Sufficient Surgical Field Research Articles

Combined Upper Fornix Transconjunctival and Endoscopic Transnasal Approach for Frontoethmoidal Osteoma with Orbital Extension - A Case Report

Abstract Rationale: Intraorbital osteomas are incidentally found and occasionally require surgical treatment. Depending on their localisation, a single technique may not provide a sufficient surgical field. Patient Concerns: We report a 16-year-old male with a left upper medial palpable mass. Diagnosis: Computed tomography revealed a dense bony mass extending from the ethmoid sinus to the superior wall of the frontal sinus, with protrusion into the orbital cavity. Treatment: The combination of upper fornix transconjunctival and endoscopic transnasal approaches was chosen for the surgical removal procedure. Outcomes: The two-pathway approaches resulted in the clear removal of the mass. Post-operative recovery was rapid, although a slight restriction of the inferomedial duction remained at three months. Take-away Lessons: This combination of techniques can provide a wide surgical field for the resection of frontoethmoidal osteomas with orbital extension.

Laparoscopic median arcuate ligament release using an anterior approach for median arcuate ligament syndrome

AbstractMedian arcuate ligament syndrome (MALS) is a rare condition characterized by nonspecific symptoms, such as abdominal pain, nausea, and vomiting. Furthermore, the development and rupture of pancreaticoduodenal artery aneurysms pose a potentially fatal risk. Median arcuate ligament release (MALR) is useful in the treatment of MALS, with most procedures performed laparoscopically. However, detailed descriptions of laparoscopic MALR (lap‐MALR) procedures are rare. In this study, we performed lap‐MALR via an anterior approach with dissection of the right lateral wall of the celiac artery (CA). For optimal visualization of the right side of the CA, the right branch of the inferior phrenic artery was divided. We believe that this procedure allows the MAL to be released within a sufficient surgical field and without excess or deficiency. Here, we present the details of six patients who underwent lap‐MALR for varying indications; three for pancreaticoduodenal artery aneurysms due to CA obstruction (unruptured, n = 1; ruptured, n = 2), two cases prior to hepato‐biliary‐pancreatic surgery, and one symptomatic case. In all cases, lap‐MALR was performed as described above, and the CA stenosis was successfully released. Our case series demonstrates the safety and reliability of our lap‐MALR procedure in the treatment of MALS‐related disorders, including pancreaticoduodenal artery aneurysms associated with CA compression.

Endoscopic far-lateral supracerebellar infratentorial approach for resection of dumbbell-shaped trigeminal schwannoma: surgical techniques and preliminary results.

Trigeminal schwannomas (TSs) are mostly benign tumors. However, dumbbell-shaped TSs are most challenging for surgeons and pose a high surgical risk. We describe the technique of the purely endoscopic far-lateral supracerebellar infratentorial approach (EFL-SCITA) for removing dumbbell-shaped TSs and further discuss the feasibility of this approach and our experience. EFL-SCITA was performed for resection of 5 TSs between January 2020 and March 2023. The entire procedure was performed endoscopically with the goal of total tumor resection. During the operation, the tumor was exposed in close proximity and multiple angles under the endoscope, and the peri-tumor nerves were carefully identified and protected, especially the normal trigeminal fiber bundles around the tumor. All the tumors of 5 patients involved the middle and posterior cranial fossa, of which total removal was achieved in 2 patients and near-total removal in 3 patients. The most common preoperative symptoms were relieved after surgery. Two patients had postoperative mild facial paralysis (House-Brackmann grade II), and 1 patient had abducens palsy; both recovered during the follow-up period. Two patients experienced new postoperative facial hypesthesia, and 1 experienced mastication weakness, which did not recover. There was no tumor recurrence or residual tumor growth during the follow-up period in any of the patients. EFL-SCITA is a new and effective alternative for the surgical treatment of TSs. For dumbbell-shaped TSs, this approach provides sufficient surgical field exposure and freedom of operation.

Standardized and Feasible Laparoscopic Approach for Tumors Located in the Caudate Lobe

Although laparoscopic hepatectomy has been widely used in the management of liver tumors for its reduced invasiveness and magnified view, in the caudate lobe it remains challenging especially for patients with cirrhosis. Thus, this study aimed to evaluate patients undergoing laparoscopic hepatectomy for hepatic tumors in the caudate lobe and establish strategies for performing such procedure. Laparoscopic hepatectomy in the caudate lobe was performed in nine patients. We performed inflow control to reduce bleeding during hepatic transection and retraction of the left lateral section to the cranial side to obtain a sufficient surgical field using a Nathanson liver retractor. We approached tumors in the Spiegel lobe (SP) from caudal side for segment 1 (S1) partial hepatectomy and from caudal and left side for Spiegel lobectomy, the lower paracaval portion (PC) from caudal side for S1 partial hepatectomy, and the upper PC from caudal and bilateral side for total caudate lobectomy. In 6 cases the tumors were in the SP and in 3 cases in the PC. The types of laparoscopic hepatectomy performed were total caudate lobectomy (n=1), Spiegel lobectomy (n=2), and partial hepatectomy of segment 1 (n=6). All the tumors were curatively resected, and no patient had complications. Operative time for tumors located in the PC was significantly longer than that for tumors located in the SP. Laparoscopic hepatectomy in the caudate lobe was safely performed for five patients with liver cirrhosis. Laparoscopic hepatectomy in the caudate lobe may become the standard surgical technique with hepatic inflow control, sufficient surgical field exposure, and appropriate approach.

The effectiveness of extremely low-pressure pneumoperitoneum on pain reduction after robot-assisted cholecystectomy

BackgroundThe robot-assisted cholecystectomy could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (ELPP; 4 mmHg) by the robot arm lifting the abdominal wall upward. This study aimed to investigate the effect of ELPP on the postoperative outcomes in benign gallbladder disease. MethodsA retrospective study was designed to compare the postoperative pain in addition with operation time, estimated blood loss, length of hospital stay, and complication of three types of cholecystectomy for benign gallbladder disease: 75 ELPP single site robot-assisted cholecystectomy (SSRC), 114 standard-pressure pneumoperitoneum (SPP) SSRC and 110 SPP conventional laparoscopic cholecystectomy (CLC). ResultsThere was no difference in whole operation time between ELPP SSRC and SPP SSRC group (p = 0.159). Postoperative pain score was significantly less in ELPP SSRC group as compared to SPP SSRC or SPP CLC group at 6, 12, and 24 h postoperatively (p = 0.004, p = 0.004, and p = 0.013 respectively). The incidence of shoulder pain was also significantly lower in ELPP SSRC group (p < 0.001). The rate of postoperative complication and length of stay were not different among the three groups. ConclusionsThis study shows that ELPP technique using robot is feasible without increasing postoperative complications in the process of cholecystectomy and the use of the ELPP can reduce postoperative pain and shoulder pain compared to the use of the SPP.

Useful traction technique for laparoscopic fundoplication without removing proceeding gastrostomy in a neurologically impaired patient with a body deformity.

Severely neurologically impaired patients often require the creation of a gastrostomy when they develop difficulty with oral intake followed by antireflux surgery. We use a traction technique for laparoscopic fundoplication without removing the gastrostomy in such cases. Right lateral traction of the round ligament of the liver and left lateral traction of the stomach body are performed using a needle device. The left liver lobe is elevated with a liver retractor inserted via the epigastrium. This traction technique allows a sufficient surgical field for manipulating forceps to be created in cases with a gastrostomy, enabling fundoplication to be performed safely without removing the gastrostomy.

Modified Lengthening Temporalis Myoplasty Using an Intraoral Approach.

Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves inserting the whole temporal tendon directly into the nasolabial fold. However, the nasolabial fold incision remains one of the difficulties of this procedure, particularly in young or female patient. To avoid the need for this incision, the authors developed an intraoral approach to manipulate the temporal muscle tendon toward the nasolabial fold. in this study, we describe the details of this procedure. The authors performed their intraoral approach procedure in 5 patients with established complete facial paralysis. instead of making an incision at the nasolabial fold to approach the coronoid process, the authors made the incision at the buccal mucosa. The results were evaluated both subjectively and objectively. The authors achieved facial reanimation without leaving any obvious scar on the face or neck and the effect of static reconstruction is obvious, even immediately after the surgery. All the patients obtained good facial movement within 4 months (2.5 months in average), and improved all evaluated parameters postoperatively. No infections or other major complications were reported following surgery; however, 1 patient developed a slight dimple that required revision. The authors could advance temporal tendon toward nasolabial fold firmly obtaining sufficient surgical field similar to that of nasolabial fold incision, and achieved fairly good results without an obvious scar on the face.Establishing LTM without nasolabial fold incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reanimation in all generation.

Evaluating the feasibility and effectiveness of extremely low-pressure pneumoperitoneum for robotic-assisted cholecystectomy

Standard-pressure pneumoperitoneum (12 to 15 mmHg) has been used to create an adequate working space during the laparoscopic surgery, but it has adverse effects such as postoperative pain, especially in the shoulder. Attempts are being made to reduce the postoperative pain by keeping low-pressure insufflation (7 to 10 mmHg). With advances in operative technology, the robotic-assisted cholecystectomy using da Vinci Xi could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (4 mmHg) by the videoscope pushing the abdominal wall upward. This study aimed to compare the postoperative outcomes using standard- and extremely low-pressure pneumoperitoneum in patients undergoing laparoscopic or robotic-assisted cholecystectomy. A retrospective study was designed to compare the postoperative outcomes of 53 extremely low-pressure robotic-assisted cholecystectomy (ELRC), 116 standard-pressure robotic-assisted cholecystectomy (SRC) and 105 standard-pressure laparoscopic cholecystectomy (SLC). The surgery took longer in robotic-assisted cholecystectomy than laparoscopic cholecystectomy (p < 0.001). Postoperative pain score was significantly less in ELRC group as compared to SRC or SLC group at 6, 12, and 24 hours (p = 0.004, p = 0.005, and p = 0.009, respectively). However, there was no significant difference between groups in the number of demands for analgesic. The incidence of shoulder pain was significantly lower in ELRC group (p < 0.001). The rate of postoperative complication and length of stay were no difference between groups. The use of the ELRC is associated with a significantly lower postoperative pain and shoulder pain. This study also shows that extremely low-pressure technique is feasible without increasing postoperative complications.

Arthroscopically Assisted Bone Pegs Fixation Without Malleolar Osteotomy for Osteochondral Lesion of Talus

Category:Ankle, ArthroscopyIntroduction/Purpose:Several surgical treatments have been suggested for osteochondral lesions of talus (OLT). Fixation of osteochondral fragment using bone pegs is physiologic and does not require removal of implants and has no risk of foreign body reaction. However, this procedure commonly requires osteotomy of malleolus to obtain sufficient surgical field. Therefore, it has longer rehabilitation and a risk of malunion of osteotomy site. We have performed bone pegs fixation without malleolar osteotomy through arthroscopic assistant. The purpose of this study was to introduce our technique and to evaluate clinical and radiographic outcomes of bone pegs fixation for OLT.Methods:Ten patients (10 ankles) with osteochondral lesions of talus were treated by arthroscopically assisted autogenous bone pegs fixation without malleolar osteotomy. Intraoperative assessments were evaluated site of lesion, size of fragment, and number of pegs. Clinical assessments were evaluated using VAS and AOFAS score preoperatively and at last follow-up. And SF-36 and ROM of ankle (comparing with uninvolved ankle (%)) was evaluated at last follow-up. Radiographic assessments were evaluated according to criteria as described by Kumai et al.Results:The lesion was on posteromedial side in 8 patients and anterolateral side in 2 patients. Mean fragment size was 9.6*13.5 mm. And mean number of used pegs were 2.6. VAS and AOFAS score significantly improved from 6.1 and 74.8 preoperatively to 1 and 93.7 at last follow-up. SF-36 was 80.5 at last follow-up. ROM of ankle joints revealed 97% of uninvolved ankle joints at the last follow-up. Radiographic results were good in 4 patients, fair in 5 patients, and poor in 1 patient.Conclusion:Arthroscopically assisted bone pegs fixation without malleolar osteotomy could be a treatment option for OTL with large fragment.

Partial Transcondylar Approach for Ventral Foramen Magnum Neurenteric Cyst: 2-Dimensional Operative Video.

The anterior foramen magnum area, ventral to the brainstem is one of the most difficult regions to access surgically, and the extent of osseous drilling through the far-lateral or transcondylar approach should be planned in each case based on the tumor extension.1,2 This video, reproduced after informed consent of the patient, demonstrates a case of a ventral foramen magnum neurenteric cyst surgically treated using the partial transcondylar approach. A 27-yr-old woman presented with gait disturbance, oscillopsia, and transient arm numbness. Neuroimaging revealed a ventral foramen magnum cystic tumor involving the basilar and bilateral vertebral arteries. The tumor extended inferiorly from the middle clivus to the C1 level, and occupied the whole premedullary cistern compressing the bilateral lower cranial nerves. The left partial transcondylar approach was performed with drilling the condylar fossa, superior part of the occipital condyle, C1 posterior arch, and posterior part of the jugular process to achieve the sufficient surgical view from the inferolateral side. The drilling of the occipital condyle was minimized so that the articular facet of the occipital condyle was preserved. The tumor on the bilateral side was completely removed as enabled by the sufficient surgical field without new neurological deficits. Three-dimensional reconstructed images based on the postoperative computed tomography scans demonstrated the appropriate extent of the osseous drilling.

Abstract P3-13-08: Usefulness of periareolar zigzag incision in oncoplastic breast-conserving surgery

Abstract Background Breast-conserving surgery (BCS) has been performed as a standard procedure because the addition of radiation therapy after breast-conserving surgery in early breast cancer patients is similar to that of mastectomy.The surgical methods for breast cancer have been developed in recent years, and the cosmetic aspect has become important.Several incisions are used to reduce the scar to the incision site during BCS. The periareolar incision is often used when the small tumor relatively close to the nipple. However, periareolar incision does not have sufficient field of sight, which can result in difficult or impossible operations if the tumor is large or far from the nipple. In plastic surgery, various methods such as zigzag incisions have been recommended to achieve satisfactory esthetic results. The periareolar zigzag incision has the advantage of a not only good surgical field but also contributed to better surgical scars. The purpose of this study was to evaluate the oncological safety of procedures by studying the status of the surgical margins of the excised tumor specimen and reduces the need for further surgery Methods From January 2016 to November 2017, we conducted a survey of female patients who underwent BCS using zigzag incision. Patients with exclusion criteria were excluded from this study if they had a Patients with bilateral breast cancer or neoadjuvant chemotherapy was included in the study. Intraoperative frozen section margin was evaluated in all patients and additional resection was performed when the positive margin was present. Final margin status was determined by examination of the permanent paraffin-embedded sections. In patients with invasive breast cancer or relatively large carcinoma in situ, axillary surgery was performed according to the presence of axillary metastasis. Patients characteristics, tumor characteristics, operative time, size of the specimen and the distance from the tumor to nipple were evaluated Results 393 patients were enrolled in the study, including 9 patients with bilateral breast cancer, and a total of 402 cases of BCS surgery were analyzed. Thirty-five patients received neoadjuvant chemotherapy. The median age of the patients was 51 (range: 25-84 years), the median time of operation was 72 minutes in patients who did not undergo axillary surgery or sentinel node biopsy only, and 83 minutes in patients who underwent axillary node dissection or supraclavicular node dissection. The median tumor size was 1.6 cm (range: 0-8.8 cm), median tumor distance from the nipple was 3.0 cm (range: 0.4-8.1 cm), mean excised specimen sized was 5.0 cm (range: 0.9-15.0 cm). Frozen biopsy of the resection margin during surgery revealed tumor-positive in 69 (17.2%) cases and re-excision was performed. All patients were discharged with no sign of infection or skin necrosis. Conclusions The periareolar zigzag incision technique has good cosmetic results and provides a sufficient surgical field, which can be useful for removing relatively large tumors or tumors far from the nipple. Citation Format: Ko B, Kim H, Chung I, Lee S, Kim J, Lee J, Son B, Ahn SH. Usefulness of periareolar zigzag incision in oncoplastic breast-conserving surgery [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-08.

Application and effect evaluation of an self-made device to fix liver in laparoscopic radical gastrectomy

To introduce the application and clinical effect of self-made liver fixing device in laparoscopic radical gastrectomy. Clinical data of 469 patients underwent laparoscopic radical gastrectomy in Nanfang Hospital, Southern Medical University from March 2014 to January 2017 were analyzed retrospectively. In laparoscopic radical gastrectomy, self-made liver fixing device was used to expose surgical field covered by hepatic lobe in gastric lesser curvature and hepatic flexure of colon. Manufacture of the self-made liver fixing device: appropriate length of the catheter was cut according to the size of liver; the lotus suture needle with a thread was put through two catheters to connect them. Then the prepared liver fixing device was sent into abdominal cavity through a 12-mm Trocar hole with needle holder and was fixed on the free hepatic lateral hepatogastric ligament with hemo-lock. Finally the application effect of the liver fixing device was evaluated by reviewing the surgical videos. A mean time of 40.3 seconds was required to complete liver fixing by using the self-made liver fixing device in laparoscopic radical gastrectomy and liver did not slip down in all the cases. Liver secondary manual fixing by assistants was 2 times averagely. Three cases had mild liver injury. The self-made liver fixing device in laparoscopic radical gastrectomy is easy to operate and can effectively expose sufficient surgical field, with high security and convenient materials.

JDSA Journal Abstracts

JDSA Journal Abstracts

Neuroendoscopic Transnasal Surgery for Skull Base Tumors: Basic Approaches, Avoidance of Pitfalls, and Recent Innovations

Since the introduction of endoscopic technology in the neurosurgical field, the role of transnasal surgery has been dramatically enlarged. With this technique, we can approach the anterior cranial base, parasellar region, clivus, cavernous sinus, and craniovertebral junction, less invasively than with conventional microsurgery. This review describes the two major approach methods in endoscopic skull base surgery, the endonasal approach and the transseptal approach. The endonasal approach uses two nostrils without nasal specula and the mucosa on the sphenoid rostrum and the posterior margin of the nasal septum are removed. In the transseptal approach, only a single nostril is available, but using the nasal speculum, sufficient surgical field can be obtained with only a small incision on the septum. In either approach method, it is very important to avoid excessive mucosal damage and to select the appropriate approach for each patient. The endoscopic skull base approach is one of the least invasive surgical procedures, which is a very promising therapeutic choice with potential for further advances. For better surgical outcomes and further progress, cooperation with rhinolaryngologists who have much more knowledge and experience about nasal surgery than neurosurgeons is essential. We believe this article will contribute to the development of safe and effective surgical procedures, and to the benefit of the patients suffering with intractable skull base lesions.

Successful Treatment of Nonunion After Sliding Genioplasty

Because chin is a major component of the lower face, underprojection, overprojection, and asymmetry of chin have been addressed via various surgical approaches. Sliding genioplasty is a popular technique to resolve this problem. This technique is rarely known to have postoperative complications, including nonunions. We experienced 1 case of nonunion after sliding genioplasty and treated it successfully.A 25-year-old woman who underwent sliding genioplasty 10 years ago at a local clinic visited our institute owing to displeasing appearance of the chin. Ten months ago, nonunion was diagnosed, and the patient underwent a second operation. We performed a longer incision than the previous operation and removed screws, plate, and an alloplastic material that was inserted previously. Shaving of the nonunion margins, refixation, and recontouring were performed, and bone chips acquired from the recontouring procedure were inserted into the interim space. During follow-up, no complications were observed, and bone union was completed on radiologic examination. Appropriate fixation is very important to prevent nonunion after sliding genioplasty. For appropriate fixation, getting a sufficient surgical field is indispensable, and shaving the nonunion margins, refixation, and bone chip implantation are helpful to address this complication.

The approaches and outcomes of skull base surgery for pediatric sarcoma after initial therapy

Objective Surgical removal of the residual pediatric sarcoma after initial therapy is common; however, that in the skull base area still presents a formidable challenge. We reviewed the approaches and outcomes of skull base surgery for pediatric sarcoma. Methods Thirteen patients with pediatric sarcoma who received skull base surgery were reviewed retrospectively. Tumor sites, surgical approach, complications, regional recurrence after surgery, and survival rate were analyzed. Results The residual tumor sites were the infratemporal fossa (8), nasal cavity and paranasal sinus (4) and orbit with anterior skull base invasion (1). Coronal skin incision (1), that with preauricular skin incision (7) and facial dismasking flap (5) were applied to patients as the skin preparation. Following skin preparations, anterior skull base surgery with frontal craniotomy (3), infratemporal fossa approach with temporal craniotomy (5), and anterior–lateral skull base with front-temporal craniotomy (1) were performed. Tumors were removed with a sufficient surgical field in all patients. Facial nerve palsy (9), facial deformity (4), orbital complications (diplopia, decreased visual acuity, narrowing of visual field) (2) and occlusal imbalance (1) occurred. However, facial palsy, diplopia and occlusal imbalance subsided gradually. Local recurrence occurred in 6 cases and distant metastasis was observed in 4 cases. The overall 5-years survival rate was 51.9% (Kaplan–Meier method). Conclusion These tumors were safely removed with minimum morbidity. Skull base surgery is recommended to remove residual pediatric sarcoma after the initial treatment.

Section 6. Digestive organs: Minimally invasive surgery for carcinoid tumors in the rectum

Most carcinoid tumors of the rectum are confined to the submucosa with a size less than 1–2 cm and are usually suitable for local excision, as metastasis to the regional nodes is limited. Endoscopic excision of carcinoid tumors has been performed for this entity as a least invasive method but incomplete resection and/or unclear surgical margin and curability have been reported to occur in 24–42% of cases because of a limited resection up to the submucosal layer and burn effect. Transanal local excision has often been applied for rectal carcinoid tumor as a least invasive method among local excision procedures to accomplish full thickness excision for determining the curability. However, it is often difficult to obtain free access with a sufficient surgical field by the conventional method. Transanal endoscopic microsurgery (TEM) has appeared as a useful option to access a high tumor with fine visibility but special caution has to be taken for tumors sited above the peritoneal reflection. To facilitate full thickness excision even for high tumors, novel local excisional technique called minimally invasive transanal surgery (MITAS) has been developed and used for local removal of carcinoid tumors in the rectum. A specially designed anal retractor connected to the Octopus retractor holder with several novel techniques facilitated excisional procedures around the anus with a sufficient fixed surgical field and an ENDO-stapler allowed the simultaneous excision and anastomosis to be performed. The technique facilitated total excisional biopsy with less operative time and blood loss, and no mobility or mortality in 12 patients with rectal carcinoid tumors.

Radiometric study on posterior inferior cerebellar aneurysms with special reference to accessibility by the lateral suboccipital approach.

Radiometric studies were conducted in 21 cases of posterior inferior cerebellar aneurysms and 52 normal subjects to determine the variability of location of the vertebral-posterior inferior cerebellar artery complex in the posterior fossa. Accessibility using a lateral suboccipital approach was evaluated in relation to the radiometric data. Lateral suboccipital openings offered a sufficient surgical field in all cases under minimal retraction of the cerebellum and the results were satisfactory. The range of accessibility of this lateral approach was between 0 to 17 mm from the midline, 1 to 23 mm from the foramen magnum, 6 to 16 mm from the clivus and 35 to 61 mm from the posterior clinoid process. Postoperative neurological deficits were seen in patients with an aneurysm within 10 mm of the midline and at more than 13 mm from the clivus. Advantages of the lateral suboccipital approach are discussed.