Minimally Invasive Surgical Techniques Research Articles

Atrésia Esofágica: Um Desafio desde o Diagnóstico Pré-natal ao Tratamento Cirúrgico

A atrésia esofágica é a anomalia congénita mais comum do desenvolvimento do esófago, caracterizando-se por uma disrupção da sua continuidade, com uma prevalência de cerca de 1 em cada 2500 a 4500 nados vivos. A abordagem desta condição, desde o seu diagnóstico no período pré-natal até ao tratamento cirúrgico no período neonatal, constitui um importante desafio, tanto para o obstetra como para o cirurgião pediátrico. No âmbito do diagnóstico pré-natal, a ecografia, a ressonância magnética, bem como a análise bioquímica do líquido amniótico poderão ser úteis. Por outro lado, no que diz respeito ao tratamento cirúrgico desta condição, dispomos hoje de técnicas cirúrgicas minimamente invasivas, associadas a menor número de sequelas musculoesqueléticas, menor dor no pós-operatório e a um melhor resultado estético final. Neste artigo, os autores fazem uma revisão do papel das diferentes técnicas de diagnóstico pré-natal disponíveis, bem como das diferentes abordagens para o tratamento cirúrgico.

Lessons from the first 70 patients operated by doppler-guided haemorrhoidal artery ligation with mucopexy in a French team specialising in surgical proctology

BackgroundDoppler-guided haemorrhoidal artery ligation with mucopexy is a minimal-invasive surgical technique. It is both effective and less painful than conventional haemorrhoidectomy. MethodsWe gathered records on all patients operated on between November 2012 and June 2014. Pre- and postoperative scores were calculated during consultation and then by phone. Unsuccessful surgical treatment was defined by persistent haemorrhoid symptoms within three months following the procedure and relapse defined by recurrent symptoms after the third postoperative month. ResultsDuring the period analysed, 70 patients underwent consecutive surgical procedures for haemorrhoid prolapse (52%), bleeding (29%), or both (17%). Hospitalisation was outpatient or overnight for 87% of patients. There were no complications in 92.7% of cases. The average period away from work was 11 days (± 6.5). The time between the procedure and last postoperative consultation, followed by telephone contact, was respectively 2.7 months (± 5.8) and 16.5 months (± 4.9). At the time of the postoperative telephone call, the Thaha et al. score decreased by 5.6 (p<0.001), while the quality of life score decreased by 2 (p<0.001). The Wexner score remained the same or improved for all patients except one. Treatment was unsuccessful for 6/67 patients (9%) and 10/61 patients (16.4%) experienced a subsequent recurrence in haemorrhoid symptoms. Only those over 51 years old were statistically associated with more frequent recurrences (p=0.044). ConclusionDoppler-guided haemorrhoidal artery ligation with mucopexy is an effective technique in the medium-term. Good tolerance in makes this treatment an attractive alternative to conventional haemorrhoidectomy.

Comparison of Intra-Peritoneal Instillation of Bupivacaine and Morphine Hydrochloride versus Bupivacaine and Magnesium Sulfate for Post-Operative Pain Relief after Laparoscopic Cholecystectomy, A Randomized Double-Blind Comparison Study

Background: Surgical and laparoscopic techniques are two different methods for the removal of gall bladder. Today, laparoscopic cholecystectomy is a preferred method for short-term hospitalization and early return to function related to minimal invasive surgical technique. However, patients still complain of significant postoperative pain, secondary inflammation of the diaphragm and the nociceptive genus of the annoying membrane's peritoneum. Multimodal analgesia is necessary for managing pain after laparoscopic cholecystectomy. Magnesium sulfate is a new emerging medication for the management of acute pain. There are no previous reports to compare the analgesic effect of intraperitoneal instillation of bupivacaine plus morphine hydrochloride and bupivacaine plus magnesium sulfate for postoperative pain after laparoscopic cholecystectomy. Aim: The purpose of this study is to compare the analgesic effect of intraperitoneal instillation of bupivacaine plus morphine hydrochloride versus bupivacaine plus magnesium sulfate in patients undergoing laparoscopic cholecystectomy under general anesthesia for better pain relief and less opioid consumption during the first 24 hours. Methods: Following the approval of the Institutional Review Board of An-Najah National University and written informed consent from patients undergoing laparoscopic cholecystectomy, hundred patients between 18 and 60 years old, American Society of Anesthesiologist (ASA) Grades I and II, were randomized to one of the following groups by the sealed envelope: (Mo group) (n=50) receiving intraperitoneal instillation of 30 ml 0.25% bupivacaine and 3 mg morphine and (Mg group) (n=50) receiving intraperitoneal instillation of 0.25% bupivacaine plus 50 mg/kg magnesium sulfate to a total volume of 30 ml. Medications were given after peritoneal wash and suctioning through intraperitoneal instillation. A drug solution is prepared by a doctor who does not participate in the study. All patients received the same anesthesia method, general anesthesia was administered. The induction protocol was standard for all patients. Patients were monitored for electrocardiogram (ECG), heart rate, blood oxygenation (SpO2%) and noninvasive blood pressure (NIBP). Postoperative pain was evaluated using visual analog scale (pain score of 0-10). The participants were evaluated for 24 hours after the operation with the registration of abdominal pain. The postoperative pain outcome was reported at 0 and 30 min, 1, 4, 8, 12, 16 and 24 hours. The cut-off value for VAS is 4 for indication of rescue medication. At VAS ≥ 4, rescue analgesics were administered on request (20 mg of pethidine) intravenously in Post Anesthetic Care Unit (PACU) and 50 mg intramuscularly in the surgical ward. Results: Patients' characteristics of age, gender and BMI were comparable in the two groups. There was no significant difference between the groups regarding the duration of the surgery. The demographic parameters (age, gender and BMI) have no effect on the mean of VAS (p value>0.05). There are significant differences between Mo and Mg groups in the total VAS score (p value<0.05). In the Mo group, the mean of total VAS (2.09) was significantly lower than the mean of total VAS in the Mg group (2.71); which means that patients in the Mo group had significantly less intensity of pain than patients in the Mg group (p=0.006). There is a significant difference between the number (percent) of patients complaining of moderate to severe postoperative pain in Mo group 15/50 (30%) compared to Mg group 25/50 (50%) (p=0.0423). When estimating the size of the treatment effect of morphine hydrochloride plus bupivacaine, found that the relative risk reduction of moderate to severe pain postoperatively is 0.40. There is also a significant difference between the number (percent) of patients complained of drowsiness in Mo Group 7/50 (14%) compared to Mg group 18/50 (36%) (p=0.0115). There are no significant differences between the two study groups regarding nausea, vomiting, dizziness and urinary retention. Patients in Mo group consume less rescue analgesic dose M (± SD) (64.29 mg+22.04) compared to patients in Mg group M (± SD) (74.40 mg+25.67) without significant relationship between both doses (p-value=0.163). Blood pressure, heart rate and oxygen saturation were examined as hemodynamic parameters. The result showed that no significant relationship between these parameters and VAS (p-value>0.05). Conclusion: Intraperitoneal instillation of combination of bupivacaine with morphine hydrochloride is superior to bupivacaine plus magnesium sulfate to reduce the intensity and incidence of postoperative pain in patients undergoing laparoscopic cholecystectomy surgery without significant increase of side effects. This peripheral effect of opioid provides a new approach to pain relief that can have major clinical benefits. Recommendation: Based on the results of this study, it is recommended to consider the intraperitoneal instillation of morphine hydrochloride with bupivacaine as a standard application for laparoscopic cholecystectomy surgery to reduce postoperative pain.

Management of penile cancer patients: new aspects of a rare tumour entity

Over the past few decades, some principles in the treatment of penile cancer have changed fundamentally. While 15 years ago a negative surgical margin of at least 2 cm was considered mandatory, organ-sparing surgery permitting minimal negative surgical margins has a high priority nowadays. The current treatment principle requires as much organ preservation as possible and as much radicality as necessary. The implementation of organ-sparing and reconstructive surgical techniques has improved the quality of life of surviving patients. However, oncological and functional outcomes are still unsatisfactory. Alongside with adequate local treatment of the primary tumour, a consistent management of inguinal lymph nodes is of fundamental prognostic significance. In particular, clinically inconspicuous inguinal lymph nodes staged T1b and upwards need a surgical approach. Sentinel node biopsy, minimally-invasive surgical techniques and modified inguinal lymphadenectomy have reduced morbidity compared to conventional inguinal lymph node dissection. Multimodal treatment with surgery and chemotherapy is required in all patients with lymph node-positive disease; neoadjuvant chemotherapy has been established for patients with locally advanced lymph node disease, and adjuvant treatment after radical inguinal lymphadenectomy for lymph node-positive disease. An increasing understanding of the underlying tumour biology, in particular the role of the human papilloma virus (HPV) and epidermal growth factor receptor (EGFR) status, has led to a new pathological classification and may further enhance treatment options. This review summarises current aspects in the therapeutic management of penile cancer.

Laparoscopic Dissection of Extensive Secondary Disseminated Peritoneal Leiomyomatosis

Study ObjectiveTo demonstrate a minimal invasive surgical (MIS) technique for curative excision of extensive secondary disseminated peritoneal leiomyomatosis (DPL). DesignThe Institutional Review Board of Human Investigation and Ethics Committee of Chang Gung Medical Foundation ruled that approval was not required for this study. PatientWoman aged 46 years. Interventions, Measurements, and Main ResultsIn MIS the myoma has to be divided into small fragments for piecemeal retrieval through a small incision [1] with a widely used technique called morcellation (confined or unconfined) [2]. DPL is a rare sequellae after laparoscopic morcellation. Because this entity is rarely reported, this video demonstrates laparoscopic technique for safe removal of DPL post laparoscopic myomectomy and morcellation. A 46-year-old woman with a past history of laparoscopic myomectomy with specimen retrieval by a power morcellation 8 years ago presented with abdominal discomfort. Computed tomography revealed multiple iso-dense lesions in the uterine corpus and pelvic cavity. Upon laparoscopy multiple nodules were identified at the previous myomectomy scar, pelvic peritoneum, ovarian surface, and over the small bowel. A total laparoscopic hysterectomy with bilateral salpingo-oophorectomy along with excision of all visible lesions was performed. ConclusionsIn this video we demonstrate a safe retroperitoneal approach for complete excision of DPL. Laparoscopic hysterectomy or myomectomy with unconfined morcellation appears to be associated with the risk of DPL [3]. Complete tissue fragment retrieval will minimize the sequelae of morcellation. Hence, myoma remnants should be carefully extracted and confined morcellation should be considered. Because DPL causes significant distortion of pelvic anatomy, thorough knowledge of pelvic surgical anatomy and retroperitoneal approach for complete excision of all lesions is recommended.

A systematic literature review of time to return to work and narcotic use after lumbar spinal fusion using minimal invasive and open surgery techniques

Chronic low back pain is a common health problem for adult workers and causes an enormous economic burden. With the improvement of minimally invasive surgical techniques (MIS) in spinal fusion and the development of fusion devices, more lumbar operations are today being performed through a less invasive technique. When compared with open surgeries (OS), MIS has demonstrated better clinical outcomes including operation time, blood loss, complication rates and length of hospital stay. The aim of this review was to identify and summarize evidence on the time to return to work and the duration of post-operation narcotic use for patients who had lumbar spinal fusion operations using MIS and OS techniques. A systematic literature review was performed including studies identified from PubMed, EMBASE, the Cochrane Collaboration, and the Centre for Review and Dissemination (CRD) (January 2004–April 2014) for publications reporting on time to return to work and post-operation narcotic use after MIS or OS lumbar spinal fusion surgeries. Out of a total of 36 included studies, 28 reported on the time to return to work and 17 on the narcotic use after MIS or OS. Four studies described the time to return to work directly comparing MIS and OS. Three studies, from the US, directly compared the duration of narcotic use between MIS- transforaminal lumbar interbody fusion (TLIF) and OS-TLIF. In addition to the time to return to work, 23 studies reported on the rate of return to work and the employment rate before and after surgery, and two Swedish studies presented sick leave data. There is a gap of good quality data describing the time to return to work and narcotic use after lumbar spinal fusion operations using MIS or OS techniques. However, the current systematic literature review indicates that patients who have lumbar spinal fusion operations, with the MIS procedure, generally return to work after surgery more quickly and require less post-operation narcotics for pain control compared to patients who have OS.

Up to twelve year follow-up of the Oxford phase three unicompartmental knee replacement in China: seven hundred and eight knees from an independent centre.

There have been few large sample studies reporting the midterm outcome of Oxford phase 3 unicompartmental knee arthroplasty (UKA) in Asian patients. The study included 708 consecutive medial Oxford UKAs between February 2005 and May 2014 in Chinese patients. All cases were performed for the recommended indications with a minimally-invasive surgical technique. The functional and radiological outcomes were subsequently examined. In particular, we divided patients into the spontaneous osteonecrosis of the knee (SONK) group and the osteoarthritis (OA) group. All patients were reviewed with a mean follow-up of 6.2years (range 2.7-12years). At the latest follow up, the mean Oxford knee score (OKS) increased from 22.5 to 38.5 points, while the mean knee society score (KSS) increased from 43.6 to 86.1 points. The mean visual analogue scale pain score decreased from 7.9 to 1.5 points and the mean range of motion (ROM) increased from 112.5° to 125.2°. A total of 13 UKAs (1.88%) required revisions. The most common reason was bearing dislocation and osteoarthritis of the lateral compartment. Using revision for any cause as an endpoint, the five-year cumulative survival rate was 98.8% and the ten-year survival rate was 94.3%. There was no statistically significant difference between the SONK group and the OA group for the five-year cumulative survival rate (98.7% vs. 98.8%, P>0.05). This study demonstrates that Oxford UKA is a good option for the treatment of anteromedial OA and SONK of the knee in Asian patients.

Revision of Minimally Invasive Sacroiliac Joint Fixation: Technical Considerations and Case Studies Using Decortication and Threaded Implant Fixation.

Sacroiliac joint (SIJ) disease is increasingly recognized as a common source of low back pain. Arthrodesis of the SIJ has been shown to be clinically effective for this condition. In the last decade, minimally invasive (MI) SIJ fusion procedures have been developed to achieve the clinical effectiveness of open fusion procedures, with lower operative morbidity and faster recovery. However, SIJ fusion patients occasionally present with symptomatic nonunions necessitating revision. Four patients who previously underwent MI SIJ arthrodesis returned with complaints of SIJ related pain confirmed by examination. Radiographic assessment showed lucency after fixation with triangular titanium interference implants. Loose implants were removed, and the patients were revised with a different MI SIJ fusion system that utilizes decortication, placement of autograft and graft extender, and fixation with cannulated threaded implants. The trajectory of the revision implants was in a more ventral-to-dorsal and caudal-to-cranial trajectory to place the implants perpendicularly through the articular portion of the SIJ. The triangular implants typically exhibited haloing lucency on radiographs and CT scans, and most were easily removed using the manufacturer's instrumentation; only one implant was left in place as it was well-fixed. The removed implants exhibited little or no bony ongrowth. Decortication of the SIJ was performed, followed by placement of local autograft and fixation with 12.5 mm or 14.5mm diameter implants, as required. A more ventral-todorsal and caudal-to-cranial trajectory was established for the revision implants through the center of the articular region of the joint in order to maximize implant purchase in residual bone stock and achieve bony fusion through the articular portion of the SIJ. By six to twelve months post-revision, the presenting symptoms were successfully resolved in all patients. Patients demonstrating symptomatic pseudoarthrosis after SIJ fixation surgery can be successfully revised with decortication, grafting and fixation with threaded implants utilizing MI surgical techniques. Implant trajectory is an important consideration for primary or revision MIS SIJ fusion. Studies with longer-term follow-up of both primary and revision procedures are needed to further understand fusion rates for both primary and revision procedures utilizing both triangular and threaded implant systems.

P1.05-061 Increased Treatment-Related Toxicity in Patients with Early-Stage Non-Small Cell Lung Cancer and Co-Existing Interstitial Lung Disease

Treatment options for early-stage non-small cell lung cancer (ES-NSCLC) are generally well-tolerated. Minimally-invasive surgical techniques, stereotactic ablative radiotherapy (SABR) and radiofrequency ablation (RFA) can all achieve post-treatment mortality of <1% in clinical trial settings. There has been increasing evidence to suggest that patients with interstitial lung disease (ILD) suffer severe toxicity after treatment for NSCLC. Treatment-related toxicity may result in death and may take the form of acute exacerbations of existing ILD following surgery or RFA, or severe radiation pneumonitis following SABR. We performed a systematic review of literature in compliance with PRISMA guidelines to investigate the rate of treatment-related toxicity and mortality following treatment for ES-NSCLC. The Medline and EMBASE databases were queried from respective dates of inception to January 2016. Treatment modalities included in the search strategy were surgery, SABR, RFA, particle beam therapy and conventionally-fractionated radiotherapy. Results were summarized with weighted statistics according to the sample size of individual studies. A total of 3,054 unique records were screened and 282 full texts were reviewed. Forty-nine journal articles were included in the final analysis, with 92% of studies being retrospective in design. Thirty surgical studies with 1716 patients, 13 SABR studies with 122 patients, 3 RFA studies with 46 patients, 2 proton beam therapy (PBT) studies with 17 patients and one carbon ion beam therapy (CIBT) study with 5 patients were included. Most patients in non-surgical studies were medically inoperable. Treatment-related or 30-day post-operative mortality was 2.3%, 15.5%, 8.7%, 5.8% and 0%, respectively, for surgery, SABR, RFA, PBT and CIBT. Treatment-related acute exacerbation of ILD or radiation pneumonitis ≥ grade 3 was 12%, 25%, 25%, 12.5% and 20%, respectively. For patients treated with surgery, 5-year overall survival (OS) was 31.4% to 61.6% (median 54.2%) for patients with ILD and 70.5% to 88.3% (median 83.0%) for patients without ILD. For medically inoperable patients treated with SABR, 2 to 3-year OS was 0% to 53.8% (median 48.8%) for patients with ILD and 54% to 86.7% (median 70.8%) for patients without ILD. Studies that included only patients with idiopathic pulmonary fibrosis reported higher treatment-related toxicity compared to other studies. An elevated level of treatment-related toxicity is observed in patients treated for ES-NSCLC with co-existing ILD. Medically inoperable patients experienced high levels of treatment-related mortality. For surgery and SABR, overall survival was worse for patients with ILD compared to those without ILD.

Clinical outcome of Percutaneous Transforaminal Endoscopic Lumbar Surgery (PTELS) in patient above 60 years of age with lowback pain

Background: Percutaneous Transforaminal Endoscopic Lumbar Surgery (PTELS) is the latest advance minimal invasive surgical technique in treatment of low back pain. Objective: To evaluate the outcome of Percutaneous Transforaminal Endoscopic Lumbar Surgeries in patient above 60 years of age and to appraise the efficacy of this technique in treatment of lumbar disc herniation and lumbar spine stenosis in these age group patients. Materials and Methods: Total 77 patients with age more than 60 years were retrospectively studied, among which 45 patients presented with Lumbar Disc Herniation (LDH) and 22 patients with Lumbar Spinal Stenosis (LSS) who had undergone Percutaneous Transforaminal Endoscopic Lumbar surgery (PTELS) in Zhongda Hospital Affiliated Southeast University from June 2013 to June 2016 A.D. The calculated mean follow up was 20.87 months. Results: Mean age of operated patient was 68.33 years. Average time of surgery was 87.31+24.746 minutes. And average hospital stay after surgery was 4.79+2.711 days. The preoperative and postoperative Oswestry Disability Index (ODI) was (52.8022+11.98299, 16.3513+12.97398, p=0.000) indicating statistical significance. The Visual Analog Scale (VAS) of leg and back was (6.27+1.213, 4.79+1.162) and (1.40+1.688, 1.30+1.436) p=0.00, p=0.00 respectively with significant difference before and after surgery. On the basis of MacNab criteria 76.1% of patients showed excellent or good, 10% showed fair and 6% with poor outcome. Overall complication was 10.5% out of which 3% (2 cases) were of incomplete removal of content and 7.5% (5 cases) were of reherniation. In Lumbar Disc Herniation (LDH) there were total 45 patients, of which 26 males and 19 females. In Lumbar Spinal Stenosis (LSS) there were total 22 patients, of which 8 males and 14 females. Time of operation in two group were 87.67+25.486 and 86.59+23.724 minute respectively with p=0.537 which showed no significance difference between two groups. Hospital stay after surgery was 5.09+3.088 and 4.18+1.593 days respectively with p=0.484. There was no statistically clinical significance difference found between LDH and LSS on the basis of Oswestry Disability Index (ODI) p=0.863, 9 Visual Analog Scale (VAS) leg and back p=0.193, p=0.897, MacNab criteria p= 0.090. Conclusion: Percutaneous Transforaminal Endoscopic Lumbar Surgery can be a good alternative technique in spine surgery to relieve symptoms for low back pain with satisfactory outcome, short hospital stay and advantage regarding no need of general anesthesia for elder patient. There is no significant difference between the clinical outcome of Percutaneous Transforaminal Endoscopic Lumbar Surgery (PTES) between lumber disc herniation and lumber spine stenosis of patient above 60 years of age.

Sacroiliac Joint Fusion: One Year Clinical and Radiographic Results Following Minimally Invasive Sacroiliac Joint Fusion Surgery.

Background:Recalcitrant sacroiliac joint pain responds well to minimally-invasive surgical (MIS) techniques, although long-term radiographic and fusion data are limited.Objective:To evaluate the one-year clinical results from a cohort of patients with chronic sacroiliac (SI) joint pain unresponsive to conservative therapies who have undergone minimally invasive SI joint fusion.Methods:SI joint fusion was performed between May 2011 and January 2014. Outcomes included radiographic assessment of fusion status, leg and back pain severity via visual analog scale (VAS), disability via Oswestry Disability Index (ODI) and complication rate. Outcomes were measured at baseline and at follow-up appointments 6 months and 12 months post-procedure.Results:Twenty minimally invasive SI joint fusion procedures were performed on 18 patients (mean age: 47.2 (14.2), mean BMI: 29.4 (5.3), 56% female). At 12 months, the overall fusion rate was 88%. Back and leg pain improved from 81.7 to 44.1 points (p<0.001) and from 63.6 to 27.7 points (p=0.001), respectively. Disability scores improved from 61.0 to 40.5 (p=0.009). Despite a cohort containing patients with multiple comorbidities and work-related injuries, eight patients (50%) achieved the minimal clinically important difference (MCID) in back pain at 12 months, with 9 (69%) patients realizing this improvement in leg pain and 8 (57%) realizing the MCID in ODI scores at 12 months. No major complications were reported.Conclusion:Minimally invasive SI joint surgery is a safe and effective procedure, with a high fusion rate, a satisfactory safety profile and significant improvements in pain severity and disability reported through 12 months post-procedure.

Ablation de plaque du radius distal par voie mini-invasive (MIPO) : étude de faisabilité à propos d’une série de 388 cas

Background The purpose of this study was to evaluate the technical feasibility of a minimally-invasive surgical technique (MIPO) to perform the removal of anterior osteosynthesis plates for fractures of the distal radius. Methods We reviewed retrospectively 388 cases of removal of plates on 387 patients, of which 357 were women, with an average age of 50 years old. The incision followed the previous surgical scar. After the removal of the plate, the incision was closed using a subcuticular suture without drains or immobilization. Results The scar was in average 22,2 mm long preoperatively, 19,8 mm long in average after the incision, and 21,4 mm in average at the end of the surgery, without significant statistical difference. The scar was enlarged 13 times by involuntary skin tear and 11 times voluntarily with a scalpel. We experienced 29 device-related complications, one osseous slot without consequence and one fractured plate. No postoperative complications were encountered. Conclusion Our results show that it is possible to perform the removal of an anterior osteosynthesis plate of the distal radius by a 20 mm long surgical approach. A subsequent study comparing the MIPO technique to conventional surgical approaches will be needed to validate it.

A novel combination of two minimally invasive surgical techniques in the management of refractory radiation necrosis: Technical note

Background: Minimally-invasive approaches are attractive alternative to standard craniotomy for large intracranial tumors with potentially lesser morbidity. In this report, we describe a sequential combination of two minimally-invasive surgical techniques to treat a large intracranial tumor. Clinical presentation: A 49year-old woman presented with a history of breast cancer and large left parietal metastasis with significant perilesional edema. This was initially managed by whole brain radiation therapy and stereotactic radiosurgery. The patient underwent laser ablation of the tumor followed by internal tumor debulking using an exoscopic-assisted tubular retractor system. Post-operative MRI showed gross total coverage of the tumor by laser ablation and alleviation of mass effect. The patient recovered well and discharged on second postoperative day. Conclusion: The minimally-invasive combination of laser ablation followed by internal debulking using a tubular retractor device could be done safely and effectively as a minimally invasive alternative to standard craniotomy for large intracranial tumors.

Minimally Invasive Cervical Foraminotomy.

The minimally invasive posterior cervical foraminotomy, a motion-preserving procedure, is an excellent treatment for patients with unilateral radiculopathy secondary to a laterally located herniated disc or foraminal stenosis. Place the patient in a prone position on a Jackson table with 6 posts and with the head resting comfortably on a soft facial pillow, and tape the shoulders down to provide traction to the skin and help with fluoroscopic visualization of the lower cervical levels. Make the skin incision adjacent to the spinous process on the side of the abnormality over the operative level. Use sequential dilators to create a working portal and secure the working tube overlying the lamina-facet junction of the operative level. Perform the laminoforaminotomy with the use of a high-speed drill and a Kerrison rongeur to create a working window into the foramen. Use a nerve hook to superiorly retract the nerve root, and perform a discectomy and decompression. Obtain hemostasis with electrocautery or hemostatic foam and close the wound with a standard layered closure. A systematic review and meta-analysis of studies on open or minimally invasive surgical (MIS) techniques for posterior cervical foraminotomy showed a pooled clinical success rate of 92.7% for the 509 patients managed with the open technique and 94.9% for the 208 patients who had the MIS technique; the difference was not significant (p = 0.418)2.

RM-058 Thoracolaproscopic esophagectomy for carcinoma esophagus: our early experience and outcome

Introduction: Background: Advances in technology have allowed us to explore the possibility of performing Esophagectomy using minimal invasive surgical technique. Minimal invasive esophageal surgery has the potential to improve morbidity, mortality, hospital stay and functional outcomes when compared with open method. Although technically complex, combined laparoscopic and thoracoscopic esophageal resection is feasible. Most studies shows thoracoscopic mobilization of the esophagus in left lateral position with single lung ventilation with respiratory complication up to 8–9% where our series show potential of the thoracoscopic part of the procedure in prone position to overcome the difficulty. Methods: From March 2009 through December 2015, TLE was performed in 50 patients. All patients had histologically proved squamous cell carcinoma of the middle and lower third of the esophagus. Only one (0.77%) patient received neoadjuvant chemotherapy. The Thoracoscopic part of the procedure was performed in prone position with double lung ventilation and comfortable port placement for better view and ergonomics which significantly decreased the operative time and better post operative respiratory result. Laparoscopy done for gastric mobilization and conduit formation, minilaparotomy done to retrieved the specimen. Feeding jejunostomy was done in selective patients. Results: There were 38 men and 18 women. Median age was 64.5 years (range 34 to 72 years). There was no conversion to open method. Median ICU stay was 1 day (range 1 to 15 days) and median hospital stay was 7 days (range 4 to 22days). Perioperative mortality was 0.5% (n = 1). Anastomotic leak rate was 0.5% (n = 1). There was no incidence of tracheal or lung injury and a very low incidence of postoperative pneumonia. At mean follow up of 24month (range 2 to 7- month), stage–specific survival was similar to open and other minimally invasive series. Conclusion: Thoracolaparoscopic Esophagectomy is complex and technically difficult, but its safe in experience hand. Due to its comfortable view and excellent ergonomics in the prone position for thoracoscopy, patient do well and benefit from a shorted stay and more rapid recovery compared with open esophagectomy. It provides comparable outcomes with other techniques of minimally invasive esophagectomy and most open series. In our experience, we observed a low mortality rate (0.5%), hospital stay of 7 days, and low incidence of postoperative pneumonia. It has the potential to replace conventional and other techniques of minimally invasive esophagectomy.

Endoscope-assisted enucleation and guided bone regeneration of a recurrent aneurysmal bone cyst in the mandibular condyle

Aneurysmal bone cyst (ABC) is a locally destructive, expansive, benign bone disease which most commonly occurs in the metaphyseal region of the long bones of children and adolescents, only 1% to 3% of ABCs have been described in the jaws. The aim of this study was to explore the minimal invasive surgical technique of treating ABC occurring in the mandibular condyle. Here we present a 10-year-old girl with recurrent ABC in her left condyle and adjacent ramus. She was treated by curettage via an extraoral endoscopic-assisted surgical approach and guided bone regeneration. The patient had an uneventful postoperative period with no injury to the facial nerves and minimal scarring. No recurrence was found in 4 years (from 2011). Computed tomography (CT) showed bone formation and remodeling of the condyle and ramus. Endoscopic-assisted curettage combined with guided bone regeneration can achieve an ideal effect in the treatment of ABC of the mandibular condyle and ramus.

Reoperation rates in minimally invasive, hybrid and open surgical treatment for adult spinal deformity with minimum 2-year follow-up.

Minimally invasive surgical (MIS) techniques are gaining popularity in the treatment of adult spinal deformity (ASD). The premise is that MIS techniques will lead to equivalent outcomes and a reduction in perioperative complications when compared with open techniques. Potential issues with MIS techniques are a limited capacity to correct lumbar lordosis, unknown long-term efficacy, and the potential need for revision surgery. This study compares reoperation rates and reasons for reoperation following MIS, hybrid, and open surgery for ASD through multicenter database analysis. We retrospectively analyzed a prospective multicenter ASD database comparing open and MIS correction techniques. Inclusion criteria were: age>18years with minimum 20° coronal lumbar Cobb angle, a minimum of three levels fused, and minimum 2-year follow-up. Patients were propensity matched for preoperative sagittal vertebral axis (SVA), pelvic incidence-lumbar lordosis (PI-LL), and number of levels fused. We included 189 patients from three propensity-matched subgroups of 63 patients each: (1) MIS: lateral or transforaminal lumbar interbody fusion (LIF) and percutaneous pedicle instrumentation, (2) Hybrid: MIS LIF with open posterior segmental fixation (PSF), and (3) OPEN: open posterior fixation±osteotomies. With propensity matching, there were significant differences between groups in pre-op SVA or PI-LL (p>0.05). The MIS group had significantly fewer levels fused (5.4) (0-14) than the OPEN group (7.4) (p=0.002) (0-17). The rate of revision surgery was significantly different between the groups with a higher rate of revision (27%) amongst the HYB group versus MIS=11.1%, and OPEN=12.0%. The most common reason for reoperation in the OPEN and HYB groups was a postoperative neurological deficit (7.9 and 11.1%), respectively. The most common reason for reoperation in the MIS group was pseudoarthrosis (7.9%). Reoperation rates were not statistically different among the MIS, and OPEN surgical groups, but differed significantly on multivariate analysis with HYB group. The incidence of reoperations was twice as high in the Hybrid group compared to OPEN and MIS.

Minimally Invasive Pedicle Screw Fixation Using Intraoperative 3-dimensional Fluoroscopy-based Navigation (CAMISS Technique) for Hangman Fracture.

Retrospective comparative cohort series. To evaluate the accuracy and feasibility of minimally invasive surgical (MIS) techniques incorporating with intraoperative 3-dimensional fluoroscopy-based navigation (ITFN) for treating Hangman fracture. MIS screw fixation for Hangman fracture can decrease iatrogenic soft-tissue injury, but increase the risk of instrumentation-related complications due to lack of anatomical landmarks. With the advantages of obtaining intraoperative real-time images, automatic registration, and 3-dimensional views, the ITFN system seems to be an inherent partner for MIS. 20 patients with Hangman fracture underwent C2-C3 pedicle screw fixation using ITFN. 6 patients used MIS technique, with the other 14 patients using conventional open technique. Operative time and blood loss were recorded. The accuracy of screw positions was studied by postoperative CT scan. Neck pain visual analogue score (VAS) was evaluated and the fusion status was ascertained in 6-month follow-up. The average operative time was 134.2 ± 8.0 minutes in computer-assisted orthopaedics surgery (CAOS)-MIS group and 139.3 ± 25.8 minutes in CAOS-open group (P > 0.01). The blood loss was 66.7 ± 25.8 mL in CAOS-MIS group and 250.0 ± 141.4 mL in CAOS-open group (P < 0.01). A total of 80 screws were inserted. No screw-related neurovascular injury was observed. 83.3% (20/24) screws in CAOS-MIS group and 89.3% (50/56) screws in CAOS-open group were grade 1 screw (P > 0.01). No grade 3 screw was detected in both groups. Compared with the CAOS-open group (1.7 ± 0.6), neck pain VAS in 6-month follow-up in CAOS-MIS group (0.3 ± 0.5) was significantly lower (P < 0.01). Solid fusion was demonstrated in all the cases. The integration of these 2 techniques MIS and ITFN, we call "computer assisted minimally invasive spinal surgery," is proved to be feasible and safe for treating Hangman fracture with the advantage of significantly reduced iatrogenic soft tissue injury. So we think CAMISS technique represents the most recent modification of spine surgery.

Modified Supraorbital Keyhole Approach to Anterior Circulation Aneurysms

ObjectiveTo select a surgical approach for aneurysm clipping by comparing 2 approaches.Materials and Methods204 patients diagnosed with subarachnoid hemorrhage treated by the same neurosurgeon at a single institution from November 2011 to October 2013, 109 underwent surgical clipping. Among these, 40 patients with Hunt and Hess or Fisher grades 2 or lower were selected. Patients were assigned to Group 1 (supraorbital keyhole approach) or Group 2 (modified supraorbital approach). The prognosis according to the difference between the two surgical approaches was retrospectively compared.ResultsSupraorbital keyhole approach (Group 1) was performed in 20 aneurysms (50%) and modified supraorbital approach (Group 2) was used in 20 aneurysms. Baseline characteristics of patients did not differ significantly between two groups. Total operative time (p = 0.226), early ambulation time (p = 0.755), length of hospital stay (p = 0.784), Glasgow Coma Scale at discharge (p = 0.325), and Glasgow Outcome Scale scores (p = 0.427) did not show statistically significant differences. The amount of intraoperative hemorrhage was significantly lower in the supraorbital keyhole approach (p < 0.05).ConclusionThe present series demonstrates the safety and feasibility of the two minimal invasive surgical techniques for clipping the intracranial aneurysms. The modified supraorbital keyhole approach was associated with more hemorrhage than the previous supraorbital keyhole approach, but did not exhibit differences in clinical results, and provided a better surgical view and convenience for surgeons in patients with Hunt and Hess or Fisher grades 2 or lower.

Prevalence of work-related musculoskeletal symptoms in surgeons performing minimally invasive surgery: a review of literature

Work-related musculoskeletal disorders (WRMSDs) are a group of disorders that are caused by occupational risk factors. The introduction of minimal invasive surgical techniques has led to increased complexities in the surgical environment and practice. To find out the prevalence of WRMSDs in surgeons performing minimally invasive procedures we reviewed papers on online databases, published till 2015 and also materials available in the internet. This review shows that there is a high prevalence of WRMSDs in surgeons. The commonly areas reported were low back, neck, shoulder, wrist, hand, knee and elbow. The awareness of ergonomic practice was relatively low. Poor posture, age, gender, higher surgical volume, equipment design, OR table height, OR layout have been identified as risk factors for development of work related discomfort. In order to better understand the pathophysiological risk and injuries associated with surgery (particularly minimally invasive surgery), comprehensive objective assessment of the surgeons in the operating room setting is the need of the hour.