Rigid Telescope Research Articles

Intraoperative narrow band imaging better delineates superficial resection margins during transoral laser microsurgery for early glottic cancer.

The high rate of positive margins after transoral laser microsurgery (TLM) remains a matter of debate. This study investigates the effect of intraoperative narrow band imaging (NBI) examination on the incidence of positive superficial surgical margins in early glottic cancer treated by TLM. Between January 2012 and October 2013, 82 patients affected by Tis-T1a glottic cancer were treated with TLM by type I or II cordectomies. Intraoperative NBI evaluation was performed using 0-degree and 70-degree rigid telescopes. Surgical specimens were oriented by marking the superior edge with black ink and sent to a dedicated pathologist. Comparison between the rate of positive superficial margins in the present cohort and in a matched historical control group treated in the same way without intraoperative NBI was calculated by chi-square test. At histopathological examination, all surgical margins were negative in 70 patients, whereas 7 had positive deep margins, 2 close, and 3 positive superficial margins. The rate of positive superficial margins was thus 3.6% in the present group and 23.7% in the control cohort (P<.001). Routine use of intraoperative NBI increases the accuracy of neoplastic superficial spreading evaluation during TLM for early glottic cancer.

Survival and complications of self-expanding covered Y stent placement in malignant lesions of the carina

But de la presentation The use of stents to restore pulmonary ventilation is the technique of reference in case of carinal obstruction resulting from bronchial tumors invasion or extrinsic compression by mediastinal tumors that most commonly originate from the esophagus. Endoscopic repermeabilization of the carina is technically difficult and the general condition of patients is often poor. The aim of our study is to evaluate the complications and the survival rate of patients treated with self-expanding covered Y stent for large tumors of the carina and to identify the potential predictive factors of postoperative survival rate. Materiel et methodes We performed a retrospective monocentric study (2008–2013). All patients underwent chest CT scan before stenting. In all cases, we used an ABS Bolton Ecostent carina Y®. Stenting was done under general anesthesia using the rigid bronchoscope with Jet Ventilation. Stent placement was performed under the control of an X-ray image intensifier. A rigid telescope was also used to confirm the good position of the three segments of the stent. Resultats Thirty-two patients (26 men, mean age = 63 years) were included in our study. 20 cases (62.5%) had lung cancer and 12 cases (27.5 %) had esophageal cancer. All tumor types were included. Advanced tumor stage (stage III–IV) was present in 27 patients (87 %). There were no intraoperative or postoperative complications related to stenting (migration, fracture, and granulation). The median survival rate was 49 days (3–673 days). In 82 % of cases, death occurred and was related to disease progression. We found no difference in survival regarding the tumor type and the stage. In a multivariate data analysis, gender, age, body mass index, preoperative and postoperative pulmonary function tests (recorded in 10 patients), and tumor site had no impact on patient survival. Conclusion The use of self-expanding covered Y stent in case of carinal obstruction is a reliable technique that can be used in a palliative setting. The poor patients’ survival rate is related to their disease. It is essential to perform a prospective study with preoperative and postoperative pulmonary function tests as well a life quality evaluation, to better target and to optimize the indications for this technique.

Office-Based Injection Laryngoplasty for the Management of Unilateral Vocal Fold Paralysis

Office-based injection laryngoplasty (OBIL) is a common method of addressing glottal insufficiency. This retrospective chart review identifies the demongraphics, laterality, technique, success rate, injectates, and complications of OBIL performed over a 3-year period at a single institution. Retrospective chart review. All OBILs performed for the management of UVFP by the senior author over 3 years (2007-2009) were identified from billing records. The age, gender, laterality, underlying disease process, augmentation material, route of injection, and complications were recorded. Eighty-two OBILs were attempted on 57 patients. The most common route of access was transoral (85.6%). All OBILs were able to be completed. Injectates used were hyaluronic acid derivatives (57.3%), calcium hydroxyapatite (16%), and Cymmetra (16.5%). Three complications (3.7%) occurred. Thirty percent of patients ultimately elected for thyroplasty or ansa reinnervation, 22% found their condition to self-resolve, 14% died, and 25% were lost to follow-up. Using a variety of approaches, OBIL is possible in almost all patients. The single surgeon transoral route using a rigid angled telescope and curved injection needle was the most commonly used approach. Multiple injectates can be used and have good safety records. The final disposition of patients may be variable and warrants further investigation.

English

In ENT OPD indirect laryngoscopy is a routine procedure to examine larynx and hypopharynx. To prevent the fogging of the mirror authors used hydrogen peroxide 0.75% w/v solution which is safe and cost effective when compared to other methods to prevent fogging. KEYWORDS: Hydrogen peroxide (H2 O2), Indirect laryngoscopy (IDL), Defogging INTRODUCTION: Indirect laryngoscopy which was invented by Manuel Garcia, in 1854 and further devoiced by Dr. Johann Czermak in1857 is a routine ENT OPD procedure to visualize larynx and pharynx which is relatively simple. (1-2). When compared to fiber optic system (Rigid telescopes) the resolution of the IDL is superior to that of endoscopic examination. Apart from naked flame and hot water and using savlon this is preferred method which eventually may lead to burning of oral mucous membrane and bad taste sensation. MATERIAL AND METHODS: Dilute hydrogen peroxide solution (0.75%w/v) is used as a defogging agent on sterilized indirect laryngeal mirrors in all cases, where indirect laryngoscopic examination is required. The same solution is also used in different other occasions like few dental procedures and as a mouth wash in post tonsillectomy patients (1.5% w/v). The solution is dropped over the mirror surface and an excess is wiped off by using a Goss piece. This way a thin film of solution is formed over the surface of the mirror the patient is examined with this mirror and no fogging occurred during the procedure. The mirror is tested by emersion into the hydrogen peroxide solution 3% w/v for 24hrs and there is no deterioration in the quality of the mirror. RESULTS: For the last two years this method of defogging the indirect laryngoscopy mirror has shown no untoward incidence in our ENT OPD. Warming the mirror with spirit lamp has caused some burning incidences previously and patients become uncooperative. So this method is bypassed. Using savlon, patients complained of bad taste in the mouth. Hydrogen peroxide solution as such acts as antiseptic and is patient friendly and safe. DISCUSSION: Since the body temperature is higher than that of the mirror, when IDL mirror is introduced in the oral cavity, as soon as the patient expires there will be condensation of water vapor over the mirror. This leads to formation of fogging of the mirror. This leads to blurring of the image, so prevention of fogging becomes necessary. To do so, many centers use spirit lamp flame to warm the mirror surface. But the fact is the spirit lamp caused untoward incidences in over 100 ENT cases in UK over the years, such as injuries by the patients and staff being burnt by naked flame(3) and injuries by overheating of the mirrors. When the mirror is heated by the flame of spirit lamp,patients get worried and apprehensive. They think that it may burn oral cavity and throat. Usage of hot water is not suitable as the risk of scalding is much greater and repeated usage of same water causes cross infections. (Few centers in UK use baby bottle warmers to keep the

Endoscopic Retro‐auricular Thyroidectomy: A Preclinical Feasibility Study in Three Cadavers

Objectives: A number of remote-access thyroidectomy techniques with the assistance of endoscopic or robotic technology have been described. Most gasless endoscopic thyroidectomies require additional incision on the chest or mammary areola for instrumentation. Recently, Terris DJ et al. developed a novel remote-access robotic facelift thyroidectomy technique. We aimed to evaluate the preclinical feasibility of endoscope-assisted thyroidectomy and central neck dissection via retro-auricular single incision in three cadavers. Methods: Three fresh, unembalmed human cadavers were used. A 5-mm, 30-degree rigid telescope, endoscopic instruments, and a Harmonic scalpel were used. Working space was created through the retro-auricular incision. Surgical procedures included the identification and ligation of the superior thyroid pedicle, peri-thyroid fascia dissection, dissection of the inferior pole, identification of the recurrent laryngeal nerve (RLN), dissection near the Berry ligament, and isthmusectomy. Results: We successfully performed total thyroidectomy and central neck dissection in all three cadavers. In all thyroidectomies, the RLN and superior or inferior parathyroid glands were preserved. There was no tracheal or esophageal injury. To confirm surgical completeness after thyroidectomy and central neck dissection, we analyzed the specimen to determine if there was violation of the thyroid capsule, and we reviewed the surgical field to check for remnant thyroid tissue. There was neither capsule injury in the specimen nor remnant thyroid tissue in the surgical field. The working space was adequate for the instrumentation, and no additional incision was needed. Conclusions: Our study demonstrates the feasibility of endoscope-assisted thyroidectomy using a gasless, retro-auricular single approach that results in safety, surgical completeness and sufficient access.

Usefulness of a novel observation method using a small-diameter rigid telescope through the gastrostomy catheter at exchange

During catheter exchange for percutaneous endoscopic gastrostomy (PEG), endoscopic or radiological observation is widely used to confirm that the catheter is placed correctly. However, to carry out these procedures in all patients at every catheter exchange costs time and money. It is therefore important to develop a reliable and safe method, which can also be used outside the clinic, to check the exchanged catheter. We examined the usefulness and safety of intragastric observation using a small-diameter rigid telescope, which can be inserted through the catheter lumen of a PEG tube. Before and after catheter exchange, observation was carried out using the rigid telescope E02700 (external diameter: 2.7 mm; Nisco Co., Tokyo, Japan). After air insufflation by the novel air-supplying adaptor, the rigid telescope was inserted through the button catheter for observation of the fistula and gastric lumen with guidewire introduction. Next, the old gastrostomy catheter was replaced by a new one, using the guidewire technique. Subsequently, the telescope was re-inserted to check the fistula and gastric lumen. With this technique, observation inside the stomach as well as inside the fistula was achieved without any complication during all 80 exchange trials in the 55 patients studied. A homemade adaptor was used effectively to convey air and water into the stomach during the observation. It is suggested that observation inside the stomach using a small-diameter rigid telescope at the time of gastrostomy exchange is useful and safe for checking the location of the newly fixed catheter.

Overcoming nasal discomfort—A novel method for office‐based laser surgery

The passage of a flexible channeled laryngoscope for office-based laser laryngeal surgery can be limited by narrow nasal passages, nasal discomfort, or both. We describe a novel method for delivering the laser fiber transorally with simultaneous laryngeal visualization to avoid these limitations. This technique can be employed with instruments available in most otolaryngologists' offices. A retrospective chart review was performed and procedural details were recorded. Technical description: A laser fiber was threaded through the shaft of an Abraham cannula. A patient was seated in an otolaryngology examination chair and instructed to hold and stabilize his own tongue. Using his nondominant hand, the surgeon placed a rigid angled telescope into the patient's oral cavity for laryngeal visualization. Using his dominant hand, the surgeon simultaneously introduced the laser fiber threaded through the Abraham cannula into the patients oral cavity and guided it towards the patients larynx. Energy from the PDL, KTP, or CO(2) flexible laser fibers was then delivered for management of glottic papillomatosis and leukoplakia. Treatment of glottic lesions was achieved successfully in all cases with titration endpoints identical to the transnasal approach. For patients who cannot tolerate transnasal passage of a flexible channeled laryngoscope during office-based laser laryngeal surgery, an attractive alternative to surgery under general anesthesia is the transoral technique. This approach does not rely on distal chip endoscopes and can be performed with existing equipment in an office setting.

NBI HDTV Magnifying Endoscopy in Laryngeal Papillomatosis and Laryngeal Spinocellular Cancer

Objective: NBI (Narrow Band Imaging) helps to visualize subtle changes in microvascular architecture linked to neoangiogenesis. Combination of NBI with HDTV (high-definition television) and magnifying endoscopy provides best sensitivity and specificity. The most frequent false positive results were reported in laryngeal papillomatosis where the micro-vascular pattern could be misinterpreted as neoplastic. Method: Patients with clinical diagnosis of papillomatosis or laryngeal cancer were included in the study. NBI HDTV camera head was used in combination with rigid magnifying telescope during microlaryngoscopy. Type and extent of micro-vascular mucosal changes were recorded. Mucosal lesions were removed radically and histologically evaluated and correlated with clinical findings. Results: Preliminary results show that increased neoangiogenesis is present in both laryngeal papillomatosis and laryngeal SCC. The presence of prolonged and enlarged capillary loops was observed in both groups. This yields difficulties in differentiation between both entities. Conclusion: The discrimination of papillomatosis and early stage of laryngeal SCC is difficult even when NBI HDTV magnifying endoscopy is used. Creation of special classification of capillary loop changes in laryngeal mucosa is needed.

Transumbilical Single-Incision Laparoscopic Cholecystectomy with Conventional Instruments and Ports: The Way Forward?

The quest for scarless surgery continues, but the goal remains elusive. The logical top contender was natural orifice surgery, but unfortunately even today it remains in infancy. Minilaparoscopy also did not generate much interest. In this scenario, transumbilical single-incision laparoscopy surgery holds promise, especially as far as cosmetics is concerned, and may be the ultimate answer. All the 240 patients were operated by the same surgeon through a transversely placed umbilical incision in the upper half of the umbilicus. Three conventional ports, 10, 5, and 5 mm, were introduced through the same skin incision but separate transfacial punctures. The instruments included 10- and 5-mm 30° rigid telescopes and rigid instruments as in standard laparoscopic cholecystectomy (SLC). Patients with acute cholecystitis and calculous pancreatitis were included, but those with choledocholithiasis were excluded. Results were compared with those with SLC. Patients were predominately female, with an average age of 37.6 years. Ten patients had difficult gallbladders, 24 had acute cholecystitis, and 10 had calculous pancreatitis. The mean operating time was 25.8 minutes, compared with 18.4 minutes in SLC. Intracorporeal knotting was required in 2 patients. Conversion to SLC was required in 5 patients. Morrisons pouch drain was left in 1 patient. Injectable analgesic was required in 138 (57.5%) patients and infection was seen in 2 (0.8%) patients. Transumbilical single-skin-incision laparoscopic cholecystectomy performed solely with conventional instruments is feasible, easy to learn, and probably the future of laparoscopic cholecystectomy.

Single-Incision Laparoscopic Transabdominal Preperitoneal Inguinal Hernia Repair Using Only Conventional Instruments: An Initial Report

Notes is the logical answer to scarless surgery, but despite being around for almost 4-5 years, it has to still garner a major support because of a number of limitations. Single-incision laparoscopic surgery, especially when done through the umbilicus, should be the perfect answer as far as the absence of any visible scar is concerned. All the 67 patients were operated by the same surgeon through a transversely placed umbilical incision in the lower half of the umbilicus. Three conventional ports, 10, 5, and 5 mm, were introduced through the same skin incision but separate transfacial punctures. The instruments included 10-mm and 5-mm 30° rigid telescopes and rigid instruments as in standard laparoscopic cholecystectomy. Patients with irreducible hernia and obstructed hernia were included, and those with strangulated hernia were excluded. All the patients were men, with an average age of 38.6 years. Three patients had bilateral hernia and 2 each had irreducible and obstructed hernia. The mean operating time was 42.8 minutes for unilateral hernias when tackers were used and 51.7 minutes in those in whom intracorporeal suturing was done. The operating time for bilateral hernias was 71.7 minutes. There was minimal flap discharge, without infection, in 3 patients. There were no other complications. There were no conversions and no recurrences upto 9 months of follow-up. Transumbilical single-skin-incision laparoscopic transabdominal preperitoneal repair for groin hernias, performed solely with conventional instruments, is feasible, easy to learn, and probably the future of laparoscopic inguinal hernia repair.

Sterilisation of hybrid Galapagos tortoises (Geochelone nigra) for island restoration. Part 1: endoscopic oophorectomy of females under ketamine-medetomidine anaesthesia

An endoscopic sterilisation technique for use in Galapagos tortoises (Geochelone nigra) was developed as part of a conservation and ecosystem restoration project. Fifteen female giant Galapagos tortoises were anaesthetised, intubated...

Contact Endoscopy as a Novel Technique in the Detection and Diagnosis of Mucosal Lesions in the Head and Neck: A Brief Review

Background. There are a variety of described noninvasive optical detection techniques for evaluation of head and neck mucosal lesions. Contact endoscopy is a promising method of in vivo microscopic examination whereby a rigid telescope is placed on a previously dye-stained mucosa allowing evaluation of the superficial cell layers of the epithelium. This technique produces real-time, magnified images of cellular architecture of surface mucosa comparable to histology without the need for biopsy. In this review, we will briefly summarize the efficacy of CE in the detection of precancerous and cancerous mucosal lesions and its potential as a novel technique in early diagnosis, monitoring, and preoperative assessment of mucosal lesions of the head and neck. Methods. PUBMED, MEDLINE, and COCHRANE search revealed five prospective articles on contact endoscopy for the diagnosis of mucosal lesions in the head and neck. Results. The literature search yielded five prospective studies examining contact endoscopy for the diagnosis of benign versus malignant head and neck mucosal lesions. These reported a sensitivity and specificity of 77–100%, specificity of 66–100% and an accuracy of 72–92%. Conclusion. Contact endoscopy is a promising optical technology that may be a useful adjunct in the evaluation and diagnosis of benign and malignant head and neck mucosal lesions. Future prospective randomized double-blind studies of this detection method are required.

Laryngeal steroid injection for vocal fold scar

Vocal fold scar is generally caused by trauma or from iatrogenic causes such as intubation, radiation therapy or phonomicrosurgery. Once a vocal fold scar has occurred it becomes a difficult problem to treat. There are many different tools that otolaryngologists use for vocal fold scar treatment. This study reviews the literature and discusses the usefulness of laryngeal steroid injection for the treatment of vocal fold scar. Steroid injection can be performed on an outpatient basis using a rigid laryngeal telescope or with a flexible laryngoscope under topical anesthesia. This technique allows easy surgical manipulation with a good visual field and an easy accurate approach to the lesion. The literature is limited regarding the benefits of steroid injection for vocal fold scar. Steroid injection of the scarred vocal fold using an office-based technique is one of the ways that we can treat vocal fold scarring that may improve the patient's voice outcomes with minimal side effects or complications.

Treatment of anterior skull base defects by a transnasal endoscopic approach in children

The object of this study was to assess the efficacy and complications of endoscopic management of anterior skull base defects. The authors reviewed the medical records of 28 children (20 boys and 8 girls) undergoing endoscopic repair of anterior skull base defects in their tertiary referral center between 2001 and 2008; 18 cases were congenital and 10 cases posttraumatic. During the endoscopic procedure, rigid telescopes--2.7 or 4 mm in diameter, with 0° or 30° lenses--were used. In 23 patients the anterior skull base defect was sealed with fragments of middle turbinate (bone and mucosa). In the remaining 5 patients it was sealed with cartilage harvested from the nasal septum (3 cases) or from the auricle (2 cases), fibrin glue, and oxidized cellulose. A combined external and endoscopic approach was required in 3 cases because of the size and extensions of the encephalocele. Outcome was primarily assessed by means of clinical examination, nasal fibroscopy, and imaging. The mean duration of follow-up was 26.7 months (range 9-57 months). One patient treated by a combined approach died of meningitis 2 years after surgery. In the remaining 27 patients, there was no recurrence of CSF leak, meningitis, or encephalocele. An iatrogenic frontal or ethmoidal mucocele was observed in 4 cases. The endoscopic approach is a minimally invasive, safe, and efficient technique for removing nasal encephaloceles in children.

Anatomical and technical correlates in endoscopic anterior skull base surgery: A cadaveric analysis

Objective The objectives of this study were to 1) evaluate anatomical relationships and 2) develop technical correlates for endoscopic anterior skull base (ASB) surgery. Study Design Cadaver study. Setting Minimally invasive surgery laboratory. Subjects and Methods Ten adult fresh-frozen cadaver heads were dissected from December 2006 to December 2007. The endoscopic trans-cribriform, trans-ethmoid approach to the anterior cranial base was refined over these consecutive dissections. Endoscopic orientation along the ventral axis was assessed with 0°, 30°, and 70° rigid telescopes. Anatomical dimensions of the ASB window were measured in the anteroposterior (posterior table of frontal sinus to planum sphenoidale) and transverse (orbit-to-orbit) dimensions at the anterior ethmoid artery (AEA) and posterior ethmoid artery (PEA). Results Endoscopic cadaveric dissections confirmed technical feasibility of ASB surgery and greatly enhanced understanding of ASB anatomical concepts. The 30° rigid endoscope provided the most optimal view from the frontal sinus to the planum sphenoidale with the least distortion, relative to 0° and 70° scopes. Careful identification of the AEA and PEA was requisite for proper orientation at the ASB. The posterior one third of the ASB was thickest and always required drilling for resection. The mean boundaries of the ASB window were 33.7 mm (anterior to posterior) and 23.5 and 19.1 mm at the AEA and PEA (orbit to orbit), respectively. Conclusion This prospective cadaveric study outlined key correlates for endoscopic ASB surgery. It serves to highlight the requisite technical steps and anatomical dimensions when the trans-nasal endoscopic route is employed for ASB pathology.

A model for 532‐nanometer pulsed potassium titanyl phosphate (KTP) laser—Induced injury in the rat larynx

The potassium titanyl phosphate (KTP) laser is emerging as a potentially effective treatment for various vocal fold pathologies. To date, the precise mechanism(s) of action of this wavelength on the layered microarchitecture of the vocal fold remains unknown. The purpose of this study is to develop an in vivo model for the use of the KTP laser in the rat vocal fold and to characterize the potential of this model for future studies. In vivo survival surgery. A model for videoendoscopic visualization and injury to the rat vocal fold was established using a microlaryngoscope and rigid telescope. Unilateral vocal fold injury was induced with the KTP laser at 10 Watts (W) 20 milliseconds (ms) pulse width. Animals were euthanized at 1 day post-treatment. Larynges were subjected to gross visual analysis and histological analyses via hematoxylin and eosin and trichrome staining. Consistent endoscopic visualization and injury was obtained without significant operative morbidity or mortality. The KTP laser caused superficial blanching and minor edema in the vocal fold, which resolved grossly by 24 hours postinjury. A modest inflammatory cell infiltrate was observed 1 day following injury. However, no remarkable alterations to the vocal fold microarchitecture were observed in the acute period. We propose that this novel model simulates the clinical scenario of laser use for the vocal folds. Use of this model will allow us to further characterize effects, mechanisms, and therapeutic efficacy of this wavelength.

Flexible Laryngoscopy: A Comparison of Fiber Optic and Distal Chip Technologies—Part 2: Laryngopharyngeal Reflux

Part 1 of this paper compared fiber optic (FO) and distal chip (DC) flexible technologies in the diagnosis of vocal fold masses and mucosal wave abnormalities. Part 2 of this study was designed to evaluate the usefulness of FO and DC flexible imaging in the diagnosis of laryngopharyngeal reflux (LPR) disease. Thirty-four consecutive patients were examined with either FO or DC flexible stroboscopy followed immediately by rigid stroboscopy. Rigid stroboscopy was considered the "gold-standard" for this study. All stroboscopy segments were evaluated by two laryngologists, an otolaryngologist, a laryngology fellow, and an otolaryngology resident for physical findings of LPR using the Reflux Finding Score (RFS) and Posterior Erythema Grade (PE grade). Both flexible systems underrepresented the physical findings of LPR compared to the rigid examination, but the FO system was frequently more accurate than the DC system. For PE grade, agreement with the rigid endoscope was 95% for the FO system and 73% for the DC system. Total RFSs for both flexible systems were significantly different than RFSs from the corresponding rigid examinations (P=0.001). Raters who used the RFS more often were more consistent. More severe PE grade scores correlated well with increasing RFSs. The number of patients diagnosed with LPR (RFS>7) showed that despite differences in the category scores, the FO and DC were almost identical in how much LPR was diagnosed compared with their matched rigid examination. Because both flexible platforms significantly underrepresented reflux signs, we recommend that a rigid laryngeal telescope be used when examining the larynx for signs of LPR. If this is not available, these data suggest that a high-quality FO endoscope may be more accurate than a DC endoscope for most otolaryngologists.

Comparison of the effects of room air and N2O + O2 used for ProSeal LMA cuff inflation on cuff pressure and oropharyngeal structure

This study aimed to evaluate the effects of different inflating gases used for ProSeal LMA (PLMA) cuff inflation on cuff pressure, oropharyngeal structure, and the incidence of sore throat. Eighty patients (American Society of Anesthesiologists; ASA I-II) were randomly divided into two groups. PLMA cuff inflation was achieved with appropriate volumes of 50% N2O + 50% O2 in group I and room air in group II, respectively. When the PLMA was removed, oropharyngeal examination was carried out immediately, using a rigid optical telescope. Patients were asked about sore throat symptoms postoperatively. Cuff pressures were significantly lower in group I, except at the initial pressure measurement. Cuff pressure was positively correlated with the length of the operation in group II, and negatively correlated in group I. PLMA cuff inflation with room air led to increased cuff pressure during the operation, possibly due to the diffusion of N2O into the cuff. We consider that a PLMA cuff inflated with an N2O-O2 mixture is convenient, especially in operations in which N2O has been used.

Laryngeal Complications of Endotracheal Intubation

An endotracheal tube placed in the larynx, even for a short time, causes at least superficial mucosal damage, an injury that normally heals readily. Long-term intubation, on the other hand, may cause pressure necrosis that can extend into submucosa, perichondrium, and eventually cartilage. The sites of involvement include the medial surface of the arytenoid cartilages, vocal processes, cricoarytenoid joints, posterior glottis, and subglottis. We review the pathogenesis, endoscopic recognition, classification, and progression of intubation injuries and examine the many variables that influence them. Diagrammatic flow charts trace the acute injuries through to their chronic sequelae, including subglottic stenosis, which is commoner in infants and children, and posterior glottic stenosis, which is commoner in adults. Systematic endoscopic assessment, under general anesthesia, using rigid telescopes to evaluate laryngeal damage during intubation is recommended and critically discussed. Endoscopy permits an informed judgment with regard to continuation of intubation. Depending on the severity and depth of ulceration, intubation can be continued (sometimes with a tube of smaller diameter) or tracheotomy performed, with an awareness of the attendant risks and benefits. Unnecessary tracheotomies may be avoided. Further, it may be possible to minimize untoward outcomes of prolonged intubation by using management techniques directed at known risk factors.

Editorial Comment on: Transumbilical Single-Port Surgery: Evolution and Current Status

Canes and colleagues focus our attention on a further modification of laparoscopic surgery: the transumbilical single-port surgery [1]. Their historical overview demonstrates clearly that this is an old technique pioneered by gynecologists in the 1960s using an operative laparoscope with an offset eyepiece comparable to the rigid nephroscopes used during percutaneous renal surgery [2,3]. However, in the year 2008, it seems that things have to be more fancy. Whereas laparoscopists initially used the umbilicus as an easy-to-hide entrance for the trocar, in the era of natural orifice transluminal endoscopic surgery (NOTES), the umbilicus has gained more importance, being recognized as an ‘‘embryonic natural orifice.’’ This has resulted in the new term ‘‘E-NOTES.’’ But the reader should be aware of the distinct differences between NOTES and the transumbilical laparoscopic single port technique. NOTES has been pioneered by gastroenterologists and surgeons who used the technology of a flexible gastroscope with different working channels to perforate the stomach and then to reach the peritoneal cavity. In the peritoneal cavity, complex procedures such as appendectomy and cholecystectomy have been carried out using specialized flexible endoscopes and devices (ie, intraluminal clip appliers). After transoral removal of the organ, the gastric wall was closed with intraluminal suturing techniques [4]. Single-port surgery is completely different and goes back to the operative resectoscope developed by Buess in the 1980s for transanal endoscopic microsurgery [5]. This device consists of a rectoscope 40 mm in diameter with up to five ports for insertion of the telescope and curved instruments. The principle of this device has been modified for transumbilical laparoscopy with three ports for insertion of a rigid or flexible telescope and flexible or bent instruments. Although the necessity and importance of an operative nephroscope, a complex gastroor coloscope, and an operative resectoscope has been proven over decades for intraluminal surgery, the role of such devices for transluminal and laparoscopic surgery remains uncertain. It is impressive to see what type of laparoscopic procedures have been carried out, but in my view, there is still no argument for not using the standard trocar technique, which provides efficient solutions to the main problems of E-NOTES, such as triangulation, retraction, instrument crowding, and in-line vision. However, endoscopic surgey will definitely benefit from the technological input (ie, flexible instruments, staplers) of these ‘‘new old’’ techniques.