Scarless Approach Research Articles

Morphometric Analysis and Observer Perceptions Following Transvestibular Chondrolaryngoplasty.

To assess novel morphometric measurement strategies and observer perception ratings as potential metrics for evaluating gender-affirming transvestibular chondrolaryngoplasty in reducing contour protrusion of the neck. High-resolution preoperative and 3-month postoperative photographs of a pilot series of 10 patients (n = 10) who underwent endoscopic transvestibular chondrolaryngoplasty were collected. Morphometric measurements of "light reflex" and lateral view thyroid protrusion angles of the neck contours were analyzed. Pre- and postoperative photographs were presented in random order in a survey to 17 untrained judges and rated on perceived masculinity/femininity and thyroid notch protrusion on a 7-point scale. A pre- to postoperative change in morphometric angles and subjective ratings was assessed using paired t-tests and Wilcoxon signed-rank tests. Mean light reflex angles were reduced after surgery from 78.6° to 40.5° in the anterior neutral view (P = .0003), from 45.2° to 24.4° in the anterior extended view (P = .003), and from 7.03° to 4.32° in the lateral view (P = .006). Median survey ratings of neck photographs were improved after surgery, from 4 to 3 in gender perception toward more feminine perception (P < .0001) and from 4 to 2 in thyroid protrusion toward less protrusive perception (P < .0001). Morphometric analysis in anterior and lateral views as well as subjective gender perception and contour protrusion measures following feminization chondrolaryngoplasty by endoscopic transvestibular scarless approach demonstrate encouraging possibilities as outcome evaluation measures for chondrolaryngoplasty.

Endoscopic laryngotracheoplasty (Maddern procedure) for idiopathic subglottic stenosis

•Endoscopic laryngotracheoplasty (Maddern procedure) is a scarless and durable therapy for iSGS. •Maddern procedure avoids risks associated with cricotracheal resection. •Surgery includes endoscopic scar excision with placement of a split-thickness skin graft and stent. •Exclusion criteria are dense posterior scar, glottic involvement, and long segment stenosis. Endoscopic laryngotracheoplasty, also known as the “Maddern procedure,” is a definitive endoscopic treatment for subglottic stenosis via a scarless approach. This technique focuses on endoscopic resection of the subglottic mucosa and scar without disturbing the cartilaginous framework of the larynx and trachea. A split-thickness skin graft is then used to reline the tracheal lumen, in order to facilitate healing and avoid scar recurrence. The skin graft is held in place by a silastic stent. This article describes the surgical technique of endoscopic laryngotracheoplasty, as well as peri-operative considerations and possible complications. Endoscopic laryngotracheoplasty, also known as the “Maddern procedure,” is a definitive endoscopic treatment for subglottic stenosis via a scarless approach. This technique focuses on endoscopic resection of the subglottic mucosa and scar without disturbing the cartilaginous framework of the larynx and trachea. A split-thickness skin graft is then used to reline the tracheal lumen, in order to facilitate healing and avoid scar recurrence. The skin graft is held in place by a silastic stent. This article describes the surgical technique of endoscopic laryngotracheoplasty, as well as peri-operative considerations and possible complications.

Scarless Modified Approach to Subcondylar Fracture Bypassing the Parotid Gland- A Case Report

Subcondylar fractures contribute about 19-29% amongst all the mandibular fractures worldwide, yet the treatment paradigm remains slightly controversial. Subcondylar fractures are pivotal in maxillofacial surgery for diverse reasons, as they can result in number of complications, whether treated or not. Initial clinical outcomes may appear pragmatic but complications such as pain, restrictions of jaw movements, muscle spasm, mandibular deviation, malocclusion, and facial asymmetry may become apparent. Fracture of tympanic part, mandibular fossa of temporal bone, may or may not be escorted by dislocation of condylar segment into middle cranial fossa, damage to blood vessels, arteriovenous fistula are some additional complications. Choosing right surgical strategy is a for minimising postoperative complications management of subcondylar fractures and it should be taken in account that, perioperative, functional, and patient-reported outcomes. The majority of studies that have been published describe the use submandibular, retromandibular, or preauricular incisions have drawbacks such as poor visibility, accessibility, and the potential to harm facial nerve and complications related to the parotid gland. Hereby, the authors present a case report of left subcondylar fracture in a 55-year-old, male patient, where a modified percutaneous approach was taken, to access the fracture, and aid in adequate reduction and proper fixation without any postoperative complications. In this approach, parotid gland is bypassed and masseter muscle fibres are excised to reach the fractured site at subcondylar region. It is small, straight forward, elementary, safe, reliable and scarless approach for the management of subcondylar fractures that ensures adequate exposure of the fractured site, osteosynthesis and minimal potential postoperative complications.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) learning curve: a regression analysis of complication rates and severity.

Transoral Endoscopic Thyroidectomy Vestibular Approach (TOETVA) is a natural orifice transluminal endoscopic surgery that offers a truly scarless approach to thyroidectomy. Introduced in 2008, there is a growing body of literature establishing it as a safe endoscopic approach for thyroid procedures. While it is not yet widely practiced, it is quickly growing in popularity. As more surgeons begin to add this technique to their repertoire the question of the learning curve has to be examined. Case series from the initial TOETVA operations of four surgeons at three different hospitals were examined. Binomial and ordinal logistic regression were used to characterize the changes in complication rate and severity as they related to case number in the series. Statistics were performed in Minitab and SAS. Each surgeon performed between 23 and 40 TOETVA operations for a total of 130 cases. Binary logistic regression shows a negative relationship between case number and complication rate (P < 0.001, Odds Ratio: 0.91). Ordinal logistic regression shows a negative relationship between case number and complication severity (P < 0.001, Odds Ratio: 1.07). The maximum slope of improvement of complication rate occurred at case number 12. The most significant decrease in complications for TOETVA occurs at case 12. As case number progresses, there is a significant decrease in both the risk of a complication occurring and of the severity of that complication. These results support the previously published data on TOETVA learning curve based on operative time.

Preferences for thyroidectomy technique: Comparing traditional and transoral approaches.

We investigated preferences between the transcervical and transoral thyroidectomy approach in the United States and Israel. An online survey assessing scar attitudes and surgical preferences, in English and Hebrew, was distributed on ThyCa.com and other platforms. 928 and 339 responses from the United States and Israel cohorts, respectively, were analyzed. In both countries, individuals without prior thyroidectomy preferred a scarless approach when hypothetical risks equaled those of traditional thyroidectomy (77% United States, 76% Israel, p = 0.61). U.S. respondents without thyroidectomy had greater preference to avoid a scar and would pay more to do so than those with thyroidectomy (both p < 0.001). Many respondents with prior thyroidectomy still expressed interest in scarless alternatives (57% United States). Populations in Israel and the United States prefer scarless thyroidectomy when risks equal the traditional approach. While individuals without prior thyroidectomy are more likely to favor a scarless option, former thyroidectomy patients may have preferred avoiding a scar.

Transoral endoscopic thyroidectomy-vestibular approach: starting a program in an inner-city hospital

: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) is quickly gaining popularity as the only truly scarless approach to central neck surgery. The literature reports more than 1,000 cases completed around the world. Starting a program incorporating this approach has obvious challenges in regards to surgeon training, building a team and recruitment of patients. We describe the methods of training and recruitment strategies used in the establishment of a transoral endoscopic thyroid program in an inner-city community hospital. In addition, we describe the demographics, nodule characteristics and operative times for our initial experience with 4 cases. These cases were performed successfully without any complications and great patient satisfaction. On review of the case load of the senior author we estimate that approximately 56% of our head and neck endocrine cases will be eligible for this approach in the future.

No-Scar Breast Reduction Utilizing Power-Assisted Liposuction Mammaplasty, Loops, and Lipofilling.

In continued interest to develop and refine minimally invasive procedures, recent publications reported a scarless approach in breast lifting. The authors sought to describe a power-assisted lipomodeling technique combined with surgical loops to achieve breast reduction and reshaping with minimal scars. Between 2014 and 2018, 94 patients underwent breast reduction by combined liposuction and loops. Following infiltration of the breasts, liposuction of the outer quadrants and the lower pole was achieved to reduce the breast footprint and the lateral and inferior heaviness of the breast. After multiaxial multiplanar tunnelization, 3 types of loops were taken around the breast to suspend and elevate the breast skin envelope and parenchyma. Each loop was guided through a 3-mm, 3-hole cannula passed through skin stab incisions. The first loop was designed to reduce the breast footprint and enhance the breast projection, whereas the second loop was designed to achieve breast conus remodeling. The third loop was passed circumferentially around the areola and then cephalad along the breast axis and pulled until the desired nipple-areola complex elevation was reached. Each loop was pulled to achieve the desired breast projection and shape. The authors achieved breast reduction with a mean nipple elevation of 7.3 cm, and 88% of patients were satisfied with their breast shape. The total complication rate was 1%, including mild cellulitis in 1 breast, treated efficiently with oral antibiotics. The proposed technique is a novel, simple, and safe alternative to achieve breast reduction and reshaping without a scar.

The Influence of Cosmetic Concerns on Patient Preferences for Approaches to Thyroid Lobectomy: A Discrete Choice Experiment.

Background: Newer transoral thyroidectomy techniques that aim to avoid scars in the neck and maximize cosmetic outcomes have become more prevalent. We conducted a discrete choice experiment (DCE) to evaluate the influence of cosmetic concerns and other factors on patients' decision-making processes when choosing among different thyroidectomy approaches. Methods: A questionnaire was developed to identify key attributes driving patient preferences around thyroidectomy approaches using mixed analyses of patient focus groups, expert opinion, and literature review. These attributes included (i) risk of recurrent laryngeal nerve (RLN) injury, (ii) risk of mental nerve injury, (iii) travel distance for surgery, (iv) out-of-pocket cost, and (v) incision site. Using fractional factorial design, discrete choice sets consisting of randomly generated hypothetical scenarios across all attributes were created. A face-to-face DCE survey was administered to patients being evaluated in clinic for thyroid lobectomy for noncancerous thyroid disease. Participants chose among scenarios constructed from the choice sets of attributes. Analyses were conducted using a mixed logit model, and the trade-offs between different attributes that patients were willing to accept were quantified. Results: The DCE was completed by 109 participants (86 [79%] women; mean age 51.3 ± 3.0 years). Overall, the risk of having RLN and/or mental nerve injury, travel distance, and cost were the most influential attributes. Participants aged ≤60 years significantly preferred an approach without a neck incision and were willing to accept an additional $2332 USD in out-of-pocket cost, 693 miles of travel distance, 0.6% increased risk of RLN injury, and 2.2% risk of mental nerve injury. Patients aged >60 years significantly preferred a conventional neck incision and were willing to pay an additional $3401 out-of-pocket and travel 1011 miles to avoid a scarless approach. Conclusions: The risk of nerve injury, travel distance, and cost were the most important drivers for patients choosing among surgical approaches for thyroidectomy. Cosmetic considerations also influenced patient choices, but in opposing ways depending on patient age.

Instrumentation and technological future directions for transoral thyroidectomy

Transoral thyroidectomy is made possible with by the use of endoscopic and robotic technology through a novel, scarless approach in the lower lip. As with any new procedure, proper instrumentation and familiarity with all elements of the operation are of paramount importance. In this chapter we review the instrumentation for endoscopic and robotic transoral thyroidectomy and look towards the future.

Transoral thyroidectomy: advantages and limitations.

In this opinion paper of the Journal of Endocrinological Investigation, leading experts in the field report on their current clinical experience with a novel approach for thyroid gland surgery, namely, "transoral thyroidectomy" (TOT). This feasible and novel surgical procedure does not require visible incisions and is, therefore, a truly scarless surgery. Patients meeting the following criteria can be considered as candidates for TOT: (a) an ultrasonographically (US) estimated thyroid diameter ≤10cm; (b) US-estimated gland volume ≤45mL; (c) nodule size ≤50mm; (d) presence of a benign tumor such as a thyroid cyst or a single- or multi-nodular goiter; (e) Bethesda 3 and/or 4 category and (f) papillary microcarcinoma without the evidence of metastasis. The procedure is conducted via a three-port technique at the oral vestibule using a 10-mm port for the 30° endoscope and two additional 5-mm ports for the dissecting and coagulating instruments. TOT is performed using conventional endoscopic instruments and is probably the best scarless approach to the thyroid because of the short distance between the thyroid and the incisions placed intra-orally that do not result in any cutaneous scar and upon following the surgical planes. Experts in TOT organized a working group of general, endocrine, head and neck ENT surgeons and endocrinologist to develop the standards for practicing this emerging technique.

Nerve-Sparing Laparoscopic Colposacropexy Using a Percutaneous Surgical System: A Case Report

Study ObjectiveThe primary aim of this study was to evaluate the feasibility, efficacy, and safeness of nerve-sparing laparoscopic colposacropexy performed with a minimally invasive approach by using 2.9-mm Percuvance percutaneous surgical system (PSS; The Percuvance System; Teleflex Inc., Wayne, PA). The secondary aim was to investigate the technical performance of these instruments as needle holder in the placement of the mesh. The final aim was to establish the rate of prolapse recurrence. DesignStep-by-step video demonstration of the surgical technique. SettingThe Internal Department Committee approved this study. PatientThe patient was adequately informed about the possible risks and benefits of this experimental technique, and a written consent agreeing to undergo the described procedure was signed. InterventionNerve-sparing laparoscopic colposacropexy with positioning of two polypropylene titanized meshes and concomitant subtotal hysterectomy and salpingo-oophorectomy entirely performed with a 2.9-mm PSS. Measurements and Main ResultsPelvic organ prolapse is a condition affecting up to 50% of multiparous women. It may be considered a significant public health problem with an important impact on general health-related quality of life. A conservative and/or medical treatment may be considered only for women with a mild degree of prolapse, women with a reproductive desire, or women unable to undergo surgery. In the remaining cases, surgery seems to be the most effective treatment. The surgical approach may be abdominal (colposacropexy by laparotomy, laparoscopy, or robot-assisted) or vaginal (autologous or prosthesic reinforcement). The aims of the surgical procedures include not only the anatomic correction of the prolapse but also the improvement of patient quality of life and prolapse symptom relief, guaranteeing normal bladder, bowel, and sexual functions and avoiding iatrogenic dysfunctional symptoms. At present, the laparoscopic technique of sacral colpopexy offers a number of important advantages, including an excellent visualization of the pelvis, reduction in adhesions formation, and decreased postoperative pain and recovery, with reported success rates of 90% to 96% with a mesh erosion rate of 1% to 8%. ConclusionThis case report is the first to report a nerve-sparing laparoscopic colposacropexy performed with a 2.9-mm PSS. The major advance of this technique is the possibility of performing a major gynecologic surgery with a scarless approach, which results in fewer traumas for the patient in the postoperative time. The use of these instruments does not increase the operation time or the rate early or late complications, most of all prolapse recurrence. Considering that this is the first case report in literature, more clinical data are needed to confirm these findings.

Sa1524 Identification of Esophago-Gastric Junction During Per-Oral Endoscopic Myotomy-Benefit of Indocyanine Green Injection

Sa1524 Identification of Esophago-Gastric Junction During Per-Oral Endoscopic Myotomy-Benefit of Indocyanine Green Injection

Grand challenge: on the way to scarless visceral surgery.

Grand challenge: on the way to scarless visceral surgery.

Laparoscopic Vaginoplasty Using a Sigmoid Graft Through the Umbilical Single-Incision Hybrid Transperineal Approach: Our Initial Experience

For better cosmetic appearance, attempts to reduce the number of laparoscopic wounds have been sought. Investigators have thus begun to carry out procedures through a single incision or natural orifice endoscopic surgery instead of using conventional laparoscopic surgery. The authors here describe transumbilical single-incision hybrid transperineal laparoscopic surgery as a novel approach for vaginoplasty using a sigmoid graft. From August 2010 to October 2012, 15 young females with Mayer-Rokitansky-Kuster-Hauser (MRKH) syndrome underwent laparoscopic sigmoid vaginosplasty using a combined transumbilical single-incision and transperineal approach. A multichannel single port was placed through the umbilical incision for the main laparoscopic procedures. A 12-mm trocar as an assisting working port was inserted into the pelvic cavity through the transvaginal dimple between the rectum and urethra. A functioning vagina 12-15 cm in length and approximately 4 cm in width was created in all the patients. The average operative time and hospital stay were 151.5±34.2 minutes and 7.4±3.2 days, respectively. The only perioperative complications were 1 case of stress ulcer and 1 case with umbilical infection. All patients were satisfied with the surgery, and 12 of them had subsequent sexual activity. Transumbilical single-incision hybrid transperineal laparoscopic sigmoid vaginoplasty offers a feasible scarless approach for females with MRKH syndrome. The favorable cosmetic results would favor use of this type of vaginoplasty as an alternative to the conventional laparoscopic approach.

Minimally invasive video-assisted thyroidectomy (MIVAT): the quest for a scarless approach

Minimally invasive video-assisted thyroidectomy (MIVAT): the quest for a scarless approach

A Comparison of Skill Acquisition and Transfer in Single Incision and Multi-port Laparoscopic Surgery

Single incision laparoscopic surgery (SILS) offers a scar-less approach to cholecystectomy. We conducted a cadaveric randomized crossover study to compare the novice learning curves for multiport laparoscopic cholecystectomy (LC) and single incision laparoscopic cholecystectomy (SILC), and to investigate the acquisition of transferable skills. Twenty medical students were randomized into SILS or LC groups. After baseline assessment and cognitive learning modules, groups completed 5 cadaveric porcine cholecystectomies in their designated modality, followed by one using the other approach. Performance was assessed using a validated surgical assessment device (ICSAD) and by expert video analysis with generic and procedure-specific rating scales [modified global rating scale (mGRS) and procedure-specific rating scales (PSRS)]. Analysis of the first case revealed significant differences between LC and SILS groups for time-taken (median 46.00 vs 68.19 min, p = 0.019), and path length (216 vs 348 m, p = 0.034). Intergroup analysis of the remaining group cases showed no difference for any of the performance metrics. Outlying performance of the 4th case in the LC group rendered learning curve comparison unviable. At crossover, performance of the SILS group on their LC compared with the 5th LC performed by the LC group showed no significant difference. However, comparing the LC group's SILC to the 5th SILC performed by the SILS group showed significant difference for all performance metrics (p < 0.05). This study suggests that the difference between novice performance for SILC and LC becomes negligible after the first procedure. Furthermore, dedicated SILC training appears to develop competencies for both SILC and LC, therefore its addition to the early surgical curriculum is likely to extend the access of SILC to patients without reducing multiport laparoscopic skill acquisition.

Endoscopic treatment of obesity

Obesity is a worldwide epidemic, complex metabolic disease associated with a variety of severe comorbidities. Bariatric surgery provides the patients with the benefits of sustained weight loss and improves obesity-related comorbidities, but can result in potentially life-threatening complications. Gastrointestinal endoscopy has recently been proposed as a scarless and noninvasive approach to obesity. Most of the current endoluminal devices and techniques are comparable to restrictive surgery. A variety of medical devices and procedures have been evaluated in recent years; however, with the exception of the intragastric balloon, evaluation of all the other endoluminal procedures is limited by the numbers of patients treated, the short follow-up and especially by the study design. Today, only a few devices have been evaluated in randomized controlled trials. The preliminary results of the first studies are extremely promising, but definitive statements cannot be drawn yet.

Single-incision laparoscopic appendectomy performed above the pubic symphysis - a new scarless approach

The three-port method is commonly used for laparoscopic appendectomy. To obtain a better cosmetic result, we have selected the single-incision laparoscopic appendectomy to be performed above the pubic symphysis. We performed six single-incision laparoscopic appendectomies above the pubic symphysis. During each operation, a 2 cm transverse incision was made in the pubic hair area 3–4 cm above the pubic symphysis. A 5 mm trocar was then placed as an observation port with another two 5 mm trocars as main- and side-operating ports. The laparoscopic appendectomy was performed using this single-incision method. Six patients (five male and one female; body mass indexes of 18.07, 19.27, 21.67, 18.34, 26.83 and 22.46 kg/m2, respectively) underwent successful single-incision laparoscopic appendectomy above the pubic symphysis. Operating times were recorded at 55, 58, 47, 51, 42 and 33 minutes, the corresponding post-operative anal ventilation times were 25, 24, 22, 18, 7 and 10 hours, while post-operative hospitalization periods stand at 3, 5, 2, 1, 3 and 2 days, respectively. No complications occurred during or post-operation. Our initial work shows that a single-incision laparoscopic appendectomy performed above the pubic symphysis is feasible and safe and yields excellent post-operative cosmetic results.

Population perception of surgical safety and body image trauma: a plea for scarless surgery?

Laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES) are prospected as the future of minimally invasive surgery. While scarless surgery (NOTES and LESS) is gaining increasing popularity, perception of these approaches should be investigated. An anonymous questionnaire describing laparoscopy, LESS, and NOTES was given to medical staff (n=120), paramedical staff (n=100), surgical patients (n=100), and the general population (n=100). The survey participants (median age, 37 years; range, 18-81 years) were queried about their expectations for surgical treatment and their approach preference. The first concern of the survey responders was the risk of surgical complications (92%). When asked about the respective importance of surgical safety, cure, and cosmetics, cure was placed first by 74%, safety by 33%, and cosmetics by 3%. These results were not influenced by sex, age, prior surgery or endoscopy, or education. When operative risk was similar, 90% of the participants preferred a scarless approach (75% preferred LESS and 15% preferred NOTES) to laparoscopy. The scarless approach preference was significantly higher among the younger participants (age<40 years; p=0.026), whereas sex showed no influence. The LESS preference was significantly higher among patients and the general population (86%) than among medical (67%) and paramedical (70%) staffs (p<0.001). A decreasing trend of preference for LESS and NOTES was observed with increased procedural risks. Although cure and safety remain the main concern, the population has a favorable perception of scarless surgery, even in the case of increased procedural risk, with LESS favored over NOTES. Such a popular adoption of scarless surgery should warrant the promotion of further research, technological innovations, and the establishment of surgeon training to improve its safety.

T1609: Intraoperative NOTES® Endosonography and Identification of Mock Hepatic Lesions

Natural Orifice Translumenal Endoscopic Surgery (NOTES) has been increasingly reported as a scarless approach for various abdominal surgeries. Intra-operative ultrasound is commonly used to identify or localize specific abdominal lesions during standard transabdominal surgery. The feasibility of translumenal Endoscopic Ultrasound (EUS) via NOTES (NOTES-EUS) for identification of abdominal lesions with a flexible echoendoscope has not been studied.