Minimal Access Surgical Techniques Research Articles

Hysteroscopy as a Therapeutic Tool: A Vision to Spare the Uterus in Premenopausal Abnormal Uterine Bleeding (AUB)/Heavy Menstrual Bleeding (HMB), an Update.

Heavy menstrual bleeding (HMB) or abnormal uterine bleeding (AUB) is a common cause of gynecological complaints in perimenopausal women. The treatment chosen by most of the women having HMB/AUB in the perimenopausal age group when medical therapy fails is hysterectomy, which unfortunately has significant issues related to safety and long-term quality of life apart from being a burden on the health care system and cost to patients. Minimal access surgical techniques like hysteroscopic targeted therapies are available which are conservative and spare the uterus and major surgery and its complications and sequelae. Hysteroscopic management of HMB is a minimally invasive and targeted approach in diagnosing and treating the pathological lesions causing the symptoms and not radical like hysterectomy which has more chances of occurrence of adverse events both intra and postoperatively. In terms of health-related quality of life, women suffering from HMB who underwent a hysteroscopic conservative approachhad better scores when compared to those with hysterectomy. The present review aims to review the evidence generated to compare the two surgical modalities, hysteroscopic targeted therapyand hysterectomy, in terms of their effectiveness, safety, and effect on the quality of life of these perimenopausal women having HMB/AUB.

Post-laparotomy Hypoxia: A Case Series

Postoperative hypoxia is a challenge for surgeons. With the advent of better anesthesia and minimal access surgical techniques, the incidence of postoperative hypoxia in elective cases has decreased. However, the incidence in life-saving emergency procedures still poses a possible threat, and cases seem under-reported. We report a series of five cases of postoperative hypoxia after laparotomy. These cases comprise mesenteric laceration, proximal jejunal perforation, perforated duodenal ulcer, abdominal tuberculosis, and fall from height. Despite different etiologies, they landed up with the complication of postoperative hypoxia, which was attributable to the type of procedure they underwent and not the indication of the procedure itself. Thus, they form an interesting collection of post-laparotomy hypoxia cases. We present them with a compilation of probable causes of postoperative hypoxia in such cases.Postoperative hypoxia presents a diagnostic challenge and requires timely suspicion, prompt intervention to eliminate the cause, and good postoperative care. The major causes include incomplete lung re-expansion, pain-induced restriction in chest-wall/diaphragm mobility, prolonged surgery, a complication of pre-existing lung disease, residual effects of some drugs, and iatrogenic causes. We, therefore, recommend the use of postoperative oxygen support and diligent monitoring of vitals in all cases of laparotomy, allowing prompt and timely patient management. Future studies are warranted to explore the prevalence and possible causes of post-laparotomy hypoxia.

Spinal metastasis: narrative reviews of the current evidence and treatment modalities.

The treatment for spinal metastasis has evolved significantly during the past decade. An advancement in systemic therapy has led to a prolonged overall survival in cancer patients, thus increasing the incidence of spinal metastasis. In addition, with the improved treatment armamentarium, the prediction of patient survival using traditional prognostic models may have limitations and these require the incorporation of some novel parameters to improve their prognostic accuracy. The development of minimally-invasive spinal procedures and minimal access surgical techniques have facilitated a quicker patient recovery and return to systemic treatment. These modern interventions help to alleviate pain and improve quality of life, even in candidates with a relatively short life expectancy. Radiotherapy may be considered in non-surgical candidates or as adjuvant therapy for improving local tumour control. Stereotactic radiosurgery has facilitated this even in radioresistant tumours and may even replace surgery in radiosensitive malignancies. This narrative review summarizes the current evidence leading to the paradigm shifts in the modern treatment of spinal metastasis.

Accidental Dural Tears in Minimally Invasive Spinal Surgery for Degenerative Lumbar Spine Disease.

Background: One of the most frequent complications of spinal surgery is accidental dural tears (ADTs). Minimal access surgical techniques (MAST) have been described as a promising approach to minimizing such complications. ADTs have been studied extensively in connection with open spinal surgery, but there is less literature on minimally invasive spinal surgery (MISS).Materials and Methods: We reviewed 187 patients who had undergone degenerative lumbar spinal surgery using minimally invasive spinal fusions techniques. We analyzed the influence of age, Body Mass Index (BMI), smoking, diabetes, and previous surgery on the rate of ADTs in MISS.Results: Twenty-two patients (11.764%) suffered from an ADT. We recommended bed rest for two and a half to 5 days, depending on the type of repair required and the amount of cerebrospinal fluid (CSF) leakage. We could not find any statistically significant correlation between ADTs and age (p = 0.34,), BMI (p = 0.92), smoking (p = 0.46), and diabetes (p = 0.71). ADTs were significantly more frequent in cases of previous surgery (p < 0.001). None of the patients developed a transcutaneous CSF leak or post-operative infection.Conclusions: The frequency of ADTs in MISS appears comparable to that encountered when using open surgical techniques. Additionally, MAST produces less dead space along the corridor to the spine. Such reduced dead space may not be enough for pseudomeningocele to occur, cerebrospinal fluid to accumulate, and fistula to form. MAST, therefore, provides a certain amount of protection.

Open and Minimal Approaches to Pancreatic Adenocarcinoma.

Surgical options and approaches to pancreatic cancer are changing in the current era. Neoadjuvant treatment strategies for pancreatic cancer combined with the increased use of minimal access surgical techniques mean that the modern pancreatic surgeon requires mastering a number of surgical approaches with to optimally manage patients. Whilst traditional open surgery remains the most frequent approach for surgery, the specific steps during surgery may need to be modified in light of the aforementioned neoadjuvant treatments. Robotic and laparoscopic approaches to pancreatic resection are feasible, but these surgical methods remain in their infancy. In this review article, we summarise the current surgical approaches to pancreatic cancer and how these are adapted to the minimal access setting with discussion of the patient outcome data.

Novel laparoscopic cornual resection of interstitial pregnancy using the Endo GIA™ Universal Stapler (Medtronic): A series of 12 cases

The maternal mortality of interstitial pregnancy is five times greater than that of other ectopic gestations due to potential haemorrhage. Minimal access surgical techniques usually comprise cornual resection and cornuostomy, requiring laparoscopic suturing skills. To describe a case series using a laparoscopic automatic stapling device with reloadable cartridges to resect the cornu, enabling surgeons less familiar with intracorporeal suturing to avoid laparotomy when managing interstitial pregnancy. Twelve cases of laparoscopic cornual resections for interstitial pregnancies with the Endo GIA™ Universal Stapler (Medtronic) were collected prospectively over eight years. Outcome measures include human chorionic gonadotropin beta subunit (hβCG) levels, successful laparoscopic completion, estimated blood loss, intra-and post-operative complications and length of stay. Median age and gestation at surgery were 31years (range: 20-44) and eight weeks (range: 5-12), respectively. All involved live interstitial gestations, and 4/12 cases had significant haemoperitoneum at laparoscopy. The median blood loss was 300mL (range 100-3500), and five women had blood loss >500mL. The median serum hβCG level was 6429IU/L (range: 1800-58690), and the median ectopic size was 4cm (range 2-6). All cases were completed laparoscopically with no intra- or post-operative complications, although two women required blood transfusions. Median length of stay was 40h. Further pregnancies could only be followed in 2/12 cases due to the migratory nature of our local population. We describe a case series of 12 laparoscopic cornual resections for interstitial pregnancies using Endo GIA™ Universal Stapler, which simultaneously staples and transects the tissues, thus minimising the need for laparoscopic intracorporeal suturing.

Laparoscopic bariatric surgery-current trends and controversies

Although the origins of bariatric surgery to treat obesity can be traced back to the 1950s with the jejunoileal bypass, which is considered a malabsorptive bariatric procedure, its practice remained in obscurity until two things happened. First, obesity becoming a pandemic disease state with life threatening comorbidities such as diabetes, hypertension, sleep apnea, dyslipidemia and metabolic syndrome, resulting in a higher risk for premature death. Second, the introduction, development, and refinement of minimal access surgical techniques along with newer laparoscopic stapling devices. With the advent of laparoscopy in the 1980s, bariatric surgery began to be performed through minimally invasive techniques. The purpose of this article is to describe the science and evolutionary development of various laparoscopic bariatric surgical techniques and the associated surgical anatomy.

Laparoscopic bariatric surgery-current trends and controversies

Although the origins of bariatric surgery to treat obesity can be traced back to the 1950s with the jejunoileal bypass, which is considered a malabsorptive bariatric procedure, its practice remained in obscurity until two things happened. First, obesity becoming a pandemic disease state with life threatening comorbidities such as diabetes, hypertension, sleep apnea, dyslipidemia and metabolic syndrome, resulting in a higher risk for premature death. Second, the introduction, development, and refinement of minimal access surgical techniques along with newer laparoscopic stapling devices. With the advent of laparoscopy in the 1980s, bariatric surgery began to be performed through minimally invasive techniques. The purpose of this article is to describe the science and evolutionary development of various laparoscopic bariatric surgical techniques and the associated surgical anatomy.

Open Prostatectomy in the Management of Benign Prostate Hyperplasia in a Developing Economy

Background: Open prostatectomy (OP) is still relatively common in developing countries and remains a useful benchmark against which the minimal access surgical techniques are compared. This study aims to document the indications and outcomes of OP in a typical developing economy. Method: The records of patients with benign prostate hyperplasia (BPH) who had OP in our university teaching hospital between July 2004 and June 2014 were retrospectively reviewed. Some analyzed parameters include the demographic characteristics, indications, pre-operative work-up, anaesthetic techniques, OP type, complications, histopathology results and follow-up duration. Results: A total of 247 cases were studied. Mean age was 67 years while the commonest surgery indication was recurrent acute urinary retention. Average prostate specific antigen (PSA) was 8.4 ng/ml while hypertension was the most common comorbidity (44.1%). Regional anaesthesia was mainly used (79.4%) while retropubic prostatectomy was the commonest OP type done (58.7%). The enucleated specimen weighed above 60 g in 91.9% of cases. All our patients were able to micturate spontaneously with urine stream above 20 mls/second on follow-up one week after discharge. Mean duration of hospital admission and follow-up were 7 days and 9 months respectively. Complications occurred in 90 patients (36.4%), of which surgical site infections were the commonest (9.8%). There was 0.4% mortality. Histopathology results showed BPH (95.5%), (incidental) prostate adenocarcinoma (2.4%) or prostatic intra-epithelial neoplasia (2.1%). Conclusion: OP remains an important therapeutic option for management of BPH in developing countries partly due to relatively large prostate size and presence of BPH complications from late presentationin many patients. The surgery is efficient and has relatively low morbidity and minimal mortality.

Current status of surgical and anesthetic interventions in fetal life

The current advancements in fetal medicine are a celebration of human ingenuity and triumph. A realm that is both poignant and captivating, the possibilities born out of progress in anesthesia and minimal access surgical techniques in the fetal microcosm are huge. A number of strategic approaches, including fetoscopic interventions, minimally invasive surgeries, and ex utero intrapartum—the so-called EXIT—procedures have facilitated correction of a number of life-threatening fetal conditions and anomalies. However, the challenges and risks in performing in utero fetal anesthesia and surgical maneuvers are so considerable that still only a few tertiary healthcare facilities across the globe carry out these procedures.

Minimally Invasive (Metrx) Resection of Intradural Spinal Lesions. A Series of 33 Consecutive Cases with Results and Complications

Spinal intradural lesions have been classically treated using open surgical techniques from a direct posterior translaminar approach. This despite the localization of the lesion with respect to the spinal cord. This “one size fits all” strategy works for many lesions, but is very limiting for others, particularly ventrally located lesions. Minimally invasive techniques allow for more flexibility in approach trajectories of almost 180° from one side to the other, while allowing for standard microsurgical techniques intradurally. The approaches are much reduced in size, are faster, and have minimal blood loss, with less muscle destruction. Retrospective patient record review from 2004-2013. Inclusion criteria include intradural spinal pathologies treated using the minimal access techniques with clinical and radiological follow up. 33 cases included in this study in 32 patients (17 male and 15 female) Ave age 50.4 years (20-80). 7 cases were in the cervical spine, 11 in the thoracic spine, and 15 cases were in the lumbosacral spine. Extramedullary pathologies All patients has postoperative MRI: 2 patients with intramedullary lesions: minimum residual teratoma stable at 5 years, AA with progressive disease but alive at 14 months after surgery. Extramedullary: 2 patients with drop mets from ependymoma stable at 8 and 43 months after surgery. 1 patient with recurrent meningioma in the T1 foramen, successfully treated the radiotherapy. 1 patient with tumor left stuck to the anterior spinal artery at C6 with stable disease. Remaining 24 patients with no residual disease. 2 patients with arachnoid cysts had normal CSF flow. Clinical complications (4 cases) Conclusions: 1. Use of minimal access surgical techniques appears to be a safe alternative to standard open approaches. Advantages are rapidity of access and closure, less blood loss, faster recovery postoperatively. 2. These techniques allow standard microsurgical techniques for lesion resection, and may enhance resection with more favorable surgical trajectories. These techniques can be used for highly selective intramedullary lesions.

Pilot study on laparoscopic surgery in port-harcourt, Nigeria.

Background:Video-laparoscopic surgery has long been practiced in western countries; however documented practice of this minimal access surgical technique are recently emanating from Nigeria. To the best of our knowledge, this is the first documented study on laparoscopic surgery from the Niger Delta region.Aim:To evaluate the feasibility of laparoscopy as a useful tool for management of common surgical abdominal conditions in our environment.Patients and Methods:This was a prospective outcome study of all consecutive surgical patients who had laparoscopic procedures in general and pediatric surgery units of our institution from August 2011 to December 2012. Data on patient's age, gender, indication for surgery, duration of hospital stay and outcome of surgery were collected and analyzed.Results:A total of 15 laparoscopic procedures were performed during this study period with age range of 2-65 years; mean: 32.27 ± 17.86 years. There were 11 males and four females. Six laparoscopic appendicectomies, one laparoscopy-assisted orchidopexy, five diagnostic laparoscopy ± biopsy, one laparoscopic trans-abdominal pre-peritoneal herniorrhaphy for bilateral indirect inguinal hernia and two laparoscopic adhesiolysis for small bowel obstruction were performed. All were successfully completed except one conversion (6.7%) for uncontrollable bleeding in an intra-abdominal tumor.Conclusion:The practice of laparoscopic surgery in our environment is feasible and safe despite the numerous, but surmountable challenges. There is the need for adequate training of the support staff and a dedicated theatre suite.

Is Minimal Access Surgery of Esophageal Atresia with Distal Esophageal Atresia by Thoracoscopy is better than Conventional Thoracotomy? A Multi-institutional Review of Literature to get the Answer

Topic: Is minimal access surgery of esophageal atresia with tracheoesophageal fistula by thoracotomy better than conventional thoracotomy? A multi-institutional review of literature. Objective: Minimal access surgical technique has been one of the most important surgical advances in the last few decades; we have reached now in such era that complex neonate surgical issue can be addressed safely by minimal access surgery without significant morbidity. Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) has been successfully treated by traditional thoracotomy, but now the trend has been shifted toward minimal access surgery via thoracoscopic repair of EA with distal EA. The quest of this multi-institutional review is to get the answer that is minimal access surgery is better than the traditional open approach. Materials and methods: A literature view was performed from 2005 to 2012 using the PubMed, science direct, OVID search EBSCOhost and search engines Google and Yahoo. The following search terms were used, thoracoscopic repair or thoracoscopic surgery, thoracotomy and EA. Inclusion criterion is EA with distal esophageal fistula with comparative study by open thoracotomy or by historical data. Exclusion criteria were other esophageal anomalies. Results: In 182 patients operated by minimal access surgery by thoracoscopy, the mean gestational age, weight, associated congenital anomalies, mechanical ventilation, perioperative pCO2, postoperative early and late complication are comparable with historical open thoracotomy. However MAS has a superadded advantage in markedly reduction in scar tissue, postoperative pain and no chest wall deformity. Conclusion: This multi-institutional review provides a recent comparison of the approached to EA with TEF without any worse effect of thoracoscopy and competes well with traditional open thoracotomy approach. There is dramatic advancement of pediatric MAS over the last decade and the result are comparable with open thoracotomy in perioperative, postoperative and long-term outcome with potential advantages of less scar tissue, less postoperative pain, less disruption of anatomy and function and better cosmoses with markedly reduced musculoskeletal complication. Thoracoscopic repair is a promising adjunct, but there are difficulties for setting it as the open thoracotomy and it still needs more subjective studies with the consideration of learning curve and long surgical time. However, thoracoscopic repair of EA with TEF is a favorable and effective procedure with good prognosis.

Role of Minimal Access Surgery in Management of Infective Pancreatic Necrosis

Aim: To study various minimal access surgical techniques of pancreatic debridement for infected pancreatic necrosis (IPN).Method: A review of literature is done using various search engines like Google, Yahoo, PubMed, etc. by using keywords: Pancreaticnecrosectomy, laparoscopic, endoscopic pancreatic necrosectomy.This article reviews various methods of minimally access pancreatic necrosectomy (MAN) can be classified by the type of scopeused flexible endoscope, laparoscope, nephroscope and the route of access transperitoneal, transgastric, retroperitoneal. Each of thescopes and access routes has its advantages and disadvantages.Result and conclusion: Only few large series of cases of MAN have been published, rest are limited to case reports. There are nocomparisons of results, either with open surgery or among different minimal access surgeries but a body of evidence now suggeststhat acceptable outcomes can be achieved and minimal access necrosectomy is technically feasible, well tolerated and beneficial forpatients when compared with open surgery.

Actualización en hiperhidrosis

Nearly 3% of the population has hyperhidrosis. Quality of life is affected, impacting on social relationships and professional activity, and social anxiety disorder can sometime develop. We review the definition and causes of hyperhidrosis and the clinical evaluation of patients. After describing the different clinical aspects of the condition, we discuss the medical and surgical treatments. Of such treatments currently available, particular mention is made of the use of botulinum toxin in some forms of hyperhidrosis as an intermediate option between the traditional treatments and surgery. We also draw attention to the use of minimal access surgical techniques (videothoracoscopy), which, over the past decade, have become established as an effective, safe, and permanent approach for the treatment of hyperhidrosis when indicated.

Comparative Study of Laparoscopic versus Open Ventral Hernia Repair.

Comparative Study of Laparoscopic versus Open Ventral Hernia Repair.

Minimal access surgical management of large juvenile polyps in children

Background Juvenile polyps have a reported incidence of up to 2% in individuals younger than of 18 years. Most polyps are small, occur in the distal colon and rectum, and present with bleeding or prolapse. Giant juvenile polyps have been rarely reported. Case Reports We encountered 2 unique presentations of very large juvenile polyps in children. A 9-year-old boy presented with recurrent rectal bleeding and anemia because of a single large polyp at the hepatic flexure. A 14-year-old boy presented with abdominal pain secondary to 2 large polyps in the cecum. The polyps were seen on colonoscopy as pedunculated masses larger than 5 cm and were not subjected to biopsy. Both patients underwent laparoscopic colon mobilizations with extracorporeal segmental resection in the first patient and colotomy and polypectomy in the second. Both patients had short hospital stays and excellent outcomes. Conclusions Giant juvenile polyps are rare in children and may not be amenable to colonoscopic removal. They can be resected effectively with minimal access surgical techniques.

Diagnosis and treatment of pudendal nerve entrapment syndrome subtypes: imaging, injections, and minimal access surgery

To improve diagnostic accuracy and achieve high levels of treatment success in patients with pudendal nerve entrapment (PNE) syndromes, the author of this study applied advanced technology diagnostics in distinguishing the various syndrome types according to the different entrapment locations and evaluated new minimal access surgical techniques to treat each subtype. Two hundred cases were prospectively evaluated using a standardized set of patient-completed functional and symptom assessments, a collection of new physical examination maneuvers, MR neurography, open MR image-guided injections, intraoperative neurophysiology, minimal access surgery, and formal outcome assessment with the Oswestry Disability Index, pain diagrams, and analog pain scales. Four primary types of PNE syndromes were identified based on the different locations of entrapment: Type I, entrapment at the exit of the greater sciatic notch in concert with piriformis muscle spasm; Type II, entrapment at the level of the ischial spine, sacrotuberous ligament, and lesser sciatic notch entrance; Type III, entrapment in association with obturator internus muscle spasm at the entrance of the Alcock canal; and Type IV, distal entrapment of terminal branches. The application of new, targeted minimal access surgical techniques led to sustained good to excellent outcomes (50-100% improvement in the pain score or functional score) in 87% of patients. Most of these patients obtained most of their improvement within 4 weeks of surgery, although some continued to experience progressive improvements up to 12 months after surgery. The application of advanced diagnostics to categorize PNE syndrome origins into 4 major subtypes and the subsequent treatment of each subtype with a tailored strategy greatly improved therapeutic outcomes as compared with those reported when only a single treatment paradigm was applied to all patients.

Fetal surgery and anaesthetic implications

Surgery to the fetus while it is still in utero is used to treat an increasing number of lethal and non-lethal conditions. The problems of preterm labour and premature rupture of membranes associated with open surgery have led to the development of minimal access surgical techniques. Although fetal surgery is a new and fast moving frontier of medicine, it is not one that all obstetric anaesthetists will encounter. The first successful human fetal operation was performed in 1983, but it is still only carried out in a limited number of specialist tertiary centres. The broad challenges presented to the anaesthetist are:

Diagnosis and Management of Pudendal Nerve Entrapment Syndromes: Impact of MR Neurography and Open MR-guided Injections

Nerve entrapment syndromes involving the pudendal nerve have been challenging for the neurologist and neurosurgeon relative to other nerve entrapment syndromes because of the nature of the presenting symptoms and the technically demanding aspects of specific diagnosis. Further, effective treatment options have been few. Recently however, there have been a series of advances in diagnosis and treatment. Application of magnetic resonance neurography imaging and the use of open magnetic resonance guided injection techniques have greatly improved diagnostic efficacy. New minimal access surgical techniques targeted at various subtypes of pudendal entrapment—greater sciatic notch, ischial spine, obturator internus/Alcock canal, and distal branch have resulted in 87% good to excellent treatment outcomes in a prospective study of 55 patients.