Endoscopic Surgery Techniques Research Articles

Underwater Endoscopic Management of Labyrinthine Fistula in Congenital Cholesteatoma

Objectives: We propose a novel technique to remove the matrix of cholesteatoma endoscopically after completely filling the mastoid cavity with saline water by perfusion for the appropriate management of labyrinthine fistulas. This “underwater” endoscopic ear surgery (UWEES) technique provides a clear operative field without requiring suction and protects the inner ear from unexpected aeration that may damage its function. Methods: A 3-year-old boy was diagnosed with congenital cholesteatoma in a group medical examination. Once the surgery was scheduled but suspended due to the Great East Japan Earthquake. At the age of 6 years, computed tomography revealed a fistula of the superior semicircular canal and surgery was performed for removal of the cholesteatoma and closure of the fistula. Retroauricular incision was chosen because of the extensive lesion, using an intact canal skin method with soft wall reconstruction. The cholesteatoma was extirpated except for the island lesion of the matrix over the fistula under the operating microscope. Subsequently, saline solution was infused into the mastoid cavity using Endo-Scrub (Medtronic). The island residual matrix was exfoliated underwater endoscopically and closed with bone paste and covered with the fascia. Results: No particular complication occurred during the surgical procedure or postoperatively. Conclusions: Saline water perfusion cleared the surgical field and prevented refraction effects in the high-definition endoscope, resulting in a clear surgical field and prevention of deterioration of cochlear function. UWEES is expected to prevent risk to inner ear function in other interventions such as cochlear implantation, stapes surgery, and temporal bone destruction corrective surgery.

Endoscope-assisted facelift thyroid surgery: an initial experience using a new endoscopic technique

A new approach to modifying facelift incision was recently developed for robotic thyroid surgery that seemed to be advantageous over other existing approaches. In this study, we aimed to investigate the feasibility and safety of the facelift approach not only for robotic thyroid surgery, but also for endoscope-assisted thyroid surgery. Endoscope-assisted facelift thyroid lobectomy was performed for 11 patients with papillary microcarcinoma. All 11 operations were successfully performed endoscopically. This approach through a modified facelift incision provided safe dissection of the laryngeal nerves and exposed an adequate working space. We identified and preserved all neighboring critical structures (parathyroid gland and superior and recurrent laryngeal nerves) during surgery. The operative duration for simple thyroid lobectomy with central lymph node dissection in 11 patients was 120-180 min (average duration: 140 min). Sensory change around the earlobe occurred in three patients and was recovered within 2 months after surgery in all patients. No patient displayed laryngeal nerve palsy or a low-pitched voice. The facelift approach seems to provide a shorter and more direct route to the thyroid, requiring minimal dissection, and an adequate workspace not only for robotic surgery but also for endoscopic surgery. It is worthwhile to develop and refine the surgical techniques of endoscopic facelift thyroid surgery.

Endoscopic cystolithotomy by mini nephroscope: A preliminary study

Objective: To introduce a novel endoscopic surgical technique with mini-nephroscope by suprapubic transvesical route for cystolithotripsy in children. Material and methods: This was a non-randomized study with a series of 12 boys, between February 2012 and September 2013. Demographic, operative, and postoperative data were recorded. Our new endoscopic surgery technique could be performed in all patients. Complications were noted. Results: Mean age was 35.1 ± 8.6 months (19–46 months), the average stone size was 16.5 ± 5.2 mm (10–20 mm). Mean operation time was 28.9 min (21–40), and mean hospital stay was 2.2 (2–3) days. In all procedures, stones were successfully fragmented and extracted by the new surgical technique. There was no intraoperative and/or postoperative complication or urethral stricture during follow-up period. In stone analyses, the main components were ammonium acid urate, calcium oxalate, and struvite. Conclusions: The new endoscopic surgery technique is safe and effective for bladder stones in children. Thus, our technique can be a strong candidate for an alternative treatment of childhood bladder stones.

A Practical Use of a 16-Gauge Peripheral Angiocatheter as an Aspiration Cautery in Endoscopic Ear Surgery

To define a technique for the practical use of a 16-gauge peripheral venous catheter as an insulated aspiration cautery in endoscopic ear surgery. Retrospective case review. Tertiary referral center. A 16-gauge intravenous catheter was prepared as a cauterization instrument with aspiration. After simple rearrangement of the exterior plastic portion, it was connected to a suction system. With the help of an unipolar cautery, aspiration of the blood and homeostasis was achieved. Hemorrhage of the external ear canal skin after incision can be easily coagulated with this instrument. During follow-up, there were no wound infection, facial nerve paresis, scar formation, and inadvertent burn of the external canal and auricular skin. With the help of this instrument, bleeding control during incision can be easily maintained. It is a simple, easily prepared, and alternative homeostasis technique in endoscopic ear surgery.

Developments in the Technique of Endoscopic Combined Intrarenal Surgery in the Prone Split-leg Position

To develop a new technique for performing endoscopic combined intrarenal surgery in the prone split-leg position and to evaluate its efficacy using computed tomography. Between December 2010 and January 2013, 60 patients with large calculi (39.2 ± 2.6 mm) underwent this surgery. A laser fiber was used with a flexible ureteroscope introduced through a ureteral access sheath, and lithoclast lithotripsy was performed through a mini-percutaneous tract. Three-dimensional computed tomography was performed to determine anatomic variations, including the ureteral location and ureteropelvic junction angle in all patients in both the supine and prone positions. All procedures were performed successfully with a single tract and the patient in the prone split-leg position. The mean surgical time was 120.5 ± 6.7 min. The initial stone-free rate was 82%, and the final stone-free rate was 87% after further treatment. One patient required blood transfusion, but none had severe complications. Computed tomography showed that the ureter between the orifice and ureteropelvic junction was straighter and the ureteropelvic junction angle was significantly smaller for surgeries conducted in the prone position than the supine position. Flexible ureteroscopy in the prone split-leg position is a viable technique. It allows easy insertion of the ureteral sheath and access of the ureteroscope to the renal pelvis. The findings suggest that this hybrid surgery is an efficient, effective, and versatile procedure for the management of renal calculi.

Minimally invasive transnasal and transmaxillary approaches to the pterygopalatine fossa

The pterygopalatine fossa is a well-protected region of the skull base, and surgical access for resection of tumors growing in this region can be challenging. Historically, the approach to this anatomical space has been an open transmaxillary technique. This results in disruption of the anterior and posterior walls of the maxillary sinus and numerous postoperative morbidities. More recently, improvements in endoscopic sinus surgery instrumentation and techniques have led to the advent of minimally invasive surgical approaches to the skull base. The use of endoscopes allows for improved visualization and surgical manipulation, as well as reduced postoperative comorbidities. We discuss a graduated, minimally invasive approach to the pterygopalatine fossa.

Mo1519 Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): First US Cases

Mo1519 Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): First US Cases

The chicken egg and skull model of endoscopic endonasal transsphenoidal surgery improves trainee drilling skills

We verified the effectiveness of training in endoscopic endonasal transsphenoidal surgery (eETSS) techniques using chicken eggs and a skull model. We verified the area of eggshell removed by drilling when five residents and four experts used the chicken eggs and a skull model. When residents performed drilling on 10 eggs, a mean (± standard deviation [SD]) area of 31.2 ± 17.5 mm2 was removed from the first egg, and 104.8 ± 3.3 mm2 from the tenth and final egg, representing an increase in area and a decrease in SD. The experts performed the same drilling operation on a single egg, and removed a mean area of 257± 31.7 mm2. These results demonstrated that skills improved as a result of this training, and suggested that this method was also capable of overcoming the initial individual differences in the amount of force applied and ability. An obvious difference between residents and experts was seen in the area removed (p = 0.00011); however, this was attributed to differences in endoscopic manipulation, rather than drilling skill. Our findings suggest that this training method could be adequate for acquiring eETSS techniques. Although experts showed superior endoscopic manipulation, residents may also be able to acquire adequate endoscopic skills through further training, and our training method appears to offer an effective means of improving eETSS techniques.

Olfactory Function following Bilateral Mucosal Preservation Nasoseptal Rescue Flap Technique in Endoscopic Skull Base Surgery: Preliminary Data

Introduction: Bilateral mucosal preservation nasoseptal rescue flap technique in endoscopic skull base surgery has been previously presented by our group. One of the perceived benefits of this technique is olfactory function preservation due to preservation of the septal olfactory strip (SOS) and middle and superior turbinates. Herein we present preliminary preoperative and postoperative olfactory function data from an ongoing IRB-approved study at our institution.

Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model

The accepted palliative treatment for malignant gastric outlet obstruction (GOO) is surgical bypass or placement of self-expandable metal stents. We developed a safe and simple natural orifice transluminal endoscopic surgery (NOTES) technique for gastrojejunostomy using a fully covered, anastomosing metal stent in a porcine model. Under general anesthesia, 11 pigs underwent gastrojejunostomy with a 4 cm length anastomosing metal stent. After gastrotomy formation using a needle knife, the jejunum was drawn into the stomach with alligator forceps. A jejunotomy was then performed in the gastric cavity, which was followed by deployment of an anastomosing metal stent under fluoroscopic guidance. Next, the first portion of the duodenum was resected by an endoscopic linear stapler via laparoscopy, thereby creating the model of GOO. Oral feeding was resumed 24 h after the procedure, and animals were euthanized at 1, 2, and 4 weeks after the operation. Side-to-side gastrojejunostomy was successfully completed through NOTES in 10/11 animals. Ten pigs stayed healthy until the planned sacrifice. The mean gastrojejunostomy procedure time was 41 min (range 15-94 min). By postmortem examination, anastomoses were still intact without intraperitoneal necrosis or adhesion. Histological examination revealed adequate submucosal apposition in all ten experimental pigs undergoing successful endoscopic gastrojejunostomy. Creating a gastrojejunostomy by NOTES using an anastomosing metal stent seems to be a safe, feasible, durable, and reproducible method for GOO.

Endoscopic ultrasound-assisted direct peritoneal visualization with a small-caliber scope: A proof of concept study in a swine model.

Background:Laparoscopic and natural orifice transluminal endoscopic surgery techniques can diagnose peritoneal findings that suggest tumor cell dissemination. However, they have not been incorporated into routine practice, mainly owing to their complexity. To develop a minimally invasive endoscopic technique for the diagnosis of peritoneal findings, we conducted feasibility study using an acute swine model.Materials and Methods:This study involved six domestic pigs. Trans-gastric access to the peritoneal cavity was performed utilizing an endoscopic ultrasound fine needle aspiration (EUS-FNA) technique. After dilation of the needle hole with a biliary dilatation catheter and balloon, a small-caliber scope was inserted into the peritoneal cavity. Peritoneal images were obtained with the scope and a high-resolution microendoscope (HRME). Main outcome measurements were technical feasibility and time needed to access the peritoneal cavity.Results:Direct visualization of the peritoneum was successful in all six pigs and gained access to the gross appearance of the peritoneal cavity. HRME imaging with topical contrast agent also obtained reasonable quality images representing nuclei of the peritoneal mesothelium. Average operation time from the initiation of EUS-FNA to acquiring peritoneal images was 26.5 min (range 15-40 min). Autopsy found no damage to the adjacent organs, and stomach wall defects were tightly closed with hemostasis clips.Conclusion:EUS-assisted direct peritoneal visualization with small-caliber scope is technically feasible. HRME may assist in the diagnosis of findings on the peritoneum.

Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): First U.S. Cases: Presidential Poster

Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): First U.S. Cases: Presidential Poster

Technical feasibility and cosmetic advantage of hybrid endoscopy-assisted breast-conserving surgery.

80 Background: We developed a new procedure called hybrid endoscopy-assisted breast-conserving surgery (EBCS), which consists of a combination of plastic surgery and endoscopic surgery techniques. The purpose of this study was retrospectively to analyze the clinical outcome of hybrid-EBCS and compare the cosmetic outcomes between hybrid-EBCS and conventional breast-conserving surgery (CBCS). Methods: We reviewed medical records of patients who had undergone hybrid-EBCS (n = 73) or CBCS (n = 90) between May 2005 and April 2011 and had been followed-up in our department until March 2012. The clinical outcomes, and cosmetic outcomes of these 2 groups were compared. The safety of hybrid-EBCS was also analyzed by confirming its complications and pathological surgical margin. Results: In the hybrid-EBCS group, operation time was longer by 30–50 minutes. Blood loss was not significantly different between the 2 groups. The surgical margin of hybrid-EBCS was as follows: 1 patient (1.4%) had a positive margin; 4 patients (5.5%) had a margin of less than 2 mm; in 9 patients (12.3%), the margin was > 2 mm and < 5 mm; and in 59 patients (80.8%), it was more than 5 mm. Seven cases (9.6%) of postoperative complications occurred in 6 hybrid-EBCS patients. To date, no local recurrence has been observed in hybrid-EBCS patients (postoperative observation period: 18.1 ± 5.6 months). Compared with the CBCS group, the hybrid-EBCS group had better cosmetic results, especially with a less noticeable operative scar (p < 0.01). Conclusions: Hybrid-EBCS can provide sufficient free margin, and its surgical curability is acceptable. Additionally, this method is superior to CBCS in terms of cosmetic outcome.

E109 The technique of endoscopic combined intrarenal surgery in the prone split-leg position: Prone position is suitable for simultaneous operation of flexible ureteroscopy and mini-percutaneous nephrolithotomy

E109 The technique of endoscopic combined intrarenal surgery in the prone split-leg position: Prone position is suitable for simultaneous operation of flexible ureteroscopy and mini-percutaneous nephrolithotomy

Comparison of Surgical Conditions During Propofol or Isoflurane Anesthesia for Endoscopic Sinus Surgery

BackgroundThe Anesthesia planning is an important and determining factor in the amount of intraoperative hemorrhage, which can affect the rate of intraoperative and postoperative complications.ObjectivesIn this study we used two different anesthesia techniques in functional endoscopic sinus surgery (FESS) and compared the amount of hemorrhage in the two groups.Patients and MethodsIn a single–blind clinical trial, 44 patients with ASA class I and II candidate for FESS in Amir-Al-Momenin hospital in Rasht were entered the study and divided into two equal groups randomly. In both groups anesthesia was induced with propofol, remifentanil and cis. atracurium and then, infusion of propofol – remifentanil in the first group and isoflurane plus Remifentanil infusion in the second group was used for maintenance of anesthesia. Systolic blood pressure was maintained about 90 mmHg. Then on the basis of maximum allowable blood loss (MABL) formula, we calculated the percentage of hemorrhage. Finally the patients' hemorrhage was categorized into three groups (< 10%, 10-20%, > 20%). The surgeon's satisfaction from surgical field was calculated according to the Visual Analogue Scale. Then the data was statistically analyzed with T- test.ResultsThere were meaningful differences between average of hemorrhage (propofol group = 155cc, and Isoflurane group = 291.3cc; P = 0.003), and surgeon’s satisfaction (propofol group = 1.9 and Isoflurane group = 2.95; P = 0.007).ConclusionsThe amount of hemorrhage in propofol group was less than Isoflurane group and the field condition was better in propofol group than the Isoflurane group.

Prospective Randomized Trial of Hybrid NOTES Colectomy Versus Conventional Laparoscopic Colectomy for Left‐sided Colonic Tumors

We conducted a randomized study of a laparoscopic technique for removing left-sided colon tumors that can reduce postoperative pain and other wound-related complications compared to the conventional technique. It is a novel technique of hybrid natural orifice translumenal endoscopic surgery (NOTES) colectomy (HNC) whereby laparoscopic colonic mobilization, transection, and anastomosis are performed intracorporeally. The specimen is then delivered through the anus using the transanal endoscopic operation (TEO) device, precluding the need for mini-laparotomy. We compared the short-term outcomes of patients who underwent HNC with those who underwent conventional laparoscopic colectomy (CL). Patients suffering left-sided colonic tumor were recruited and were randomized into two groups: HNC and CL. Operative data and complications were prospectively recorded and analyzed. During a 3-year period, we recruited 70 patients (35 per group). No significant difference was observed between the two groups with respect to operating time (105 vs. 100 min, p = 0.851), blood loss (30 vs. 30 ml, p = 0.954), or length of hospital stay (5 vs. 5 days, p = 0.990). The maximum pain score during the first week was significantly lower in the HNC group (1 vs. 2, p = 0.017). No patients in the HNC group developed wound infection, whereas four patients in the CL group did so (p = 0.005). With this hybrid NOTES technique, selected patients with left-sided colonic tumors can enjoy the full benefits of minimally invasive surgery with significantly less wound pain and a lower wound infection rate than are observed with CL.

A new modified speculum guided single nostril technique for endoscopic transnasal transsphenoidal surgery: an analysis of nasal complications

The endoscopic transnasal, transsphenoidal surgical technique for pituitary tumour excision has generally been regarded as a less invasive technique, ranging from single nostril to dual nostril techniques. We propose a single nostril technique using a modified nasal speculum as a preferred technique. We initially reviewed 25 patients who underwent pituitary tumour excision, via endoscopic transnasal transsphenoidal surgery, using this new modified speculum-guided single nostril technique. The results show shorter operation time with reduced intra- and post-operative nasal soft tissue injuries and complications.

First experience of a single-stage simultaneous single access endoscopic surgery in a child with a disorder of sex development

A clinical case and treatment of a disorder of sex development (46XX, ovotesticular type) who underwent a simultaneous surgery including diagnostic laparoscopy using the single access endoscopic surgery followed by gonadectomy and the single-stage feminizing genitoplasty, is described. Endocrinology service needs for determination of treatment approach in children with disorders of sex development are closely entwined with capabilities of endoscopic surgery, particularly laparoscopy. It’s necessary to quickly determine the gonadal structure due to the high risk of malignancies while examining these patients. The most useful method is the direct visualization of the gonads in the abdominal cavity by laparoscopy. In these cases the single access endoscopic surgery technique reduces the trauma and is welcomed in pediatrics. From our point of view, the preference for the patients with disorders of sex development management with expected gonadal dysgenesis must be given to a single access endoscopic surgery.

New devices and techniques for management of pancreatic fluid collections

New devices and techniques for management of pancreatic fluid collections

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model. An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope. The transgastric gastrojejunostomy was technically successful in all cases. A total of four to six stitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.