Surgical Footprint Research Articles

Endoscopic Treatment of Lumbar Degenerative Disc Disease: A Narrative Review of Full-Endoscopic and Unilateral Biportal Endoscopic Spine Surgery

BackgroundDegenerative lumbar spine disease is the leading cause of disability and work absenteeism worldwide. Lumbar microdiscectomy became the standard treatment for herniated discs and stenotic disease. With the evolution of different techniques, endoscopic spinal surgery emerged to minimize the surgical footprint while providing at least non-inferior results. Currently, two different types of endoscopic spine procedures are dominating the surgical scenario: “Full-Endoscopic” (FE) and Unilateral Biportal Endoscopic”(UBE) Spine Surgery. The aim of this study is to describe and analyze their indications, their technical characteristicswithitsadvantagesanddisadvantagesofbothtechniquesandtheirfuture trends. MethodsWe performed a narrative review of the most relevant articles published up to August 2023 through a Pub Med search. The search terms "Full-Endoscopic Spine Surgery" and "Unilateral Biportal Endoscopic Spine Surgery" were used. The articles selected, were independently reviewed by 3 authors and 55 full text articles were reviewed. ResultsThe FE and UBE Spine Surgery techniques were described. The FE technique is performed with a monoportal access under constant saline irrigation. The FE comprises the transforaminal and the interlaminar approaches, and the indication depends from the pathology to treat, and still remains controversial. UBE can approach also the spine from a posterior, postero lateral,and para spinal route. It uses two different ports addressed to a target with continuous irrigation. The process of establishing these two portals is called triangulation. ConclusionFE and UBE spine surgery have demonstrated outcomes comparable to open surgery, minimizing complications and surgical footprint.

Evolution of the Transforaminal Lumbar Interbody Fusion (TLIF): From Open to Percutaneous to Patient-Specific.

The transforaminal lumbar interbody fusion (TLIF) has seen significant evolution since its early inception, reflecting advancements in surgical techniques, patient safety, and outcomes. Originally described as an improvement over the posterior lumbar interbody fusion (PLIF), the TLIF began as an open surgical procedure, that notably reduced the need for the extensive neural retractation that hindered the PLIF. In line with the broader practice of surgery, trending toward minimally invasive access, the TLIF was followed by the development of the minimally invasive TLIF (MIS-TLIF), a technique that further decreased tissue trauma and postoperative complications. Subsequent advancements, including Trans-Kambin's Triangle TLIF (percLIF) and transfacet LIF, have continued to refine surgical access, minimize surgical footprint, and reduce the risk of injury to the patient. The latest evolution, as we will describe it, the patient-specific TLIF, is a culmination of the aforementioned adaptations and incorporates advanced imaging and segmentation technologies into perioperative planning, allowing surgeons to tailor approaches based on individual patient anatomy and pathology. These developments signify a shift towards more precise methods in spine surgery. The ongoing evolution of the TLIF technique illustrates the dynamic nature of surgery and emphasizes the need for continued adaptation and refinement.

Self‐Stretchable Christmas‐Tree‐Shaped Ultraflexible Neural Probes†

This paper devised a novel Christmas‐tree structure for flexible neural probes, which features recording sites on side‐branches that can be folded along the shank of the probe by temporary encapsulation before implantation. This design reduces the size of the implant and minimizes the surgical footprint. Upon implantation, the temporary encapsulation dissolves in vivo, leading to self‐stretching of the branches, and an expansion of the lateral detecting range of the probe. We conducted in vitro experiment with our probe in 0.6% agar that mimics the brain tissue environment. The results demonstrate that the neural probe we have developed exhibits self‐stretching ability and provides an increased lateral recording range without causing additional damage to the brain tissue. © 2024 Institute of Electrical Engineer of Japan and Wiley Periodicals LLC.

Rapid (enhanced) recovery for fusion surgery in the degenerative spine: Clinical outcomes in 100 consecutive patients with a minimum 1-year follow-up

IntroductionSpinal surgical procedures became very frequent in the last decades with fusion techniques being widely used for several indications. Many of these surgeries imply a significant tissue disruption and muscle atrophy with subsequent pain and functional impairment. Research questionHow to prepare and manage patients according to a rapid/enhanced recovery (RR/ERAS) protocol in a private setting while improving patient’s peri-operative experience and minimizing surgical footprint? Material and methodsAll patients suffering from a thoracolumbar degenerative disease and with an indication for fusion between January 2018 and October 2021 were screened. Pain control, functional recovery, complication rate and patient’ satisfaction were recorded for at least one-year of follow-up (FU). Results100 patients were prospectively followed for at least one year after surgery. More than two thirds (n = 69, 69.0 %) had a trans-psoas extreme lateral interbody fusion (X-LIF) or anterior approach with posterior instrumentation and direct decompression when needed, 14 (14.0 %) had an anterior lumbar interbody fusion (ALIF) and 17 (17.0 %) patients had a posterior approach only (posterior LIF or transforaminal LIF). Most patients had multi-level surgery (n = 56, 56.0 %). All patients improved their quality of life and back and leg pain at one year FU with those having an antero-lateral approach improving significantly more. Overall satisfaction rate was higher than 90 %. Discussion and ConclusionThe application of RR/ERAS protocols to fusion surgery in degenerative spine proves to feasible and beneficial in a private care setting. Patients having anterolateral approaches tend to improve more than those with posterior only approaches.

201 The Surgical Hour: Improving the Surgical Footprint of Undergraduate Surgical Teaching

Abstract Aim To deliver an online surgical teaching programme for medical students to enhance undergraduate surgical education and evaluate its effectiveness. The drive was for increasing the surgical footprint in a curriculum surgeons felt lacked exposure during the COVID-19 pandemic. Method Surgical speakers across 9 different surgical specialties were recruited via email. Topics included basic surgical principles, common pathologies, the surgical portfolio and surgical innovation. The programme was advertised to students via social media and a newsletter. Quantitative and qualitative feedback was collected via attendee feedback forms. Attendees’ knowledge in topics covered before and after each lecture was measured via self-assessment using a 5-point Likert scale. A paired t-test was performed to measure pre- and post-session knowledge. Results 17 lectures were delivered between October 2021 and May 2022. 463 feedback forms were completed across the series by students across all years. Mean knowledge ratings improved after each session. 16/17 teaching sessions produced a statistically significant improvement in surgical knowledge (p<0.05). The most statistically significant improvement was seen following the acute abdomen lecture (p = 0.00) Vascular surgery showed an increase from 2.8 to 4 (p = 0.07). Common themes in written feedback were relevance to clinical practice, enthusiastic speakers, and exposure to content not otherwise taught in the curriculum. Conclusions Supplementary surgical series successfully address the demand for increased surgical teaching within the undergraduate curriculum. They improve insight into a career in surgery with exposure to positive role models, significant improvement in knowledge and practical advice on career development, empowering students to pursue surgery.

Electrodeposited NaYF4:Yb3+, Er3+ up-conversion films for flexible neural device construction and near-infrared optogenetics.

Near-infrared optogenetics based on up-conversion materials provides a promising tool for the dissection of neural circuit functions in deep brain regions. However, it remains a challenge to combine near-infrared up-conversion optogenetic stimulation with high-density electrophysiological recording in a minimally invasive manner. Here, we develop a flexible device for simultaneous electrophysiological recording and near-infrared optogenetics. The flexible device is constructed by integrating polymer-based flexible recording microelectrodes with electrodeposited NaYF4:Yb3+, Er3+ up-conversion films that can convert deep-tissue-penetrating near-infrared light into visible light for optogenetic activation of C1V1-expressing neurons. The emission properties of the up-conversion films are optimized for green light emission to stimulate C1V1 opsins. Owing to their minimized surgical footprint and high mechanical compliance, chronically implanted devices enable simultaneous electrophysiological recording and near-infrared optogenetic modulation of neuronal activities in the brain.

Lunatocapitate and Triquetrohamate Arthrodeses for Degenerative Arthritis of the Wrist: A Midterm Follow-Up.

Degenerative arthritis of the wrist is a common condition often treated with 4 corner arthrodesis (FCA) or a partial wrist fusion. A number of limited intercarpal arthrodeses have been proposed for treatment of this condition. One technique, described by Wang and Bednar in 2012, involves fusion of the lunatocapitate and triquetrohamate joints. This study presents midterm follow-up of outcomes following this 2 column arthrodesis. From 2000 to present, patients who underwent lunatocapitate and triquetrohamate arthrodesis were evaluated. The original cohort from the 2012 study was reviewed, as well as any additional patients who since underwent this procedure. Only patients who had greater than 5 years of follow-up data were included. Outcomes included demographics, wrist range of motion, grip strength, complications, and radiographic evidence of union. Twenty-one cases were included in the final analysis. Mean follow-up was 8.75 years. Wrist extension and flexion were 58% and 90% of the unaffected side, respectively. Grip strength was 92% of the unaffected side. Osseous union was achieved in 95.2% of cases. Two cases underwent revision surgery, one for nonunion and one following a fall. Lunatocapitate and triquetrohamate arthrodesis offers a treatment for wrist arthritis that yields good clinical outcomes, low nonunion rates, and no conversions to total wrist arthrodesis, as shown by 5-year follow-up data. Limited intercarpal arthrodesis is an alternative to FCA, with the advantage of a smaller surgical footprint and simpler technique, while still providing excellent mid- to long-term outcomes.

Novel Minimally Invasive Sliding Calcaneal Osteotomy: A Case Series

Category:Hindfoot; AnkleIntroduction/Purpose:Sliding calcaneal displacement osteotomy is a mainstay in the treatment of hindfoot deformity. A lateral oblique or L shaped incision and direct visualization of the calcaneus is the traditional open approach to this osteotomy.Complications of this approach are not common and include wound dehiscence, delayed union, neurovascular damage, tarsal tunnel syndrome, symptomatic bony overhang and peroneal fibrosis. Several techniques have been developed to address the limitations of the open approach including osteotomy with a Gigli saw, percutaneous endoscopic assisted osteotomy, and most recently minimally invasive osteotomy (MICO) with a low speed, high torque burr. Each of these techniques has limitations. This report presents a simple minimally invasive technique that may help mitigate wound issues without the technical hurdles of a steep learning curve.Methods:Patients undergoing MICO procedures with the senior author from February 2019 - June 2020 who had not undergone previous foot/ankle surgery were retrospectively enrolled. Patients underwent clinical and radiographic assessment preoperatively as well as at 2, 6, 12, and 24 weeks postoperatively. The technique utilizes a 1.5cm incision along the plane of osteotomy, centered about a K-wire placed through both cortices of the calcaneus at the midpoint of the osteotomy plane. The plane and K-wire placement are determined under radiographic guidance. A micro-sagittal saw is rested on the K-wire and used as a cutting block in the coronal plane. After the osteotomy is created and mobility of the calcaneus confirmed, the K-wire is removed. The mobile segment is adjusted as needed, held in placed by dorsiflexing the ankle, and fixed using two posterior-to-anterior 6.5 cannulated screws, one 1cm superior to the other. The wounds can then be irrigated and closed.Results:37 patients were treated using this technique. 24 (65%) patients were female, with average age 56.9 years. Osteotomies were performed concomitantly with procedures including flexor digitorum longus transfer, subtalar fusion, triple arthrodesis, talonavicular fusion, hallux valgus corrective osteotomy, and Strayer gastrocnemius recession. Thirty-five (95%) patients achieved radiographic fusion within 1 year postoperatively with 28 (76%) fusing by 3-month follow up. Two (5%) patients developed a radiographic non-union without instability and opted to be managed expectantly. Of note, one patient is a diabetic current smoker with Rheumatoid Arthritis, while the other is a non-diabetic former smoker. A single patient was readmitted within 90 days for incision and debridement of a dehisced wound from subtalar fusion performed concomitantly. One patient underwent eventual removal of the screw compressing the calcaneal osteotomy site due to hardware prominence. No patients reported peroneal symptoms postoperatively. No patients reported any other complications related to the osteotomy.Conclusion:Sliding calcaneal displacement osteotomy is a well-established component in the treatment of hindfoot deformity. Although larger lateral oblique and L shaped incisions allow direct visualization of the osteotomy, more minimally invasive approaches have been used. The proposed technique in the current report offers a low non-union rate, minimal surgical footprint, easily available surgical instruments, reliable osteotomy plane, and short surgical time.

Laser interstitial thermal therapy for brain metastases.

Laser interstitial thermal therapy (LITT) is a minimally invasive treatment for intracranial lesions entailing thermal ablation via a stereotactically placed laser probe. In metastatic disease, it has shown the most promise in the treatment of radiographically progressive lesions after initial stereotactic radiosurgery, whether due to recurrent metastatic disease or radiation necrosis. LITT has been demonstrated to provide clinical benefit in both cases, as discussed in the review below. With its minimal surgical footprint and short recovery period, LITT is further advantaged for patients who are otherwise high-risk surgical candidates or with lesions in difficult to access locations. Exploration of the current data on its use in metastatic disease will allow for a better understanding of the indications, benefits, and future directions of LITT for these patients.

This Month in Adult Urology

This Month in Adult Urology

Defining Surgical Terminology and Risk for Brain Computer Interface Technologies.

With the emergence of numerous brain computer interfaces (BCI), their form factors, and clinical applications the terminology to describe their clinical deployment and the associated risk has been vague. The terms “minimally invasive” or “non-invasive” have been commonly used, but the risk can vary widely based on the form factor and anatomic location. Thus, taken together, there needs to be a terminology that best accommodates the surgical footprint of a BCI and their attendant risks. This work presents a semantic framework that describes the BCI from a procedural standpoint and its attendant clinical risk profile. We propose extending the common invasive/non-invasive distinction for BCI systems to accommodate three categories in which the BCI anatomically interfaces with the patient and whether or not a surgical procedure is required for deployment: (1) Non-invasive—BCI components do not penetrate the body, (2) Embedded—components are penetrative, but not deeper than the inner table of the skull, and (3) Intracranial –components are located within the inner table of the skull and possibly within the brain volume. Each class has a separate risk profile that should be considered when being applied to a given clinical population. Optimally, balancing this risk profile with clinical need provides the most ethical deployment of these emerging classes of devices. As BCIs gain larger adoption, and terminology becomes standardized, having an improved, more precise language will better serve clinicians, patients, and consumers in discussing these technologies, particularly within the context of surgical procedures.

Defining the surgical footprint in cataract surgery: patient-related outcomes dependent on the experience of the surgeon.

To investigate which patient-related outcomes are dependent on the experience of the cataract surgeon. The study was designed as a prospective observational study. Novice (<150 surgeries performed) and experienced (>1000 surgeries performed) cataract surgeons from the Department of Ophthalmology, Rigshospitalet - Glostrup and Nordsjaellands Hospital - Hillerød were included in the study. Patients operated by the included surgeons were examined preoperatively, 1day, 3days, and 3weeks after standard, noncomplicated cataract surgery. Primary outcomes were change in central corneal thickness and endothelial cell loss. Secondary outcomes were best-corrected visual acuity, intraocular pressure, aqueous flare, central macular thickness, and surgical complications. Surgery performed by novice surgeons resulted in significantly lower visual acuity (mean -3.6 letters (Early Treatment Diabetic Retinopathy Study (ETDRS)); 95% CI: -7.3; -0.4, p=0.03) and greater corneal thickness (mean 26.7µm; 95% CI: 6.8; 46.6, p=0.01) on the first day postoperative than surgery performed by experienced surgeons. The experience of the cataract surgeon affected visual acuity and central corneal thickness in the immediate postoperative period. In the future, these patient-related outcomes may be used to assess the technical proficiency of surgical trainees and investigate the effect of different training programs.

Minimally invasive plate osteosynthesis: An update of practise

Since its conception in 1989, minimally invasive plate osteosynthesis (MIPO) has gained widespread popularity. It has been studied in over forty countries with most of the publications originating from Asia, Europe and North America. This review aims to describe the scientific path of MIPO from the very beginning to where it stands in current day times; study the pattern and contributing factors influencing its global spread. Finally, the up to date evidence is discussed with regard to several anatomical regions in which MIPO is mostly used. In the meantime, MIPO treads steadily towards accomplishing the same or better outcomes for more and more indications with the goal to leave a smaller surgical footprint to allow for undisturbed bone healing.

Cannulated Screw Fixation of Femoral Neck Fractures: An Intraoperative Pearl to Avoid a Common Mistake

Percutaneous cannulated screw fixation is a well-described and relatively successful technique aimed at addressing femoral neck fractures. The advantages of this technique are limited primarily to its small surgical footprint and ability to preserve native femoral neck bone stock. Although the “3-point principle” described by Bout and colleagues aims at minimizing the potential complications and modes of mechanical failure of this fixation technique, the new literature suggests that our intraoperative radiographs may not be as reliable at detecting erroneous screw position as we may think. Hoffmann and colleagues recently demonstrated through a cadaveric study that 70% of the cranial-posterior screw in the “inverted triangle” construct, which were deemed cortically contained on fluoroscopy, actually breached the cortex. Although the clinical ramifications of this technical error are not fully understood, there is undoubtedly concern surrounding the biomechanical impact of altering the femoral neck’s ability to resist tension while upright and compression while seated because of the location of this breach. This article aims to provide a technical pearl for accurately placing screws to abut the femoral neck cortex while avoiding cortical breach in the “inverted triangle” fixation construct.

Initial experience with extraperitoneal robotic-assisted simple prostatectomy using the da Vinci SP surgical system.

Robotic-assisted simple prostatectomy (RASP) has emerged as a safe and effective treatment option for symptomatic patients with lower urinary tract symptoms related to significant benign prostatic enlargement (BPE) above 80g. The recent release of the da Vinci SP robotic system (Intuitive, Sunnyvale, CA, USA) continues to advance the minimally invasive nature of robotic surgical technology. We now report our institution's initial experience performing RASP using the da Vinci SP robotic system. An IRB-approved, retrospective chart review was performed of all patients undergoing robotic-assisted simple prostatectomy using the da Vinci SP surgical system in the treatment of benign prostatic enlargement by a single surgeon from March to June 2019. Pre-operative, intraoperative, and post-operative data were collected for descriptive analysis. A total of 10 men, mean age of 69 ± 4years, with mean prostate volume of 104 ± 11g underwent surgery. The robotic cannula and a single assistant port were utilized in all cases. No cases required conversion to a multi-port robotic platform or open approach, nor required the placement of additional assistant ports. No intraoperative or immediate post-operative complications were noted. Mean estimated blood loss was 141 ± 98mL and operative time was 172 ± 19min. Mean catheter time was 1.9 ± 1.8days. One patient reported transient de novo stress urinary incontinence. Single-port RASP is a safe and effective intervention for BPE. The smaller surgical footprint from the device appears to make earlier catheter removal possible. Comparative evaluation with multi-port RASP and other modalities is warranted.

Parallel, minimally-invasive implantation of ultra-flexible neural electrode arrays

Objective. Implanted microelectrodes provide a unique means to directly interface with the nervous system but have been limited by the lack of stable functionality. There is growing evidence suggesting that substantially reducing the mechanical rigidity of neural electrodes promotes tissue compatibility and improves their recording stability in both the short- and long-term. However, the miniaturized dimensions and ultraflexibility desired for mitigating tissue responses preclude the probe’s self-supported penetration into the brain tissue. Approach. Here we demonstrate the high-throughput implantation of multi-shank ultraflexible neural electrode arrays with surgical footprints as small as 200 µm2 in a mouse model. This is achieved by using arrays of tungsten microwires as shuttle devices, and bio-dissolvable adhesive polyethylene glycol (PEG) to temporarily attach a shank onto each microwire. Main results. We show the ability to simultaneously deliver electrode arrays in designed patterns, to adjust the implantation locations of the shanks by need, to target different brain structures, and to control the surgical injury by reducing the microwire diameters to cellular scale. Significance. These results provide a facile implantation method to apply ultraflexible neural probes in scalable neural recording.

The Chopsticks Technique for Endoscopic Endonasal Surgery–Improving Surgical Efficiency and Reducing the Surgical Footprint

Variations and additions to the endoscopic endonasal exposure have been proposed around a modular strategy. These extensions are often necessary to provide additional working space and reduce conflict between the instruments and the endoscope. Resection of endonasal structures, which affects negatively the sinonasal quality of life, is thus undertaken not only to obtain tumor exposure but also to improve the maneuverability of the instruments. Our objective was to achieve the same skull base exposures and tumor resections and limit the surgical footprint on sinonasal structures and patients' quality of life. Our team developed a surgical technique in which the endoscope and a malleable rotative aspirator are held by the nondominant hand and the other main instrument in the dominant hand. This modification, which we call the chopsticks technique, allows the surgeon to use minimalistic exposures with an improved dynamic perception of the surgical field and reduced conflicts between the instruments. The endonasal structures that are left intact help support the instruments. The same surgical objectives, in terms of exposure and resection, are achieved. We describe our technique and a series of patients operated with this uninarial 3-instruments technique to discuss relevant operative nuances. We propose a technical modification that allows the surgeons to benefit from the advantages of a bimanual technique while still holding the endoscope. In our opinion, this technique may improve dynamic understanding of the anatomy and surgical efficiency and reduce the footprint of the surgery.

The use of arthroscopy in acute foot and ankle trauma: a review.

The use of arthroscopy in the management of acute traumatic conditions of the foot and ankle has increased in recent years, primarily because of an appreciation of fracture morphology and the utility of reducing the surgical footprint. This article presents an overview of the use of this modality in foot and ankle trauma and presents an anatomical survey of the various fractures where arthroscopic assistance can be of benefit. In addition, a discussion of the seminal articles on this subject is included. Therapeutic Level IV: Review.

Surgical footprints, then and now: response to comment by Dietz

Dear Editor, It’s always heart-warming to receive a response to what you write [1] – be it positive or negative. Especially from prominent figures in the field. I think that Professor Dietz [2] and I speak the same language, but on different levels. He refers to the pathogenesis of prolapse, I to the surgical options available to rectify the damage and the imprints these operations leave in the pelvis. The purpose of my editorial was to highlight the damage that different approaches to pelvic organ reconstructive surgery can do. The focus of the classical anterior repair is to reduce the bulging anterior wall directly by plicating the support tissue in the midline. The focus of paravaginal repairs is on reducing the bulging anterior wall indirectly by attaching the bladder base to the pelvic sidewalls. I think that Prof. Dietz agrees, and in fact he has proved already with his imaging studies ( and even with his educated index finger study in a more recent issue of the journal [3]), that the pathology is lateral and not central. This is enough proof to me that when one performs a central plicating procedure the strain put on the weakened sidewall (be it due to levator muscle damage or to supportive collagen damage) can in due course lead to a recurrence. By focussing on the lateral sidewall and strengthening the support here the damage can be undone. To go back to the editorial: the main purpose of the reconstructive surgeon is to reconstruct. The new kids on the block, namely the “mesh kits” are all based on paravaginally fixing a bridge for the bulging anterior wall. To do this one has to break down the lateral supports of the bladder base – in a sense causing a “paravaginal defect”. The damage done with this type of surgery is tremendous. To remove these synthetic bridges in the advent of complications leads to further damage, and an added dilemma is how to support the bladder in the secondary procedure. Sounds very destructive to me. To put a permanent mesh between two hollow organs goes against all surgical principles. This is why I want to highlight that this route is not the path to take. As an alternative to – what I see as the discredited concept of – central plications this is not the answer. A third option is overlooked, namely building a lateral support for the bladder base and indirectly reducing the bulge of the anterior wall, plus improving the collagen quality of the support. Clearly the damage caused by the surgeon is less than the above alternatives. Maybe this is one of the reasons why there is “confusion in the field of prolapse repair”. These were the surgical footprints to which I referred. I can assure Prof. Dietz that I do not “propagate rumour and hearsay” – although I had my training in the sphere of the “confusion of the 1970s and 1980s”, as I am sure he had! As they say: watch this space.

Comment on editorial by Nieuwoudt: “Surgical footprints, then and now”

Dear Editor,I would like to comment on the above editorial published inthe September issue of International Urogynecology Journal[1]. The author defends the defect-specific approach toanterior vaginal wall reconstruction and claims that thisapproach can “directly restore” damaged/altered anatomy,following the “simple rules of proper reconstructive surgicaltechniques”.I agree that such an approach is possible, feasible andsuccessful in the posterior compartment, but there is no proofthat this is the case for the anterior compartment. Nobody hasever credibly shown fascial defects of the anterior compart-ment in vivo, either by imaging or intra-operatively — andI’m sayingthisassomeonewhohasbeenlookingbyimagingand intra-operatively for over 20 years. What people havetakenforparavaginaldefectsarelevator defects, and that’sanentirely different matter: well documented by MR andultrasound, palpable by anyone with an educated indexfinger, and occasionally visible in the labour ward.In my view the author is propagating rumour andhearsay as regards the discredited concept of paravaginalrepair. There is enough confusion in the field of prolapserepair already without going back to the confusion of the1970s and 1980s.Reference