Endoscopic Surgery Techniques Research Articles

Sigmoid incision rescue nasoseptal flap technique for endoscopic endonasal skull base surgery

Conclusion The sigmoid-incision (S-I) rescue flap technique has the advantage of both reduced-invasiveness and providing a sufficient surgical corridor for endoscopic endonasal skull base surgery (EESBS). Objective Skull base reconstruction with nasoseptal flap (NSF) is critically important in managing post-operative cerebrospinal fluid (CSF) leakage after tumor removal by EESBS. The NSF needs to be elevated before sphenoidotomy and posterior septectomy to preserve the pedicle. However, most extradural surgery without CSF leakage does not require NSF and, therefore, NSF preparation is often futile. As a result, a rescue flap technique to overcome this problem has been developed, whereby a new S-I rescue flap method is used that enables wide exposure of the sphenoidal rostrum and smooth manipulation of surgical instruments to preserve the NSF pedicle. Materials and methods Starting in April 2014, 19 cases underwent EESBS with S-I rescue flap. Results All patients underwent tumor resection under an adequate operative field with smooth manipulation of surgical instruments. Two complications were experienced. One patient had CSF leak after removal of the nasal packing, but the leakage was successfully closed by conventional NSF. Another patient had epistaxis from the septal wall, but this was controlled by electrocautery.

The usefulness of 3-dimensional endoscope systems in endoscopic surgery.

The image quality and performance of 3-dimensional video image systems has improved along with improvements in technology. However, objective evaluation on the usefulness of 3-dimensional video image systems is insufficient. Therefore, we decided to investigate the usefulness of 3-dimensional video image systems using the objective endoscopic surgery technology evaluating apparatus that we have developed, the Hiroshima University Endoscopic Surgical Assessment Device (HUESAD). The participants were 28 student volunteers enrolled in Hiroshima University (17 men and 11 women, age: median 22.5, range 20-25), with no one having experienced endoscopic surgery training. Testing was carried out by dividing the subjects into two groups to initially carry out HUESAD with 2-dimensional video imaging (N=14) and with 3-dimensional video imaging (N=14). Questionnaires were carried out along with the investigation regarding both 2-dimensional and 3-dimensional video imaging. The task was carried out for approximately 15min regarding both 2-dimensional and 3-dimensional video imaging. Lastly, the Mental Rotation Test, which is a standard space perception ability test, was used to evaluate the space perception ability. No difference was observed in the nauseous and uncomfortable feeling of practitioners between the two groups. Regarding smoothness, no difference was observed between 2-dimensional and 3-dimensional video imaging (p=0.8665). Deviation (space perception ability) and approaching time (accuracy) were significantly lower with 3-dimensional video imaging compared to 2-dimensional video imaging. Moreover, the approaching time (accuracy) significantly improved in 3-dimensional video imaging compared to 2-dimensional video imaging in the group with low space perception ability (p=0.0085). Objective evaluation using HUESAD and subjective evaluation by questionnaire revealed that endoscopic surgery techniques significantly improved in 3-dimensional video imaging compared to 2-dimensional video imaging. Moreover, it is believed that this effect is more effective in people with low space perception ability and beginner students.

Dynamic Article: Full-Thickness Excision for Benign Colon Polyps Using Combined Endoscopic Laparoscopic Surgery.

Benign colon polyps are commonly encountered but may not always be amenable to endoscopic excision because of their size, shape, location, or scarring from previous attempts. The addition of laparoscopy allows a greater degree of bowel manipulation, but the current technique is still limited when encountering a polyp with inadequate lifting attributed to polyp morphology or scarring. We describe an extension to the existing combined endoscopic laparoscopic surgery technique using a full-thickness approach to increase polyp maneuverability and local excision of difficult but benign polyps. The purpose of this study was to report the technical details and preliminary results of a new approach for full-thickness excision of difficult colon polyps, combined endoscopic laparoscopic surgery full-thickness excision. This study is a retrospective review of our experience from December 2013 to May 2015. The study was conducted at a single academic institution. All of the patients had previous incomplete colonoscopic polypectomy performed at other institutions. Patients were selected for our technique if the polyp had a benign appearance but was unable to be resected by traditional endoscopic or combined endoscopic laparoscopic surgery methods because of polyp morphology or scarring from previous biopsies. The safety and feasibility of this procedure were measured. Three patients underwent combined endoscopic laparoscopic surgery-full-thickness excision for difficult colon polyps. There were no intraoperative or postoperative complications. The length of stay was 1 day for all of the patients. All 3 of the patients had benign final pathology. This study was limited by the small number of patients in a single institution. Full-thickness excision for benign colon polyps using combined endoscopic laparoscopic surgery is safe and feasible. Using this technique, difficult polyps not amenable to traditional endoscopic approaches can be removed and colectomy may be avoided.

Vision Loss after Endoscopic Sinus Surgery: A First Case Report Assessed by OCT and VEP

Background: Purpose of this case report is to describe, for the first time in literature assessed by optical coherence tomography (OCT) and visual evoked potentials (VEP), a rare case of partially reversible unilateral vision loss accompanied by retrobulbar optic neuritis symptomatology, after nasal polyps removal using endoscopic sinus surgery (ESS) technique. Case presentation: A 41-year old Greek male developed unilateral vision loss, partially reversible within 72 hours, reduced color vision, superior scotoma and retrobulbar pain on eye movement immediately after recovering from nasal polyp removal with (ESS) technique. He underwent complete ophthalmological examination including optical coherence tomography, fluorescein angiography, visual fields and visual evoked potentials. A magnetic resonance imaging (MRI), neurological examination and laboratory evaluation were also performed revealing no abnormalities. Conclusions: Sinus surgeons and ophthalmologists should be familiar with the possibility of irreversible visual impairment after endoscopic sinus surgery and enhance collaboration for facilitating better recognition and early treatment.

Advances in Surgery: Extended Procedures for Sinonasal Polyp Disease.

In the standard functional endoscopic sinus surgery (FESS) procedure, the amount of dissection is often determined by the extent of disease with the goal to preserve as much normal mucosa as possible while restoring ventilation and reestablishing mucociliary clearance. A subset of patients with chronic rhinosinusitis with nasal polyposis (CRSwNP), however, may continue to have persistent mucosal inflammatory and aggressive polyp regrowth despite standard FESS and maximal pharmacology therapy, leading to recurrent and recalcitrant disease. Advanced endoscopic surgery techniques such as the modified endoscopic medial maxillectomy, endoscopic modified Lothrop procedure, otherwise known as a Draf 3 frontal sinusotomy, and nasalisation or radical ethmoidectomy are extensive surgical procedures to maximize disease clearance while providing sizeable drainage pathways for effective postoperative surveillance and topical delivery of medications. Studies have shown a decreased risk of revision surgery as well as a longer time interval for revision surgery in patients with refractory CRSwNP who have undergone extensive sinus surgery for polyps.

Feasibility of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors (with video)

Laparoscopic gastric resection is widely used for gastric submucosal tumors (SMTs). However, determining an appropriate resection line using only the laparoscopic approach is difficult. We developed a laparoscopic and endoscopic cooperative surgery (LECS) technique by combining laparoscopic gastric resection with endoscopic submucosal dissection, and we have used this procedure to resect gastric SMTs. In this study, the procedure is presented and its safety and feasibility for resecting gastric SMTs are evaluated. This retrospective study included 100 patients who underwent LECS for SMTs at the Department of Gastroenterological Surgery, Cancer Institute, between June 2006 and November 2014. The demographics, tumor histopathologic characteristics, and operative and follow-up data were reviewed. Complete resection with negative surgical margins was achieved in all patients, and LECS was performed regardless of tumor location. The mean operation time was 174.3 minutes, with an estimated blood loss of 16.3mL. In addition, the mean time until the initiation of oral intake was 1.4 days, and the mean postoperative hospital stay was 8.4 days. Moreover, no local or distant tumor recurrence was observed. The only severe adverse event was leakage, which was observed in 1 patient. LECS was performed with a reasonable operation time, low blood loss, and minimal adverse events. Therefore LECS is safe and feasible for resecting gastric SMTs.

134 Comparison of Extent of Tumor Resection and Endocrine Outcomes for Nonfunctioning Pituitary Adenomas of a Less Experienced Surgeon Using a Fully Endoscopic Transsphenoidal Surgery Technique to a Very Experienced Surgeon Using a Microscopic Transsphenoidal Surgical Technique

134 Comparison of Extent of Tumor Resection and Endocrine Outcomes for Nonfunctioning Pituitary Adenomas of a Less Experienced Surgeon Using a Fully Endoscopic Transsphenoidal Surgery Technique to a Very Experienced Surgeon Using a Microscopic Transsphenoidal Surgical Technique

Transaxillary single-incision robotic neck dissection for metastatic thyroid cancer.

In head and neck area, neck dissection (ND) is one of the most complex and precision-needed procedure. The long cervical scar and post-operative neck discomfort have been also inevitable brands after this procedure. Heretofore, few dare to try endoscopic surgical technique to the ND mainly due to its complexity and jeopardy of complication. Although, there have been several reports about the endoscopic approaches for functional ND or ND, they had so many technical and instrumental limitations. The dexterities of the surgical robotics have advanced the techniques of endoscopic surgery, and have facilitated the most precise and delicate endoscopic surgical procedure in head and neck area. The technical feasibility and early surgical outcomes of robotic ND using the transaxillary approach for the management of metastatic thyroid cancer have already been reported as satisfactory. Robotic ND can allow complete compartment-oriented lymph node (LN) dissection without any fatal complications, or compromising oncologic principles. We previously described a novel method of robotic thyroidectomy with ND using a gasless transaxillary approach for metastatic thyroid cancer, and here, we firstly introduce a less invasive robotic procedure which has been modified from the original one, which we refer to as the transaxillary single-incision robotic ND.

Sa1526 Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): a Single Center Experience

Sa1526 Natural Orifice Endoscopic Surgery (NOTES) Techniques for Full Thickness R0 Endoscopic Resection of Deep Seated Subepithelial Tumors (SETs): a Single Center Experience

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

Endoscopic Endonasal Repair of Congenital Defects of the Anterior Skull Base: Developmental Considerations and Surgical Outcomes

Techniques of endoscopic endonasal surgery, initially developed primarily for intracranial neoplasms, have been adapted to treat a wide variety of pathologies previously approached with open craniotomy, including congenital and acquired defects of the anterior skull base. Congenital defects can lead to herniation of leptomeninges containing CSF alone or with brain tissue. Categories of encephalocele can be defined based on associated abnormal bony anatomy. The most widely used classification scheme divides anterior fossa encephaloceles into sincipital and basal categories. Sincipital encephaloceles, which are associated with a skull defect at the foramen cecum, are anterior to the cribriform plate. These can be nasofrontal, nasoethmoidal, nasoorbital, or interfrontal. Basal encephaloceles, protruding through the cribriform plate or planum sphenoidale, are classified as sphenopharyngeal, spheno-orbital, sphenomaxillary, or sphenoethmoidal.

Optic Canal Decompression: Comparing the Endonasal Endoscopic and Transcranial Approaches

Introduction: Several pathologies can affect the optic canal (OC) and the optic nerve (ON) and ophthalmic artery. Tumors, vascular abnormalities, bony dysplasia, connective tissue disease, and trauma are examples. The compression of the ON, leading to visual impairment, is an indication for decompression OC. The OC decompression is usually recommended through a transcranial approach. Recently, the advances in endoscopic skull base surgery techniques allowed achieving the decompression through an endoscopic endonasal approach (EEA), because of the straightforward access to the OC in the sphenoid sinus.

Endoscopic Endonasal Repair of Congenital Defects of the Anterior Skull Base: Developmental Considerations and Surgical Outcomes.

Techniques of endoscopic endonasal surgery, initially developed primarily for intracranial neoplasms, have been adapted to treat a wide variety of pathologies previously addressed with open craniotomy including congenital and acquired defects of the anterior skull base. Congenital defects can lead to herniation of leptomeninges containing cerebrospinal fluid alone or with brain tissue. Specific types of encephalocele can be defined on the basis of the associated abnormal bony anatomy. Endoscopic endonasal surgery represents a relatively recent development in the treatment of these entities. Technical considerations include relatively younger age range of the patient population, dimensions of preexisting bony defect, volume of herniated meninges and brain tissue, and distorted anatomy from abnormal development of the affected craniofacial skeleton. Recent highly detailed anatomical studies have quantitatively verified the utility of endoscopic endonasal surgery in the pediatric population. Particular attention has been directed toward adequacy of nasoseptal flap reconstruction in pediatric patients. Several reports have described patients with encephalocele of the anterior cranial fossa successfully treated with endoscopic surgery. The literature on endoscopic repair of congenital encephalocele is reviewed. Outcomes have generally been reported as favorable, although long-term follow-up and systematic studies have not been pursued.

Full Endoscopic Spinal Surgery Techniques: Advancements, Indications, and Outcomes.

Advancements in both surgical instrumentation and full endoscopic spine techniques have resulted in positive clinical outcomes in the treatment of cervical, thoracic, and lumbar spine pathologies. Endoscopic techniques impart minimal approach related disruption of non-pathologic spinal anatomy and function while concurrently maximizing functional visualization and correction of pathological tissues. An advanced understanding of the applicable functional neuroanatomy, in particular the neuroforamen, is essential for successful outcomes. Additionally, an understanding of the varying types of disc prolapse pathology in relation to the neuroforamen will result in more optimal surgical outcomes. Indications for lumbar endoscopic spine surgery include disc herniations, spinal stenosis, infections, medial branch rhizotomy, and interbody fusion. Limitations are based on both non spine and spine related findings. A high riding iliac wing, a more posteriorly located retroperitoneal cavity, an overly distal or proximally migrated herniated disc are all relative contra-indications to lumbar endoscopic spinal surgery techniques. Modifications in scope size and visual field of view angulation have enabled both anterior and posterior cervical decompression. Endoscopic burrs, electrocautery, and focused laser technology allow for the least invasive spinal surgical techniques in all age groups and across varying body habitus. Complications include among others, dural tears, dysesthsia, nerve injury, and infection.

A Case of Frontal Mococele Treated with Transblepharoplasty Approach Combined with Endoscopic Approach

In recent years, endoscopic sinus marsupialization has become the treatment of choice for the treatment of paranasal sinus mucoceles due to its noninvasiveness and successful outcome. However, mucoceles located at the lateral portion of the frontal sinus and protruding into the orbit with erosion of the frontal sinus floor arestill difficult to address with standard endoscopic sinus surgery techniques. Here, we report a case of a mucocele located atthe lateral side of the frontal sinus and successfully marsupialized with a transblepharoplasty approach combined with an endoscopic approach.

Trans Oral-Substernum Incision Thoracic Endoscopic Surgery: A Minimally Invasive Endoscopic Approach in Thoracic Surgery

Flexible endoscope is used in Natural Orifice Trans-luminal Endoscopic Surgery. Cervical incision thoracic surgery has recently been described. The use of a flexible endoscope through a natural orifice into the thoracic cavity still remains ethically doubtful. The authors present a surgical experimental study using a flexible endoscope through oral-substernum incision for the exploration of both the thoracic cavity in dog model. An experimental work on 5 male mongrel dogs was initiated. Through a small incision at oral floor, we performed simultaneous exploration of the pleural cavities. Identification and biopsies of pleural and lung was performed. None chest tube was placed in the thoracic cavity at the end of all pleural procedures. The potential advantages of this approach are exploration of the thoracic cavity and the performance of several thoracic interventions through oral floor. The flexible endoscope could become a surgical tool for thoracic surgery. The treatment of lung cancer and other thoracic tumors usually involves thoracic surgeries. Cancer staging is a necessary step before cancer treatment. Mediastinal lymph nodes, pleural biopsies and lung biopsies are frequently needed for staging tumors. Despite the development of less invasive techniques, such as trans-bronchial needle aspiration (TBNA), endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA), and more recently, endobronchial ultrasoundguided fine-needle aspiration (EBUS-FNA), mediastinoscopy and video-thoracoscopy still remain the more satisfactory and commonly performed invasive techniques for mediastinal and pleural staging of thoracic tumors [1,2]. The development of thoracoscopic approaches during the early 1990s excited thoracic surgeons due to multiple advantages of this technique. Thoracoscopy unquestionably decreased the length of hospital stay, hospital cost, and rate of scar complications; and provided some cosmetic advantages. However, it did not significantly reduce postoperative pain. Thoracic ports and chest tubes are a major cause of persistent pain [3]. Minimally invasive techniques in thoracic surgery are evolving. And several recent thoracic surgical interventions were performed through cervical incisions [4,5]. There is a trend in favor of using flexible endoscopy in general surgery [6]. Flexible endoscope is used in Natural Orifice Trans-luminal Endoscopic Surgery (NOTES) techniques [7]; and few cases were reported on its application in abdominal surgery. Latest attempts in minimizing surgical trauma lead to an experimental trans oral access to the mediastinal for lymph node biopsies. Human application has been described for NOTES in thoracic surgery [8], but ethical restraints and the risk of major mediastinal complications limit its application on humans. The aim of this experimental work on animal is to evaluate the use of flexible endoscope for the exploration of thoracic cavity and pleura through a single trans oral incision.

Endoscopic surgery - exploring the modalities.

The adoption of endoscopic surgery continues to expand in clinical situations with the recent natural orifice transluminal endoscopic surgery technique enabling abdominal organ resection to be performed without necessitating any skin incision. In recent years, the development of numerous devices and platforms have allowed for such procedures to be carried out in a safer and more efficient manner, and in some ways to better simulate triangulation and surgical tasks (e.g., suturing and dissection). Furthermore, new novel techniques such as submucosal tunneling, endoscopic full-thickness resection and hybrid endo-laparoscopic approaches have further widened its use in more advanced diseases. Nevertheless, many of these new innovations are still at their pre-clinical stage. This review focuses on the various innovations in endoscopic surgery, with emphasis on devices and techniques that are currently in human use.

Anaesthesia for Endoscopic Sinus Surgery: A Survey of Anaesthesiologists in Restructured Hospitals in Singapore

Introduction: A cross-sectional survey of anaesthesiologists in Singapore's restructured hospitals was conducted to explore strategies employed to obtain a bloodless surgical field during endoscopic sinus surgery. Methods: All practicing anaesthesiologists in public institutions in Singapore were invited to answer an anonymous questionnaire. A point of contact per institution assisted in distribution and collection of questionnaire forms over a nine-month period. Results: A total of 114 anaesthesiologists completed the survey (response rate 60%). It was observed that 64.9% of respondents do not routinely employ controlled hypotension for endoscopic sinus surgery. Sixty-seven point five per cent chose general anaesthesia without nitrous oxide as the preferred anaesthetic technique for endoscopic sinus surgery. Forty-seven point four per cent opined that anaesthetic technique made no significant difference to outcomes in endoscopic sinus surgery. The most commonly used narcotics in endoscopic sinus surgery by the respondents were morphine (59.6%) and fentanyl (54.4%). However, where total intravenous anaesthesia was adopted, 86.0% of respondents opted to use remifentanil. The most commonly used class of antihypertensives for controlled hypotension was beta-blockers (66.7%). Factors limiting the use of total intravenous anaesthesia were also explored. Conclusion: This survey identifies variations from current evidence in the anaesthetic management of endoscopic sinus surgery among anaesthesiologists in Singapore's public institutions. The reasons behind these variations, which could include surgical preferences, financial, logistical, cultural, and educational factors, should be explored and any issues found addressed as necessary.

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

Introduction: Most UGI SETs are GISTs, potentially malignant tumors. Many guidelines recommend surgery for suspected GISTs ≥2 cm and endoscopic surveillance of those <2 cm. This approach creates a large burden of surgery and endoscopy for small SETs the majority of which are low-risk. This situation motivated endoscopists, mostly from Asia, to use ESD to “enucleate” muscularis propria (MP) based SETs. However, such enucleation may leave microscopic residual tumor within the MP. Recently, pioneering Asian centers reported two endoscopic techniques that achieve R0 en bloc resection of MP-based SETs: submucosal tunnel endoscopic resection (STER)- an offshoot of peroral endoscopic myotomy utilizing the submucosal tunnel method to ensure secure closure of the full-thickness defect in the wall of the GI tract, and endoscopic full-thickness resection (EFTR)-direct full thickness resection with closure of the defect with clips or sutures. We report possibly the first series of EFTR and STER in the U.S. Methods: Procedures were performed from 4/2012-6/2014. Data were retrieved from a prospectively maintained database. 33 resections (26 EFTR, 7 STER) were performed by a gastroenterologist with extensive ESD/POEM experience. Results: Mean age 58 (18-84). ASA Class I 12%, II 70%, III 18%. Anesthesia: General 45%, propofol 55%. SET location: 6 esophagus, 22 stomach, 2 colon, 3 rectum. 17 GISTs, 8 leiomyomas, 2 pancreatic rests, 1 schwannoma, 1 leiomyosarcoma and 4 other. Mean size 22 mm (10- 55). Mean resection time 72 minutes (21-220). Closure: endoclips 30%, endoscopic suturing 49%, both 21%. Most patients admitted mainly for observation. Complete en bloc resection achieved in 91%. Piecemeal resection in 3 patients (2 pancreatic rests, 1 5cm GIST). Adverse events: 2 needle decompression of capnoperitoneum, 3 bleeding requiring prolonged endoscopic hemostasis with 2 requiring transfusion, 3 patients 12-24 hour ICU observation, 2 patients required laparoscopic “standby” for immediate assistance that was not needed, 1 patient required laparoscopic conversion due to left gastric artery abutting tumor and 1 balloon dilation of stricture at tunnel closure site. Mean LOS 1.5 days (1-3). Conclusion: Unlike traditional ESD, EFTR and STER achieve en bloc R0 resection of MP-based SETs and represent a NOTES alternative to laparoscopic wedge resection. The excellent outcomes probably reflect our extensive experience with POEM, advanced closure techniques, and ESD for SETs. Advantages include: 1. Incision-less approach 2. “Wedge” resection of SETs at locations where laparoscopic “wedge” resection is challenging or impossible such as the GE junction, esophagus and gastric cardia 3. Definitive diagnosis and complete resection obviating any further endoscopic surveillance for low risk lesions. Disclosure - Stavros Stavropoulos: Boston Scientific Consultant.

Assessment of a Manipulator Device for NOTES With Basic Surgical Skill Tests

Advanced complex surgery performed with the natural orifice translumenal endoscopic surgery technique requires use of a multitasking platform. The aim of this study is to evaluate the basic functionality of a prototype multitasking platform "EndoSAMURAI" with the use of a biosimulation model and ex vivo porcine stomach. We compared the performance of basic surgical skill tasks between the EndoSAMURAI and standard laparoscopic instrumentation. Basic surgical tasks include cutting, dissection, and suturing and knot tying. Main outcome measurements were the time to complete each task and leak pressure to evaluate the quality of the suturing and knot tying. Although it took longer to perform all basic surgical tasks with the EndoSAMURAI than with laparoscopic instrumentation, all tasks could be performed precisely and with an accuracy comparable to that of the laparoscopic technique. Leak pressures of the gastric closure site between both techniques were also comparable.