Minimal Access Techniques Research Articles

Laparoscopic Conservative Management Of A Spontaneously Ruptured Spleen: Case Report

A case of an acute abdomen secondary to a ruptured spleen managed laparoscopically is presented. Laparoscopy is currently widely used for the initial diagnosis and management of such cases as an alternative to laparotomy due to the numerous advantages of the minimal access techniques. With widespread availability and adequate training in laparoscopy, minimal access surgery is likely to play a bigger role in the initial management of patients with an acute abdomen in Kenya. It is with this realisation that we present the case of a 25 year old male who presented with an acute abdomen and thrombocytopaenia due to a ruptured spleen following severe malaria that was managed laparoscopically. The aim is to highlight and encourage conservative management of acute abdomen due to splenic rupture in a patient with malaria.

Oesophageal achalasia: An argument for primary surgical management

Achalasia is a primary oesophageal motility disorder resulting from damage to the ganglion cells of the myenteric plexus. Impaired relaxation of the lower oesophageal sphincter and aperistalsis causes its cardinal symptoms of dysphagia, chest pain and reflux-type symptoms. Management is somewhat controversial, with options including systemic and local pharmacotherapy, dilatation and oesophagomyotomy. We review the presentation, investigation and management of oesophageal achalasia and make an argument for primary surgical management. We performed a Medline search of the term 'achalasia', limiting the search to clinical trials and meta-analyses. We then selected articles based on their abstracts using four main criteria: previously unreported findings, previously unreported techniques, size of patient cohort and journal impact factor. References in selected articles were manually searched for other relevant articles. Achalasia has been managed using a variety of techniques including systemic and local pharmacotherapy, forced dilatation and oesophagomyotomy. Success rates vary widely between techniques. Mechanical disruption ofthe lower oesophageal sphincter is most successful. In achalasia, mechanical disruption of the lower oesophageal sphincter using forced dilatation or surgical myotomy offers the only realistic prospect of long-term symptom relief. Recent evidence suggests that previous medical treatment or dilatation makes oesophagomyotomy more difficult and increases the risk of complications. As the morbidity associated with surgery continues to decrease with improvements in minimal access techniques, the argument for primary management of achalasia with oesophagomyotomy becomes more compelling.

Counterpoint: Minimally invasive bipolar radiofrequency ablation of lone atrial fibrillation: Early multicenter results

The challenges facing surgeons performing surgical ablation for atrial fibrillation include the evolution of techniques and development of technologies that will provide maximum cure rates, reducing the clinical burden of atrial fibrillation and thereby enhancing quality of life and reducing health care costs. The surgical procedure itself must minimize mortality, morbidity, and disability. Less invasive surgical approaches have been developed to avoid a sternotomy, avoid cardiopulmonary bypass, and approach the atrium through minimal access incisions and through ports. As surgeons, we desire ergonomic devices to perform reliable and transmural lines of ablation. Several energy sources in clinical use have limitations, such as energy loss from epicardial fat and the circulating blood pool. These technical challenges are compounded by the difficulty related to device design. The size, flexibility, and shape of the device often are the limiting factors in delivering the energy to epicardial surfaces when minimal access incisions are preferred. Controversy remains regarding the appropriate lesion set. Surgeons are motivated to offer less invasive approaches to improve their referral base by adopting minimal access procedures. The procedure requires an effective lesion set, with minimal complexity that can be easily and reliably performed by all cardiac surgeons. The electrophysiology of paroxysmal atrial fibrillation is most likely due to triggers from the pulmonary veins and the left atrium. Therefore, approaches that solely isolate the pulmonary veins will inevitably produce failures, inasmuch as 20% of the other triggers in nonpulmonary vein sites are in both the left or right atrium. In more complex forms of atrial fibrillation, in which the patient is continuously in atrial fibrillation, it is not possible to perform the recommended full or modified Cox maze lesion set easily with current minimal access techniques and technologies.

Treating non-tubal ectopic pregnancy

The purpose of this review is to examine the current state of knowledge regarding the treatment of non-tubal ectopic pregnancies. This review looks at the management of cervical, caesarean scar, ovarian, interstitial, cornual and abdominal pregnancies. Traditionally these pregnancies have been diagnosed late and managed by open surgery. Earlier diagnosis has led to the use of minimal access techniques, medical and conservative management for all types of non-tubal pregnancies. Increased awareness and the experience of specialised centres have led to an improved understanding of the best way to manage non-tubal ectopic pregnancies and the development of new techniques.

Long-term symptomatic outcomes after Collis gastroplasty with fundoplication

Collis gastroplasty with fundoplication is an accepted treatment for gastroesophageal reflux disease (GERD) complicated by short esophagus. The procedure can be done either via left thoracotomy or using minimally invasive laparoscopic techniques. Few centers have reported long-term follow-up for patients undergoing a Collis gastroplasty using both the open and minimal access techniques. Retrospective review of prospectively collected data at Creighton University was done to identify patients who underwent Collis gastroplasty with fundoplication for GERD. After approval from the institutional review board, the patients were contacted and administered a questionnaire regarding symptoms and satisfaction. Data were entered in a dataset and analyzed from the patient's perspective. Eighty-five patients underwent a Collis gastroplasty procedure over a period of 13 years. Forty-eight percent (41 cases) were performed laparoscopically, and a transthoracic open repair was performed in the rest. Long-term data (more than 9 months) was available on 52 patients. Surgery resulted in complete resolution of heartburn, chest pain, regurgitation, and dysphagia in 52, 22, 54, and 29% of patients, respectively. More than 75% of the patients were satisfied with the outcome of surgery, and more than 85% would recommend the procedure to another patient. Collis gastroplasty with fundoplication results in good long-term patient satisfaction and symptom control.

Cervical Spine Imaging Using Standard C-Arm Fluoroscopy

A cadaveric cervical spine specimen is imaged with a standard C-arm fluoroscope during a simulated procedure. Patient and surgeon exposure to radiation is estimated by placing dosimeters at various locations in 3-dimensional space. The purpose of this study was to evaluate radiation exposure to patient and surgeon when using C-arm fluoroscopy during a simulated cadaveric surgical procedure involving the cervical spine. The use of mobile fluoroscopy has become commonplace in orthopaedics. With the current trend towards minimal access techniques, fluoroscopy has become requisite to achieving satisfactory outcomes. Studies have shown that spine surgeons may be at elevated risk for radiation exposure compared to other orthopaedists. Exposure while using C-arm fluoroscopy for procedures involving the pelvis, as well as thoracic and lumbar spine has been documented. However, there are no equivalent studies that evaluate exposure during cervical spine imaging. A standard OEC 9800 C-arm was used to image a prepared cadaveric cervical spine specimen, which was suspended on an adjustable platform. Film badge dosimeters were mounted at various positions and angles to detect direct and scatter radiation. Testing was conducted in various radiation dose mapping "scenarios." The configurations tested altered the proximity of the specimen and jig relative to the radiation source. We attempted to capture radiation exposure in various locations, from a best-case to a worst-case scenario, as may be realistically encountered in a procedural setting. RESULTS.: Potential exposure to the patient and surgeon were consistently measurable, and of concern. As the imaged specimen was positioned closer to the radiation source, exposure to the patient was markedly amplified. Exposure to the surgeon did not increase as dramatically. There was a great degree of variability in the exposure doses recorded by the peripheral dosimeters. Even dosimeters that were placed in the same plane diverged widely in their measured exposure. This highlights the influence of the shape of the imaged specimen on reflected scatter. Scatter radiation doses on both sides of the specimen were similar. Care should be taken when working on both sides of the imaged subject. Considerable radiation exposure can be encountered when working with a C-arm fluoroscope if appropriate precautions are not observed. All appropriate radiation dose-reducing measures should be strictly enforced by the supervising physician to minimize risk to the patient and the medical team.

Level of Evidence in Minimal Access Pediatric Surgery

The use of minimal access techniques is rapidly expanding in pediatric surgery. Our aim was to answer two questions: (1) What is the current quality of evidence for minimal access pediatric surgery (MAPS)? and (2) Has the evidence for MAPS improved with respect to focus and methodology over a 12-year period (1995-2006)? A systematic review was performed. Data collected included: study characteristics, methods, and outcomes recorded. Approval by a research ethics board (REB) was recorded, where applicable, and articles were assessed for the reporting of learning curves and study limitations. Studies were divided into two eras according to publication date. Data were compared by using correlation, chi-squares, and univariate analyses. Four hundred and ten studies met the inclusion criteria. Of those, 260 (63.4%) were published in the late era. Only 1.46% of studies were level 1, whereas level 4 evidence was predominant (71.46%). The two eras were comparable with regard to country of origin, single-institution studies, length of follow-up, and quality of outcomes reporting. More studies reported REB approval (P = 0.0001) and clearly documented limitation of study design (P = 0.03) in the late era. There has been a significant increase in the number of articles dealing with MAPS. Recent studies were more likely to report limitations of study design and REB approval, but overall, there was no increase in level of evidence in the MAPS literature over the past 12 years. Although more research is being published, more attention needs to be paid to producing higher quality evidence.

Current minimal access techniques in the treatment of heavy menstrual bleeding

Current minimal access techniques in the treatment of heavy menstrual bleeding

THORACOSCOPIC VERTEBRAL BODY REPLACEMENT WITH AN EXPANDABLE CAGE AFTER VENTRAL SPINAL CANAL DECOMPRESSION

Minimally invasive thoracic anterior surgery using a thoracoscopic approach has evolved to include spinal biopsy, debridement, discectomy, decompressive corpectomy, interbody fusions, and internal fixations. Minimal access techniques can potentially decrease surgical access morbidity and also reduce the time required for recovery and healing. The thoracoscopic approach for decompression, stabilization, and anterior vertebral reconstruction of thoracolumbar fractures is described. In this article and video, we discuss patient selection, surgical positioning, port placement, thoracic level localization, exposure and removal of fractured vertebral bodies, anterior vertebral column reconstruction using an expandable cage, instrumentation, and postoperative management. The potential advantages of using a minimally invasive thoracoscopic approach include direct trajectory to anterior spine pathology, minimal tissue and rib retraction, and decreased postoperative pain and length of hospital stay. The associated disadvantages include the steep learning curve for the surgeon, the need to operate with two-dimensional visual information and long instruments, and the requirement that one have an experienced surgical assistant. Minimally invasive surgery using a thoracoscopic approach for vertebral body replacement with an expandable cage can be performed safely. Expandable cages facilitate the vertebral body reconstruction via minimal access surgery.

Reoperation for dysphagia after cardiomyotomy for achalasia

Background Although laparoscopic cardiomyotomy is considered to be the treatment of choice for achalasia, there is no consensus about how persistent or recurrent dysphagia after myotomy should be treated. In the current study we evaluated our experience with reoperation following previous cardiomyotomy. Methods Between 1992 and 2006, 19 patients underwent re-myotomy: 7 for persistent dysphagia, 12 for recurrent dysphagia. Different operative approaches were used, depending on surgeon’s preference and the technique used for the first operation. Results The mean interval between the cardiomyotomies was 81 months. In 12 patients, the alternative body cavity to that used for the first operation was used for access in the revision operation. This was associated with a shorter operation time. Mean follow-up after the revision operation was 3.6 years. Mean satisfaction score was 7 (out of 10), and 89% of patients had an improvement in symptoms. Conclusion Reoperation for persistent or recurrent achalasia achieves a satisfactory outcome in most patients. Using the alternative body cavity to that used in the original procedure facilitates minimal access techniques, and gives easier access to the operative field.

Current minimal access techniques in the treatment of heavy menstrual bleeding

Key content Heavy menstrual bleeding remains a major problem for some women. Hysterectomy is the leading treatment for this condition but it is recognised to have some serious complications. First‐generation endometrial ablation techniques have a steep learning curve and are carried out under hysteroscopic visualisation. Second‐generation techniques are simpler and have lower complication rates, lower analgesia requirements and potential for outpatient use. Individual assessment is important in deciding the route and method of treatment for heavy menstrual bleeding, taking clinical factors into consideration. Learning objectives To know about the various options currently available for endometrial ablation. To learn about the clinical application, advantages and limitations of various methods of endometrial ablation. To be able to make an informed choice when deciding which modality to use. Ethical issues Intense competition will continue to drive device manufacturers to make claims of effectiveness based on poor‐quality evidence. All users have a responsibility to be well informed and to offer evidence‐based advice to women. Please cite this article as: Justin W, Ibraheim M, Bagtharia S, Haloob R. Current minimal access techniques in the treatment of heavy menstrual bleeding. The Obstetrician & Gynaecologist 2007;9:223–232.

Valuable lessons from two decades of pectus repair with the Willital–Hegemann procedure

Pectus deformities are the most common congenital hereditary chest wall deformity. The aim of this study was to evaluate the efficacy of thoracic wall reconstruction using a uniform technique of internal stabilization with stainless-steel struts. Hospital charts of patients with chest wall deformities managed with the Willital-Hegemann procedure between January 1984 and January 2004 were reviewed. Surgical corrections were performed in 1262 patients with pectus deformities (968 male and 294 female patients). The corrections were completed with successful repair in 1244 (98.6%) patients, along with a low complication rate of 5.7%. The median age of the patients was 14.9 years (range, 2-53 years). The follow-up period ranged from 2 to 12 years (mean, 5.4 years). Major recurrences were observed in 18 (1.4%) patients, and mild recurrences were observed in 46 (3.6%) patients. There was 1 death in this series. The struts were removed after a period of 24 to 36 months and were associated with a complication rate of 2.6% at the time of removal. Custom-tailored molding of the chest wall can be achieved by using this method, which is not possible with minimal-access techniques. Open repair is effective for all variations of chest wall deformities and in patients of all ages, causes only mild pain, and produces good physiologic and cosmetic results. Improvement of subjective complaints, satisfactory long-term results, and improvement in psychological problems indicate the need to offer this procedure among other surgical correction options for low-risk children.

The Immunomodulatory Effects of Laparoscopic Surgery

Laparoscopic alternatives to conventional surgical procedures confer many advantages to patients including reduced postoperative pain, shortened convalescence and, perhaps, improved disease-related outcomes. The diminished degree of immune dysfunction apparent with these techniques may underpin these beneficial aspects. However, minimal access is accompanied by various ancillary anesthetic and mechanical associations (including the induction of a carbon dioxide pneumoperitoneum), which must be considered in addition to reduced tissue trauma when attempting to correlate cause with effect. Furthermore, the opportunity to establish causation between the immunomodulatory aspects of laparoscopy and subsequent clinical outcome by prospective, randomized study is difficult because of the rapid incorporation of minimal access techniques into clinical practice. Therefore, experimental in vitro and in vivo studies must be used to complement the limitations of clinical studies in this area. Although the initial investigations into the immunological effects of laparoscopy are encouraging, many of the intricacies associated with this approach still await elaboration.

HP19 RE‐OPERATION FOR DYSPHAGIA AFTER CARDIOMYOTOMY FOR ACHALASIA

Purpose Although laparoscopic cardiomyotomy is considered to be the treatment of choice for achalasia, there is no consensus about how persistent or recurrent dysphagia after myotomy should be treated. In this study we evaluated our experience with re‐operation following previous cardiomyotomy.Methodology From a prospective database, all patients were identified who underwent a re‐cardiomyotomy for persistent or recurrent dysphagia between 1992 and 2006.Results 19 patients (6 female, 13 male) underwent a re‐operation: 7 for persistent and 12 for recurrent dysphagia. The mean time interval between both cardiomyotomies was 81 months. Different operative approaches for reoperations were used, depending on surgeon’s preference and the technique used for the first operation. In 12 patients, the alternative body cavity to that used for the first operation (thoracic versus abdominal) was used for access in the revision operation. This was associated with a shorter operation time (90 vs.128 minutes). An incomplete myotomy or scar tissue were the most common causes of failure identified. Mean hospital stay was 4 days. Mean follow‐up after the revision operation was 3.6 years. 89% of patients had an improvement in symptoms, and the mean satisfaction score (0–10) was 7.Conclusion Re‐operation for persistent or recurrent achalasia achieves a satisfactory outcome in most patients. Using the alternative body cavity to that used in the original procedure facilitates minimal access techniques, and gives easier access to the operative field.

Is Infrainguinal Bypass Grafting Successful Following Failed Angioplasty?

Angioplasty is often used in the management of lower limb ischaemia and can reduce the need for infrainguinal bypass in some patients. There is an associated failure rate with this technique and bypass surgery is often used in this situation as a secondary limb salvage procedure. We aimed to evaluate the outcome of infrainguinal bypass grafting following failed attempt at angioplasty. All cases of infrainguinal bypass at a single centre over a seven year period were identified and notes reviewed. Cases were divided into four groups according to their indication for surgery; acute ischaemia, chronic critical ischaemia, failed angioplasty and an 'other' group including aneurysmal disease and claudicants. The failed angioplasty group was compared with the other three groups. Survival analysis was performed using Kaplan Meier curves and groups compared in terms of long term patency and survival. Primary patency was 61.2% in the failed angioplasty group at 12 months compared with 60.6% in the other groups (P=1.11). There was also no significant difference in primary patency at 60 months (50% vs 40.6%, P=0.26). Survival at 12 months was also comparable between the groups (failed angioplasty group 74.2% compared with 77.3% in the other groups, P=0.662) as was 60 months survival (33.3% and 35.4% respectively, P=0.166). In this study, outcome of infrainguinal bypass following failed angioplasty was comparable to outcome of surgery performed for another indication. This paper supports the use of distal bypass surgery for limb salvage in cases where minimal access techniques have failed.

Outpatient thyroid surgery is safe and desirable

Thyroid surgery has traditionally been done on an inpatient basis. With the advent of minimal access techniques, drains are frequently not required and ambulatory thyroidectomy is possible. Prospective, nonrandomized analysis of consecutive series of patients. Patients undergoing thyroid surgery between 12/1/04 and 10/31/05 were stratified based on admission status. Demographic data were collected and outcome measures were considered. Ninety-one patients underwent thyroid surgery. Fifty-two were done on an outpatient basis, 26 patients were observed under a 23-hour status, and 13 were admitted. There were two complications in the outpatient group and one in the inpatient group (P = 1.0). Costs were significantly lower for outpatients ($7,814) than for inpatients ($10,288; P < 0.0001). In carefully selected patients who prefer convalescence at home, outpatient thyroidectomy can be performed safely and cost-effectively, particularly when prophylactic calcium supplementation is utilized after total thyroidectomy to prevent transient postoperative hypocalcemia.

Management of extra-tubal and rare ectopic pregnancies: case series and review of current literature

Management of extra-tubal ectopic gestations remains an inadequately explored clinical field due to the rarity of the presentations. We present a synopsis of the management highlighted by our personal case series. A literature search was conducted through Pubmed and Medline databases. We reviewed all cases presenting with extra-tubal nidations in our institute, including seven interstitial, two cervical, three ovarian and two abdominal pregnancies. The advances in minimal access techniques and imaging modalities have resulted in novel fertility preserving endoscopic procedures. All except one of the patients were treated by endoscopic procedures, including a novel procedure for evacuation of cornual ectopics. A high index of suspicion is essential, combined with meticulous review of clinical findings and imaging modalities to make an accurate diagnosis. Treatment with the least invasive method, either by minimal access techniques, non-invasive radiological procedures or medical treatment should be encouraged.

Intraoperative surgical considerations for enhanced recovery after elective colonic surgery

SUMMARYCareful planning of the intraoperative stage of the surgical stay plays an important role in achieving progress through the perioperative component of a multimodal care pathway. This period will play a significant part of the patient’s hospital experience and may dictate the ability to achieve the postoperative targets of an enhanced recovery program. A review of the available evidence demonstrates where benefits can be made to contribute to the overall progress of the patient’s recovery. Elements considered include: wound siting and care, minimal access techniques, use of diathermy, insertion of drains and catheters, and aspects of surgical techniques. These areas, when combined as part of an ‘enhanced recovery after surgery’ program, should contribute to a more rapid patient recovery without any increase in complications.

Minimally Invasive Surgery for Atrial Fibrillation

Although the surgical treatment of atrial fibrillation has become technically simpler and faster with the advent of new ablative technologies, the ultimate goal of treating large numbers of patients for lone AF remains elusive. The ideal procedure would be performed epicardially, on the beating heart, with minimal risk to and impact on the patient, a rapid recovery and high cure rates. As minimal access techniques improve along with device designs and our understanding of pathophysiology, the field continues to move toward this objective. This article provides a brief overview of the progress made, questions yet unanswered and possible future directions.

Minimally invasive far lateral microendoscopic discectomy for extraforaminal disc herniation at the lumbosacral junction: cadaveric dissection and technical case report

Background context Extraforaminal lumbar disc herniations (ELDHs) at the lumbosacral junction are an uncommon cause of L5 radiculopathy. The surgical anatomy of the extraforaminal space at L5–S1 is uniquely challenging for the various open surgical approaches that have been described for ELDHs in general. Reports specifically describing minimally invasive surgical approaches to lumbosacral ELDHs are lacking. Purpose To report the novel use of a far lateral microendoscopic (FLMED) approach to lumbosacral ELDH. To better define the unique anatomical features of extraforaminal approaches to the lumbosacral junction as they apply to minimal access techniques. Study design/setting A cadaveric investigation and clinical case were performed at a single institution. A thorough review of the literature was conducted. Patient sample A single patient with an extraforaminal disc herniation at the lumbosacral junction underwent evaluation and surgery. Outcome measures The patient's self-reported pain levels were documented. Physiologic outcome was judged on pre- and postoperative motor and sensory examinations. Functional capacity was assessed by work status and ability to perform activities of daily living. Methods FLMED was performed in two fresh human cadavers at the lumbosacral junction. Qualitative assessments of the surgical anatomy were made, and intraoperative fluoroscopy and endoscopic photographs were obtained to document the findings. A patient with refractory pain and sensorimotor deficits from compression of the L5 nerve root by an ELDH underwent FLMED. The literature was carefully reviewed for the epidemiology of ELDHs at the lumbosacral junction and the surgical techniques used to treat them. Results The posterolateral surgical corridor to the lumbosacral disc was consistently constrained by the sacral ala and to a lesser extent the lateral facet and L5 transverse process. Resection of the superior ala exposed the exiting nerve root and provided ample access to the disc. In the clinical case, the patient enjoyed immediate pain relief, was discharged in 3 hours, and returned to full work and social activities. Follow-up neurological examination revealed no sensory or motor deficit. Conclusions FLMED offers a safe and efficacious approach to ELDHs at the lumbosacral junction by combining satisfactory visualization for adequate resection of the sacral ala with the benefits of reduced tissue injury and faster recovery times that accompany minimally invasive techniques.