization time of (35.2±12.8) d and medical expense of (96, 755.3±20, 568.1) CNY. Conclusion In the emergency treatment of patients with hemodynamically unstable pelvic fracture, the intravascular interventional embolization has become an important measure of comprehensive treatment that allows fast and mini-invasive procedure hemostasis, and deserves clinical promoting. Key words: Hemodynamics; Pelvis; Fractures; Embolization, therapeutic

Hip Arthroscopy and Heterotopic Ossification: Is NSAID Prophylaxis Justified? Commentary on an article by James T. Beckmann, MD, MS, et al.: "Effect of Naproxen Prophylaxis on Heterotopic Ossification Following Hip Arthroscopy: A Double-Blind Randomized Placebo-Controlled Trial".

Heterotopic ossification (HO) is a process in which unwanted and potentially disabling bone tissue forms in abnormal locations such as muscles, musculotendinous junctions, and joint capsules. It may occur after trauma and after surgery. It is well known around the elbow and hip following fracture surgery and total hip replacement. The number of hip arthroscopies performed has increased exponentially over the last decade, and HO has become well recognized following this mini-invasive procedure. Although not as commonly experienced as a clinical problem, it is frequently demonstrated on postoperative radiographs. It is therefore of interest to investigate whether this abnormal bone formation can be reduced in a controlled study. Nonsteroidal antiinflammatory drugs (NSAIDs) have been used to prevent HO for years in other settings and are also commonly used following hip arthroscopy. However, NSAIDs may also cause serious complications, and knowledge about the effect and risk in each specific indication is important. The article by Beckmann et al. addressed this problem in a well-conducted double-blind randomized controlled trial (RCT) in which three weeks of treatment with 500 mg of naproxen twice daily was compared with a placebo. They found a remarkable difference between the NSAID group and the placebo group with regard to radiographic findings of HO (documented in 4% and 46% of the patients, respectively). Medication compliance was 69% overall, and minor adverse events were reported in 42% in the treatment group and 35% in the control group. Only one patient developed symptomatic HO that required revision surgery. Unfortunately, few RCTs have been performed in orthopaedics, including the quickly evolving field of hip arthroscopy. New techniques have been developed and implemented without full knowledge of the benefit for the patients and how to select the right treatment for the right patient. In a PubMed search for “hip arthroscopy,” 801 studies were found, but when the search was limited to RCTs there were eight (and all were not actually RCTs). However, there is promising research under way: RCTs on the general efficacy of hip arthroscopy are ongoing. The study by Beckmann et al. is an important and welcomed contribution to this so far limited number of Level-I hip arthroscopy studies. NSAIDsmay affect tissue healing. Healing of soft tissue (such as a tendon) to bone has been shown to be impaired byNSAIDs in experimental studies. A negative effect of NSAIDs on the healing of the sutured labrum or capsule in hip arthroscopy may therefore be an issue. NSAIDs have potential serious side effects, and although Beckmann et al. did not report serious or fatal complications in their study of 108 patients, they may occur sooner or later in a larger patient population. Clinically relevant HO is uncommon, and this has to be weighed against the risk of serious side effects caused by NSAIDs. Another question is whether the HO is a temporary phenomenon. A follow-up study of this patient cohort would be of great interest to see to what extent the HO develops further, is reduced, or disappears. This well-performed double-blind RCT documents that NSAIDs can reduce the frequency of radiographic evidence of HO following hip arthroscopy to a minimum. However, the clinical benefit and potential harm of routine NSAID prophylaxis are still unknown. As the authors point out, the lowest dose and shortest duration of NSAID prophylaxis that still prevent HO remain to be determined. This important study raises new questions, and there are many possible directions for further research in this field. Sverre Loken, MD, PhD* Oslo University Hospital, Oslo, Norway

Detection of recurrent nerve paralysis: Development of a Computer Aided Diagnosis system

Recurrent nerve paralysis (RP) is one of the most frequent complications of thyroid surgery. It reduces vocal fold mobility. Nasal endoscopy, a mini-invasive procedure, is the reference procedure to detect RP, and is based on the examination of vocal fold mobility. A new approach based on laryngeal ultrasound acquisition and using a dedicated data analysis was designed to help with the automated detection of RP.One hundred and fifty subjects were enrolled for this feasibility study: 50 controls, 50 patients with RP and 50 patients without RP, according to nasal endoscopy. The ultrasound protocol was based on a ten-second B-mode acquisition in an axial plane during normal breathing. Image processing included three steps: 1) the detection of two consecutive closing and opening images corresponding to extreme positions of vocal folds in the sequence of B-mode images; 2) the positioning of three landmarks and the robust tracking of these points using multi-pyramidal refined optical flow approaches; 3) the estimation of quantitative parameters indicating left and right fractions of mobility and motion symmetry.Results provided by the first two image processing steps were compared to those obtained by an expert. Motion symmetry and fraction of mobility indices were systematically computed using the automated procedures. Associated sensitivity and specificity values for detecting RP were then calculated. To optimize the performances of the system, a mixed CAD system, which integrates the automatic steps of image processing and a possible correction of its results by a trained operator, was developed.Laryngeal ultrasound combined with appropriate image processing helped in the diagnosis of recurrent nerve paralysis and could be proposed as a first-line method.

Combined laparoscopic pyelolithotomy and endoscopic pyelolithotripsy for staghorn calculi: long-term follow-up results from a case series.

Staghorn renal stones are a challenging field in urology. Due to their high recurrence rates, particularly those associated with an infective process, a complete removal is the ultimate goal in their management. We report our experience with a combined approach of laparoscopic pyelolithotomy and endoscopic pyelolithotripsy, the stone clearance rate, and long-term, follow-up outcomes. From June 2012 to October 2014, nine adult patients with large staghorn renal calculi (mean size, 7.2 cm; range, 6.2-9.0 cm) underwent a combined laparoscopic and endoscopic approach. The technique comprised laparoscopic pyelolithotomy and holmium-YAG laser stone fragmentation with the use of a flexible cystoscope introduced through a 12 mm trocar. The average operative time was 140 min (range, 90-190 min). The mean estimated hemoglobin loss was 0.6 mmol/l (range 0.5-0.7 mmol/l). None of the patients required an open- surgery conversion. The mean hospital stay was 4 days (range, 2-6 days). A computed tomography urogram control at 6 months of follow up did not show any stone recurrence. Laparoscopic pyelolithotomy combined with endoscopic pyelolithotripsy could be a therapeutic option in cases where mini-invasive procedures, that is, extracorporeal shock wave lithotripsy, ureteroscopic lithotripsy, and percutaneous nephrolithotomy (PCNL) have failed. This technique has a high stone-clearance rate (75-100%) comparable with open surgery and PCNL. However, it could be technically demanding and should be performed by skilled laparoscopy surgeons.

Multimodality fusion imaging in abdominal and pelvic malignancies: current applications and future perspectives.

Medicine is evolving toward personalized care and this development entails the integration, amalgamation, and synchronized analysis of data from multiple sources. Multimodality fusion imaging refers to the simultaneous visualization of spatially aligned and juxtaposed medical images obtained by two or more image modalities. PET/MRI scanners and MMFI platforms are able to improve the diagnostic workflow in oncologic patients and provide exquisite images that aid physicians in the molecular profiling and characterization of tissues. Advanced navigation platforms involving real-time ultrasound are promising tools for guiding personalized and tailored mini-invasive interventional procedures on technically challenging targets. The main objective of the present essay was to describe the current applications and future perspectives of multimodality fusion imaging for both diagnostic and interventional purposes in the field of abdominal and pelvic malignancies. We also outlined the technical differences between fusion imaging achieved by means of simultaneous bimodal acquisition (i.e., integrated PET/MRI scanners), retrospective co-registration, and multimodality fusion imaging involving ultrafast or real-time imaging modalities.

Ultrasound Guidance in Paravertebral Injections of Oxygen-Ozone: Treatment of Low Back Pain

Background: Paravertebral injection of ozone is an established clinical practice for the treatment of Low Back Pain (LBP). The role of Ultrasound Guidance (USG) in mini invasive procedures has become important in many clinical practice thanks to the greater precision this technique can add. As matter of fact, a large volume of ozone in a single administration may have some adverse or side effects. In this study we wanted to verify if the use of USG in Oxygen/ Ozone (O2/O3) infiltrations could allow the administration of a smaller volume of gas mixture, increasing the safety and the comfort of the procedure itself, obtaining however similar or better results in pain decrease. Methods: We compared two groups of 25 patients affected by LBP, undergoing 10 infiltrations of O2/O3, by using USG (group U) or only anatomical landmarks (group AL). Pain intensity, by calculating Visual Analogical Scale (VAS) difference before and after the treatment, and the discomfort were evaluated in both groups. Results: The mean of the VAS before the treatment was 6.44 in group U and 6.48 in group AL. The mean of the VAS after the treatment was 2.22 in group U and 3.04 in group AL. The mean of discomfort rate was 2.84 in group U and 5.44 in group AL. The number of patients with unbearable discomfort was 0 in group U and 7 in group AL. Conclusions: As many other treatment, also paravertebral injections of O2/O3 benefits of the advantages of the US device which makes this treatment safer and more accurate.

A mini-invasive procedure for treating arthrofibrosis of the knee

A mini-invasive procedure for treating arthrofibrosis of the knee

Robotic System for Imagery-Guided Surgery [Industrial Activities

The radiology and surgery worlds need to merge for operations guided by imagery, such as mini-invasive procedures (stenting, valve implants, and so on). Consequently, the current trend is the hybridization of radiology and surgery rooms. These rooms are said to be hybrid when the operating room combines the features of a conventional cardiac surgery operating room with those of a radiology room, thereby linking medical imaging and surgery.

HF ultrasound vs PET-CT and telethermography in the diagnosis of In-transit metastases from melanoma: a prospective study and review of the literature.

BackgroundOver the past several years the incidence of cutaneous melanoma has rapidly increased. This tumor develops often in-transit metastases that significantly reduce patient survival at 5 years. To improve prognosis and quality of life in patients with melanoma metastases, a mini invasive procedure like electrochemotherapy (ECT) is adopted to remove superficial tissue lesions. To detect the melanoma metastases, high frequency (HF) ultrasound (US) is used. This technique, though, can be time-consuming and it needs an expert operator and a high performing machine. Therefore, we asked whether the US could be replaced or integrated with other less time-consuming techniques such as 18-FDG positron emission tomography/computed tomography (PET-CT) and telethermography (TT).MethodsFifteen patients (4 males and 11 females - age range: 63–91) affected whit advanced stage melanoma were enrolled. They presented 52 in-transit metastases as detected by the three techniques used, HF-US, PET/CT and TT within 30 days before ECT.ResultsAll the 52 lesions were detected by HF-US (100%), 24/52 were detected by PET-CT (42,6%) and 15/52 were detected by TT (27,7%). PET-CT reported 3.7% false positives, while no false positive were reported by TT.ConclusionsAs US detected 100% lesions, compared to the other two techniques used, US, along with clinical examination, has still to be considered as gold standard in the diagnosis of metastatic lesions. US, associated with an exhaustive anamnesis and accurate clinical examination, cannot be replaced by either PET-CT or TT. When US performing devices and experienced operators are not available, though, it is highly recommended to integrate US with at least one of the other techniques. Under certain circumstances, as in the case of obese and non-collaborating patients or in patients with lymphatic stasis, these techniques should be integrated to obtain exact in-transit metastases evaluation.

Imaging visceral adhesion to polymeric mesh using pneumoperitoneal-MRI in an experimental rat model.

Intraperitoneal mesh implantation is often associated with formation of adhesion to the mesh. This experimental study examines the potential of minimally invasive pneumoperitoneal-MRI to assess these adhesions in a preclinical context. Uncoated polyethylene terephthalate meshes were placed intraperitoneally in rats, in regard to the caecum previously scraped to promote petechial bleeding and subsequent adhesions. Examinations were performed 2-weeks post mesh implantation using a rodent dedicated high field MRI. Respiratory-triggered T2-weighted images were acquired prior to and after intraperitoneal injection of ~8-10 mL gas to induce a mechanical stress on the abdominal wall. Adhesions are occasionally seen in sham-operated rats as opposed to rats receiving polyethylene terephthalate meshes. On high-resolution images, meshes can be detected due to their characteristic net shape. However, evidence of adherence is only found if intraperitoneal gas injection is performed, when a ~1-cm elevation of the abdominal wall is observed. When adherence occurs between the mesh and the caecum, the latter remains in contact with the wall. Looser adherences between visceral tissue and meshes are also observed. T2-weighted pneumoperitoneal-MRI is a powerful tool for assessing adherence after intraperitoneal mesh implantation. According to the mini-invasive procedure adopted here, this approach may allow a temporal follow-up of adherence fate.

Sialendoscopy - a diagnostic and therapeutic approach subjectively rated by patients.

IntroductionSialendoscopy is a miniinvasive procedure which shows the excretory ducts of the salivary glands.AimTo evaluate patient satisfaction with sialendoscopy in submandibular and parotid gland sialolithiasis.Material and methodsThe study group included 100 consecutive patients with sialolithiasis, treated by means of sialendoscopy. The analysis was designed prospectively. The patients answered closed questions of our own, in-house made questionnaire.ResultsThe number of sialendoscopic procedures necessary for symptom resolution ranged from 1 to 3. The mean value was 1.2 and the median was 1. In 64 patients (64%) one procedure was sufficient for symptom resolution, while 10 (10%) and 8 (8%) patients required 2 and even 3 procedures, respectively. Sixty-three patients (63%) did not report any postoperative complications; 33 patients (33%) reported transient swelling of the submandibular region and 4 patients (4%) reported inflammation of the salivary gland. The level of treatment efficacy was 82%. Among 53 patients treated using sialendoscopy for the first time 92.3% rated this approach subjectively as a very good or good technique, whereas among 47 patients who had previously undergone non-endoscopic treatment, this percentage increased to 96.4%. The general level of satisfaction with the applied method did not depend on the age, gender, duration of ailments, the number of previously performed procedures or the number of sialendoscopic procedures necessary to obtain improvement and postoperative complications.ConclusionsSialendoscopy may be performed practically in any case without risking the patient's discomfort or unpleasant experience. Assessment of sialendoscopy by the patients confirmed the minimally invasive character of this technique.

Insertion and management of peripheral intravenous cannula in the adult medical wards of Universiti Kebangsaan Malaysia Medical Center: a best practice implementation project

Executive Summary Background Peripheral intravenous cannulation is a common invasive procedure done in hospitals. Although a minor invasive procedure, it has the potential to introduce infection into the local tissue at site of cannulation or directly into the blood stream. Objectives The aim of this project was to implement international best evidence in the insertion and management of peripheral intravenous cannula of adult patients in the medical wards at Universiti Kebangsaan Malaysia Medical Centre. Methods A prospective audit based on best-practice evidence was used to determine the existing practices of Registered Nurses in the insertion and management of peripheral intravenous cannula in the adult medical wards at Universiti Kebangsaan Malaysia Medical Centre. A total of 66 inpatients with peripheral intravenous cannula inserted for the first time were surveyed. Following the baseline audit issues were identified by the project team and interventions in the form of education, and creating awareness of existing local and international evidence-based guidelines were undertaken. Results There was improvement following the short training workshop and discussion of the national evidence-based guidelines. Compliance of 85% and more was achieved in seven criteria. However, key criteria critical to reducing infection still require improvement. Conclusions The findings show that education in the insertion and management of the peripheral intravenous cannula improves patient care. Further investment in training and certification of nurses to undertake cannulation may result in further improvements.

Is it necessary to remove the whole trapezium in thumb osteoarthritis

Carpometacarpal (CMC) arthritis of the thumb is a common condition seen in GP consultation. This disease can cause significant disability and affected patients often need a surgical intervention. Up to recently, surgical treatment included the resection of the whole trapezium in different possible modifications. In this article, we review mini-invasive procedures for treatment of thumb carpometacarpal joint arthritis.

The use of double balloon enteroscopy for diagnosis and treatment of strictures of hepaticojejunal anastomoses after primary correction of bile duct injuries.

IntroductionDevelopment of strictures of hepaticojejunal anastomoses (HJA) is observed in 6–30% of patients and mortality after repeated reconstructive interventions ranges from 13% to 25%. Double balloon enteroscopy (DBE) allows one to visualize the zone of Roux-en-Y anastomosis after reconstructive operations on the bile ducts for differentiation between stricture of HJA and recurrent cholangitis.AimReport on the first experience of DBE of jejunal loop studies after reconstructive operations on the biliary tract.Material and methodsDuring the period 2002–2012 we performed in our centre 86 hepaticojejunostomies after iatrogenic bile duct injuries. Mean age was 51 ±6 years. Patients with Roux-en-Y HJA and jejunum loop with Braun's bypass anastomosis who underwent DBE with endoscopic retrograde cholangiography (DBE-RChG) in our unit between February 2009 and December 2012 were enrolled in this study. A total of 33 procedures were performed during this period. All of them involved examination of HJA through a jejunum loop by DBE with capture of bile for bacteriology, Roux loop wall for biopsy and miniinvasive procedures.ResultsThe DBE-RChG after visualization of the HJA zone was performed in 21 cases: 3 of them had the jejunum loop to Braun's bypass, 18 – HJA on the Roux loop. In 13 cases stricture of HJA was confirmed: at 6 reoperations were performed, in 7 – miniinvasive procedures (3 – laser vaporizations, 2 – stone extraction, 1 – lithotripsy, 1 – at the first stage stone extraction was carried out, then laser vaporization). The DBE-RChG was performed in 13 (61.9%) patients. The overall diagnostic success with Braun's bypass was 100%, after Roux-en-Y reconstruction in 10 of 13 cases (55.6%). In connection with accumulation of experience, in 2012 diagnostic success in DBE-RChG of HJA on Roux loop increased to 81.3%.ConclusionsThe MRI-ChG in our series frequently (10.3%) shows a false-positive result in favor of HJA strictures. The DBE examination of HJA with additional cholangiography is a modern and precise method of detection of HJA strictures. Their DBE-balloon dilation and argon-laser vaporization or DBE lithoextraction are new ways of miniinvasive treatment.

Clinical study of gasless abdominal-wall lifting laparoscopic myomectomy with 5 mm laparoscope

To explore the feasibility, advantages and clinical value of gasless abdominal-wall lifting laparoscopic myomectomy with 5 mm laparoscope and 2 abdominal holes (1.5-hole-gasless-laparoscopic myomectomy). A total of 90 cases of uterine fibroids were randomly divided into 2 groups. Lifting gasless group (n = 46) underwent gasless abdominal-wall lifting laparoscopic myomectomy with 5 mm laparoscope and 2 abdominal holes, and pneumoperitoneum group (n = 44) pneumoperitoneum laparoscopic myomectomy. The operative duration, blood loss volume, average time of single-myoma-removal, intestinal function recovery and hospital stay of both groups were compared. The operative duration, blood loss volume and average time of single-myoma-removal of lifting gasless group were respectively significantly less than those of pneumoperitoneum group (P < 0.01) . The postoperative intestinal function recovery and postoperative hospital stay had no significant difference between two groups (P > 0.05). Three cases of pneumoperitoneum group were converted successfully into myomectomy with traditional 3-hole gasless abdominal wall lifting laparoscopy because of large fibroids in uterine isthmus. A total of 12 newly discovered myomas, not pre-detected ultrasonically, were removed in 10 cases of lifting gasless group. 1.5-hole-gasless-laparoscopic myomectomy, like traditional gasless laparoscopy, may avoid the complications of laparoscopic CO2 pneumoperitoneum. The smaller laparoscope-hole and sole operating hole make this maneuver a safe, easy and mini-invasive procedure. It is more suitable for clinical application and popularity in primary care.

HF ultrasound vs PET-CT and telethermography in the diagnosis of In-transit metastases from melanoma: a prospective study and review of the literature

Over the past several years the incidence of cutaneous melanoma has rapidly increased. This tumor develops often in-transit metastases that significantly reduce patient survival at 5 years. To improve prognosis and quality of life in patients with melanoma metastases, a mini invasive procedure like electrochemotherapy (ECT) is adopted to remove superficial tissue lesions. To detect the melanoma metastases, high frequency (HF) ultrasound (US) is used. This technique, though, can be time-consuming and it needs an expert operator and a high performing machine. Therefore, we asked whether the US could be replaced or integrated with other less time-consuming techniques such as 18-FDG positron emission tomography/computed tomography (PET-CT) and telethermography (TT). Fifteen patients (4 males and 11 females - age range: 63–91) affected whit advanced stage melanoma were enrolled. They presented 52 in-transit metastases as detected by the three techniques used, HF-US, PET/CT and TT within 30 days before ECT. All the 52 lesions were detected by HF-US (100%), 24/52 were detected by PET-CT (42,6%) and 15/52 were detected by TT (27,7%). PET-CT reported 3.7% false positives, while no false positive were reported by TT. As US detected 100% lesions, compared to the other two techniques used, US, along with clinical examination, has still to be considered as gold standard in the diagnosis of metastatic lesions. US, associated with an exhaustive anamnesis and accurate clinical examination, cannot be replaced by either PET-CT or TT. When US performing devices and experienced operators are not available, though, it is highly recommended to integrate US with at least one of the other techniques. Under certain circumstances, as in the case of obese and non-collaborating patients or in patients with lymphatic stasis, these techniques should be integrated to obtain exact in-transit metastases evaluation.

Mini-invasive tension-free surgery for female urinary incontinence

The Authors describe the techniques they perform of prepubic, retropubic and transobturator mini-invasive anti-incontinence surgical procedures and point-out some technical details. The state of art and the results of these three main surgical procedure are compared and discussed. Data from the Literature have been reviewed in order to evaluate the efficacy of the techniques. A Medline search has been performed, and 65 relevant articles from 1996 to 2012 were selected. Literature showed similar cure rates among retropubic (71,4-91%), trans-oburator (77,3-95%) and prepubic (81-87,2%) anti-incontinence procedures. Cystoscopy was considered necessary in the retropubic, optional in transobturator and in the prepubic techniques. Intra-operative cough stress test was believed useful only in the retropubic and prepubic procedures. Obstruction symptoms prevailed in the retropubic, were rare in the transobturator and missing in the prepubic technique. Erosion rate was very low and similar for all the three techniques. Intra-operative vascular and perforating risks prevailed in the retropubic technique, due to the danger present in the retropubic space, whereas late infective complications overcame in the transobturator procedure. Severe complications in the prepubic procedure were not reported, but the procedure is performed only in few centers.

Transoral robotic surgery in retrostyloid parapharyngeal space schwannomas.

Parapharyngeal space (PPS) tumors are very rare, representing about 0.5% of head and neck neoplasms. An external surgical approach is mainly used. Several recent papers show how transoral robotic surgery (TORS) excision could be a prospective tool to remove mainly benign lesions in PPS; no cases of neurogenic tumors from the retrostyloid space treated with TORS have been reported. We present two cases which underwent TORS for schwannomas from the retrostyloid compartment of the parapharyngeal space. Clinical diagnosis of schwannoma was performed by magnetic resonance imaging (MRI). In the first case a 6 cm neurogenic tumor arose from the vagus nerve and in the second case a 5 cm mass from the sympathetic chain was observed. Both cases were treated successfully by the TORS approach using a new “J”-shaped incision through the mucosa and superior pharyngeal constrictor muscle. Left vocal cord palsy and the Claude Bernard Horner syndrome, respectively, were observed as expected postsurgical sequelae. In case 1 the first bite syndrome developed after three months, while no complications were observed in case 2. Both patients regained a normal swallowing function. TORS seems to be a feasible mini-invasive procedure for benign PPS masses including masses in the poststyloid space.

Unilateral hemilaminectomy for the microsurgical removal of intraspinal tumors

Objective To evaluate the advantages and disadvantages of unilateral hemilaminectomy for the microsurgical removal of intraspinal tumors. Methods Clinical data of 19 patients with intraspinal tumors were analyzed from August 2008 to April 2013. All cases were treated microsurgically using unilateral hemilaminectomy procedures. Results Tumors were totally removed in all patients, including 12 cases of schwannoma, 1 case of neurofibroma, 5 cases of spinal meningioma and 1 case of hemangioblastoma. After operation signs and symptoms of every patient were significantly improved. Postoperative follow-up period was 6-60 months. No recurrence and spinal instability were found. The average area of intraoperative unilateral hemilaminectomy was (15 ± 2) mm × (32 ± 5) mm. Conclusion Unilateral hemilaminectomy for the removal of intraspinal tumors is a mini-invasive procedure, and is beneficial to the stability of spine, with the advantages of short hospitalization time, slight postoperative reaction and good long-term outcome. However, the procedure requires a skilled technology. doi: 10.3969/j.issn.1672⁃6731.2013.11.007 Video: http://www.cjcnn.org/index.php/cjcnn/pages/view/v13n11a7