Use Of Small Incisions Research Articles

S156 – What Can Determine the Length of a Thyroidectomy Incision?

Objectives Patient expectations regarding cosmesis following surgical procedures have increased. Subsequently, many surgeons are now utilizing very small incisions when performing thyroidectomy. This study evaluated the association between patient weight, nodule size, and maximum thyroid diameter, and the length of a thyroidectomy incision. Methods Data from a cohort of 28 consecutive patients treated by a single surgeon was analyzed. Patient demographics, clinical exam, ultrasound findings, operative findings, and pathology were recorded. All incisions were measured pre-operatively. Results Of the 28 patients (79% female), 24 underwent a hemithyroidectomy and isthmusectomy. One patient had papillary thyroid cancer and 7 (25%) required operation for compressive symptoms. The mean patient weight was 200.76 lbs (median=188 lbs; IQR 75lbs). The mean clinical nodule diameter was 3.64 cm (median=3.7 cm; IQR=1.7 cm), and the mean maximum thyroid diameter was 6.22 cm (median=5.25 cm; IQR=3.7 cm). The mean incision size was 5.32 cm (median=5.0 cm; IQR=2.0 cm). Independently, patient weight, maximum thyroid diameter, and maximum nodule diameter were shown in regression models to be statistically significant predictors of incision size. In stepwise regression analysis that included all three listed variables, only maximum thyroid diameter remained a significant predictor of incision size (p<0.0001). Conclusions The use of small incisions when performing thyroidectomy is becoming common. To further reduce incision size, video-assisted thyroidectomy is now being advocated. For thyroidectomy, surgeon preference and comfort level are obviously important factors in deciding incision length. This retrospective study has shown that this decision is taken in context of the patients’ weight, maximum nodule diameter, and most importantly, maximum thyroid diameter.

Transblepharoplasty Brow Suspension

Brow position and hyperfunction of the muscles of forehead facial expression contribute to the aging diathesis of the upper one third of the face. In many cases, the eyelids and brows are addressed together to achieve a satisfying rejuvenation effect. Many different approaches to the brow are used, including the long coronal or pretricheal incisions, direct incision of the suprabrow or forehead, and finally the use of smaller incisions with an endoscopic technique. Another technique, deserving of further consideration, is the transblepharoplasty brow lift (TBBL). Though generally reserved for occasional use, this technique is easy to perform, minimizes facial incisions and operative time, and can achieve results comparable to other, more extensive, approaches.

Miniature in vivo Robots for Remote and Harsh Environments

Long-term human space exploration will require contingencies for emergency medical procedures including some capability to perform surgery. The ability to perform minimally invasive surgery (MIS) would be an important capability. The use of small incisions reduces surgical risk, but also eliminates the ability of the surgeon to view and touch the surgical environment directly. Robotic surgery, or telerobotic surgery, may provide emergency surgical care in remote or harsh environments such as space flight, or extremely forward environments such as battlefields. However, because current surgical robots are large and require extensive support personnel, their implementation has remained limited in forward environments, and they would be difficult, or impossible, to use in space flight or on battlefields. This paper presents experimental analysis of miniature fixed-base and mobile in vivo robots to support MIS surgery in remote and harsh environments. The objective is to develop wireless imaging and task-assisting robots that can be placed inside the abdominal cavity during surgery. Such robots will provide surgical task assistance and enable an on-site or remote surgeon to view the surgical environment from multiple angles. This approach is applicable to long-duration space flight, battlefield situations, and for traditional medical centers and other remote surgical locations.

Early Complications of Primary Total Hip Replacement Performed with a Two-Incision Minimally Invasive Technique

Total hip replacement performed through a small incision theoretically results in less trauma to the underlying structures, reduced blood loss, less pain, and a shorter hospital stay, but it may result in increased complications, particularly early in a surgeon's experience with a new technique. In the present study, we reviewed the early results of two techniques involving the use of smaller incisions; specifically, we evaluated one series of primary total hip replacements that had been performed through two small incisions and another series of total hip replacements that had been performed through a single small incision. Eighty-nine consecutive primary total hip replacements were performed with use of the two-incision technique as described by Mears and Berger; all procedures were performed without cement and with use of fluoroscopic guidance. Outcomes data were reviewed at a minimum of six months following the procedure. The results of these procedures were retrospectively compared with those of a historical control series of ninety-six total hip replacements that had been performed by the same surgeon with use of a single miniincision technique. No special attempt was made to discharge any patient early from the hospital. In preparation for the use of the two-incision technique, the surgeon attended a two-day seminar that included cadaveric training and mentoring by surgeons who had experience with this technique. In the two-incision group, nine patients (nine hips; 10%) required repeat surgery because of a femoral fracture that had been identified postoperatively (two hips), dislocation (one hip), a wound complication (two hips), or subsidence and loosening of the femoral implant (four hips). Twenty-two patients (twenty-two hips; 25%) sustained an injury of the lateral femoral cutaneous nerve, and one patient (one hip) had a neuropraxia of the femoral nerve. In the comparative series of ninety-six total hip arthroplasties that had been performed with use of a single mini-incision and a direct lateral exposure of the hip joint, the overall complication rate was 6% (six of ninety-six) and the reoperation rate was 3% (three of ninety-six). The rate of complications associated with the two-incision technique decreased significantly as the surgeon gained experience with the procedure (p = 0.0202). Although total hip arthroplasty with use of the two-incision technique was performed by a surgeon who was experienced in the performance of total hip replacement surgery with use of a single small incision, the rates of complications and repeat surgery associated with the two-incision technique initially were very high. While the rate diminished with increasing experience, total hip replacement with use of two incisions and fluoroscopic guidance is a technically demanding procedure that may be associated, especially initially, with higher rates of complications and repeat surgery.

Modeling, Analysis, and Experimental Study of In Vivo Wheeled Robotic Mobility

Laparoscopy is abdominal surgery performed with long tools inserted through small incisions. The use of small incisions reduces patient trauma, but also eliminates the surgeon's ability to view and touch the surgical environment directly. These limitations generally restrict the application of laparoscopy to procedures less complex than those performed during open surgery. This paper presents a theoretical and experimental analysis of miniature, wheeled, in vivo robots to support laparoscopy. The objective is to develop a wireless mobile imaging robot that can be placed inside the abdominal cavity during surgery. Such robots will allow the surgeon to view the surgical environment from multiple angles. The motion of these in vivo robots will not be constrained by the insertion incisions. Simulation and experimental analyses have led to a wheel design that can attain good mobility performance in in vivo conditions

Mobile in vivo camera robots provide sole visual feedback for abdominal exploration and cholecystectomy

The use of small incisions in laparoscopy reduces patient trauma, but also limits the surgeon's ability to view and touch the surgical environment directly. These limitations generally restrict the application of laparoscopy to procedures less complex than those performed during open surgery. Although current robot-assisted laparoscopy improves the surgeon's ability to manipulate and visualize the target organs, the instruments and cameras remain fundamentally constrained by the entry incisions. This limits tool tip orientation and optimal camera placement. The current work focuses on developing a new miniature mobile in vivo adjustable-focus camera robot to provide sole visual feedback to surgeons during laparoscopic surgery. A miniature mobile camera robot was inserted through a trocar into the insufflated abdominal cavity of an anesthetized pig. The mobile robot allowed the surgeon to explore the abdominal cavity remotely and view trocar and tool insertion and placement without entry incision constraints. The surgeon then performed a cholecystectomy using the robot camera alone for visual feedback. This successful trial has demonstrated that miniature in vivo mobile robots can provide surgeons with sufficient visual feedback to perform common procedures while reducing patient trauma.

Early Complications of Primary Total Hip Replacement Performed with a Two-Incision Minimally Invasive Technique

Total hip replacement performed through a small incision theoretically results in less trauma to the underlying structures, reduced blood loss, less pain, and a shorter hospital stay, but it may result in increased complications, particularly early in a surgeon's experience with a new technique. In the present study, we reviewed the early results of two techniques involving the use of smaller incisions; specifically, we evaluated one series of primary total hip replacements that had been performed through two small incisions and another series of total hip replacements that had been performed through a single small incision. Eighty-nine consecutive primary total hip replacements were performed with use of the two-incision technique as described by Mears and Berger; all procedures were performed without cement and with use of fluoroscopic guidance. Outcomes data were reviewed at a minimum of six months following the procedure. The results of these procedures were retrospectively compared with those of a historical control series of ninety-six total hip replacements that had been performed by the same surgeon with use of a single mini-incision technique. No special attempt was made to discharge any patient early from the hospital. In preparation for the use of the two-incision technique, the surgeon attended a two-day seminar that included cadaveric training and mentoring by surgeons who had experience with this technique. In the two-incision group, nine patients (nine hips; 10%) required repeat surgery because of a femoral fracture that had been identified postoperatively (two hips), dislocation (one hip), a wound complication (two hips), or subsidence and loosening of the femoral implant (four hips). Twenty-two patients (twenty-two hips; 25%) sustained an injury of the lateral femoral cutaneous nerve, and one patient (one hip) had a neuropraxia of the femoral nerve. In the comparative series of ninety-six total hip arthroplasties that had been performed with use of a single mini-incision and a direct lateral exposure of the hip joint, the overall complication rate was 6% (six of ninety-six) and the reoperation rate was 3% (three of ninety-six). The rate of complications associated with the two-incision technique decreased significantly as the surgeon gained experience with the procedure (p = 0.0202). Although total hip arthroplasty with use of the two-incision technique was performed by a surgeon who was experienced in the performance of total hip replacement surgery with use of a single small incision, the rates of complications and repeat surgery associated with the two-incision technique initially were very high. While the rate diminished with increasing experience, total hip replacement with use of two incisions and fluoroscopic guidance is a technically demanding procedure that may be associated, especially initially, with higher rates of complications and repeat surgery.

EARLY COMPLICATIONS OF PRIMARY TOTAL HIP REPLACEMENT PERFORMED WITH A TWO-INCISION MINIMALLY INVASIVE TECHNIQUE

Background: Total hip replacement performed through a small incision theoretically results in less trauma to the underlying structures, reduced blood loss, less pain, and a shorter hospital stay, but it may result in increased complications, particularly early in a surgeon's experience with a new technique. In the present study, we reviewed the early results of two techniques involving the use of smaller incisions; specifically, we evaluated one series of primary total hip replacements that had been performed through two small incisions and another series of total hip replacements that had been performed through a single small incision. Methods: Eighty-nine consecutive primary total hip replacements were performed with use of the two-incision technique as described by Mears and Berger; all procedures were performed without cement and with use of fluoroscopic guidance. Outcomes data were reviewed at a minimum of six months following the procedure. The results of these procedures were retrospectively compared with those of a historical control series of ninety-six total hip replacements that had been performed by the same surgeon with use of a single mini-incision technique. No special attempt was made to discharge any patient early from the hospital. In preparation for the use of the two-incision technique, the surgeon attended a two-day seminar that included cadaveric training and mentoring by surgeons who had experience with this technique. Results: In the two-incision group, nine patients (nine hips; 10%) required repeat surgery because of a femoral fracture that had been identified postoperatively (two hips), dislocation (one hip), a wound complication (two hips), or subsidence and loosening of the femoral implant (four hips). Twenty-two patients (twenty-two hips; 25%) sustained an injury of the lateral femoral cutaneous nerve, and one patient (one hip) had a neuropraxia of the femoral nerve. In the comparative series of ninety-six total hip arthroplasties that had been performed with use of a single mini-incision and a direct lateral exposure of the hip joint, the overall complication rate was 6% (six of ninety-six) and the reoperation rate was 3% (three of ninety-six). The rate of complications associated with the two-incision technique decreased significantly as the surgeon gained experience with the procedure (p = 0.0202). Conclusions: Although total hip arthroplasty with use of the two-incision technique was performed by a surgeon who was experienced in the performance of total hip replacement surgery with use of a single small incision, the rates of complications and repeat surgery associated with the two-incision technique initially were very high. While the rate diminished with increasing experience, total hip replacement with use of two incisions and fluoroscopic guidance is a technically demanding procedure that may be associated, especially initially, with higher rates of complications and repeat surgery. Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

Does laparoscopic surgery spell the end of the open surgeon?

Barely fifteen years have passed since the laparoscopic era was launched with a cholecystectomy by the French surgeon Philippe Mouret.1 Yet today by far the majority of cholecystectomies are done in this way,2 and laparoscopic surgery finds many other indications. The UK has been slower than some other countries to adopt these techniques; indeed, the President of the Association of Coloproctology, Neil Mortensen, has declared ‘... it is scandalous how far we are behind on keyhole surgery for bowel cancer and other bowel problems’ (Daily Telegraph, 6 May 2003). The range of operations now extends from simple procedures such as herniorrhaphy and ovarian cystectomy to complex operations including radical prostatectomy, nephrectomy, and adrenalectomy.3 Where will this end? Do such techniques spell the demise of open surgery? In discussing this matter we confine ourselves to laparoscopy, though the argument applies also to numerous other procedures whereby open operation is replaced by use of small incisions and long thin instruments, with display of the surgical field on a monitor. The question in our title requires analysis of two key elements: is laparoscopic surgery better for the patient (without unduly hampering the surgeon); and is it practically and financially feasible?

Minimally invasive approaches to mediastinal neoplasms.

The goal of minimal-access surgery is to cause the least trauma necessary to gain exposure for an operative procedure. Application of this principle to mediastinal neoplasms involves the use of small incisions with both mediastinoscopy and video-assisted thoracoscopic surgery (VATS). The mediastinum is divided into anterior, middle, and posterior compartments, and this anatomy provides a framework for discussion of diagnostic and therapeutic procedures. Neoplasms occur with a characteristic frequency that varies with age and location. Neurogenic tumors and thymic neoplasms account for one third of all masses. Knowledge of the potential cause of a neoplasm and the surrounding anatomy provides the context for determining the surgical approach. The operative indications and goals of a procedure should not be significantly affected by the operative approach. Conversion from a minimal-access approach to a more traditional incision should be an anticipated possibility that is often undertaken as the next logical step rather than an expression of exasperation.

What Is ‘Minimally Invasive’ Coronary Bypass Surgery?: Experience With a Variety of Surgical Revascularization Procedures for Single-Vessel Disease

Although the use of small incisions is theoretically appealing, it has been argued that the true advantage of minimally invasive approaches to myocardial revascularization lies in the avoidance of cardiopulmonary bypass. Of 25 patients referred for surgical revascularization of single-vessel coronary disease, 20 elected to undergo a minimally invasive coronary artery bypass grafting (MICABG) procedure, while 5 opted to have conventional surgery with cardiopulmonary bypass (CPB). Patients having MICABG underwent single-vessel revascularization without CPB, via limited anterior thoracotomy, hemisternotomy, or median sternotomy. Intraoperatively, hemodynamics, anastomotic time, and total operative time were recorded. Postoperatively, length of hospital stay, incidence of myocardial infarction, indexes of end-organ function, and morbidity rates were recorded. In addition, patient questionnaires were used to assess subjective end points such as postoperative pain, wound drainage, and quality of life. Fifteen of 20 patients undergoing MICABG underwent revascularization without CPB, while 4 were converted to standard coronary artery bypass grafting with CPB due to technical reasons and 1 for intraoperative ventricular fibrillation. Patients undergoing MICABG had no perioperative myocardial infarctions, while those having CPB had two infarctions (20%). Furthermore, there were no differences in length of stay or postoperative morbidity among the various approaches, while the MICABG procedures, especially via median sternotomy, were associated with shorter operative times. The advantage of MICABG lies mainly in the avoidance of CPB. Thus, we advocate that surgeons initially utilize the median sternotomy and limited skin incision for MICABG to assure adequate exposure, technical precision, and patient safety. After a reasonable level of technical proficiency and experience are attained, the limited anterior thoracotomy approach can be used.

Use of small incisions to control induced astigmatism and inflammation following cataract surgery

A series of 55 small incision (3 mm) silicone-implanted cataract cases closed with horizontal sutures and a concurrent series of 48 6 mm to 7 mm incision poly(methyl methacrylate)-implanted cases closed with radial incisions were compared retrospectively for surgically induced astigmatism. At two to three weeks after surgery, the mean surgically induced astigmatism in the poly(methyl methacrylate) group was more than twice as high as in the silicone group (2.27 D vs 1.07 D, P < .01). In addition, a series of 41 small incision cases and a concurrent series of 61 cases with 6 mm to 7 mm incisions were compared for inflammation as measured by an FC-1000 laser flare/cell meter. The larger incision cases had significantly higher average cell counts at one day and one week postoperatively (P = .005 and P = .03, respectively) and had significantly higher average flare measurement at one day (P = .01) than the smaller incision cases.

Astigmatic keratotomy: A review of basic concepts with case reports

Despite the use of small incisions, better wound closure, and other technical improvements in cataract and corneal surgery, astigmatism remains a problem for the cataract and refractive surgeon. Case reports illustrate the applicability of astigmatic keratotomy in postcataract and idiopathic astigmatism. The basic concepts of corneal relaxing incisions are reviewed and the frequently misunderstood coupling phenomenon is explained in the light of the “law of elastic domes.” Properly used, astigmatic keratotomy with coupling effectively corrects a wide variety of types of astigmatism.