Invasiveness of surgical procedures

Endoscope-assisted sp.inal decompression surgery for lumbar spinal stenosis

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Abstract

OBJECT

The authors undertook this study to document the clinical outcomes of microendoscopic laminotomy, a minimally invasive decompressive surgical technique using spinal endoscopy for lumbar decompression, in patients with lumbar spinal stenosis (LSS).

METHODS

A total of 366 patients were enrolled in the study and underwent microendoscopic laminotomy between 2007 and 2010. Indications for surgery were single- or double-level LSS, persistent neurological symptoms, and failure of conservative treatment. Microendoscopy provided wide visualization through oblique lenses and allowed bilateral decompression via a unilateral approach, through partial resection of the base of the spinous process, thereby preserving the supraspinous and interspinous ligaments and contralateral musculature. Clinical symptoms and signs of low-back pain were evaluated prior to and following surgical intervention by applying the Japanese Orthopaedic Association (JOA) scoring system, Roland-Morris Disability Questionnaire (RMDQ), Japanese Orthopaedic Association Back Pain Evaluation Questionnaire (JOABPEQ), and 36-Item Short Form Health Survey (SF-36). These items were evaluated preoperatively and 2 years postoperatively.

RESULTS

Effective circumferential decompression was achieved in all patients. The 2-year follow-up evaluation was completed for 310 patients (148 men and 162 women; mean age 68.7 years). The average recovery rate based on the JOA score was 61.3%. The overall results were excellent in 34.9% of the patients, good in 34.9%, fair in 21.7%, and poor in 8.5%. The mean RMDQ score significantly improved from 11.3 to 4.8 (p < 0.001). In all categories of both JOABPEQ and SF-36, scores at 2 years’ follow-up were significantly higher than those obtained before surgery (p < 0.001). Twelve surgery-related complications were identified: dural tear (6 cases [1.9%]), wrong-level operation (1 [0.3%]), transient neuralgia (4 [1.3%]), and infection (1 [0.3%]). All patients recovered, and there were no serious postoperative complications.

CONCLUSIONS

Microendoscopic laminotomy is a safe and very effective minimally invasive surgical technique for the treatment of degenerative LSS.

Source: JNS.

Surgery Without Scars.

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Report of Transluminal Cholecystectomy in a Human Being

 

ABSTRACT

Hypothesis  Natural orifice transluminal endoscopic surgery (NOTES) provides the potential for performance of incisionless operations. This would break the physical barrier between bodily trauma and surgery, representing an epical revolution in surgery. Our group at IRCAD-EITS (Institut de Recherche contre les Cancers de l’Appareil Digestif [Institute of Digestive Cancer Research]–European Institute of TeleSurgery) has been actively involved in the development of NOTES since 2004 with a dedicated project created to develop feasibility and survival studies and new endoscopic technology.

Design  NOTES cholecystectomy in a woman via a transvaginal approach.

Setting  University hospital.

Patient  The patient was a 30-year-old woman with symptomatic cholelithiasis.

Intervention  The procedure was carried out by a multidisciplinary team using a standard double-channel flexible videogastroscope and standard endoscopic instruments. The placement of a 2-mm needle port, mandatory to insufflate carbon dioxide and to monitor the pneumoperitoneum, was helpful for further retraction of the gallbladder. At no stage of the procedure was there need for laparoscopic assistance. All of the principles of cholecystectomy were strictly adhered to.

Results  The postoperative course was uneventful. The patient had no postoperative pain and no scars, and was discharged on the second postoperative day.

Conclusions  Transluminal surgery is feasible and safe. NOTES, a radical shift in the practice and philosophy of interventional treatment, is becoming established and is enormously advantageous to the patient. With its invisible mending and tremendous potential, NOTES might be the next surgical evolution.

The abolishment of pain in surgery is a chimera. It is absurd to go on seeking it. . . . Knife and pain are two words in surgery that must forever be associated in the consciousness of the patient.—Dr Alfred Velpeau, French surgeon (1839)

Change is part of surgery but it is never easy to accept. At the dawn of surgery, excellence was associated with big incisions: “Big scar, big surgeon.” Surgery with no scars was an impossible reverie. Now natural orifice transluminal endoscopic surgery (NOTES) is being performed, and the philosophy of surgery will be dramatically changed. Transluminal surgery has the potential to break the physical barrier between bodily trauma and surgery, representing an epical evolution in surgery.

Laparoscopic gallbladder resection changed the focus of surgery and the mindset of nearly all surgeons. Cholecystectomy seems to be the logical next step in developing the clinical application of NOTES.

In 1882, Langenbuch, as cited by van Gulik,1 successfully removed the gallbladder in a 43-year-old man who had cholelithiasis. His initial report was ignored. Nevertheless, Langenbuch’s open cholecystectomy remained the standard criterion for the treatment of symptomatic cholelithiasis for more than a century. In 1985, Muhe, as cited by Reynolds,2 performed the first laparoscopic cholecystectomy using a modified laparoscope, called the galloscope. In 1986, he presented his technique at the German Surgical Society Congress but was strongly criticized. In 1987, Mouret3performed the first laparoscopic cholecystectomy with an approach that would become the standard technique within 2 years, that is, use of 1 optical trocar and 2 other trocars. The world of general surgery was soon divided into a small group of enthusiastic surgeons convinced of the superiority of laparoscopic over conventional cholecystectomy and a second, large group of surgeons with varying opinions ranging from curiosity to frank condemnation of laparoscopic cholecystectomy.

The controversy was intense but short. In 1992, the National Institutes of Health Consensus Development Conference4 statement on gallstones and laparoscopic cholecystectomy concluded that, compared with open cholecystectomy, laparoscopic cholecystectomy was safe and effective in most patients and should be the treatment of choice. Even if surgeons were reluctant to acknowledge this shift in treatment, patients applauded the new minimally invasive surgery. Whenever it was possible, patients would ask for a surgical procedure that left no outer scarring and resulted in no postoperative pain. Patients, both male and female, independent of age and body shape, dislike scars, not only for cosmetic reasons but because scars indicate they have undergone treatment because of illness. This resulted in NOTES, with its general goal of minimizing the trauma of any interventional process by eliminating the incision through the abdominal wall and using natural orifices. To our knowledge, this is the first report of the use of NOTES to treat cholecystectomy in a human being via transvaginal access, performed at University Hospital in Strasbourg, France.

CONCLUSION

With the successful performance of the first transluminal cholecystectomy, we witnessed the introduction of NOTES into clinical practice with mixed feelings of excitement and caution. Even if the advantages of NOTES in this first clinical case are apparent, transvaginal cholecystectomy is time consuming and difficult. Will NOTES generate a major paradigm shift in surgical care? We know that laparoscopic surgery is just the beginning of the minimally invasive evolution of surgery. We have come to an even more critical juncture in the history of surgery. With its invisible mending and tremendous potential for improving patient care and well-being, NOTES might represent the next greatest surgical evolution.

Source:JAMA

 

 

 

 

 

Researchers Say Breath Test Could Help Identify Stress.

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stess

According to a new pilot study conducted by scientists at Loughborough University, Leicestershire, UK, a deep breath could become stress-detector.

“If we can measure stress objectively in a non-invasive way, then it may benefit patients and vulnerable people in long-term care who find it difficult to disclose stress responses to their carers, such as those suffering from Alzheimer’s,” said Prof Paul Thomas.

The study, reported in the Journal of Breath Research, involved 22 young adults (10 male and 12 female) who each took part in two sessions. In the first, they were asked to sit comfortably and listen to non-stressful music. In the second, they were asked to perform a common mental arithmetic test that has been designed to induce stress.

A breath test was taken before and after each session, whilst heart-rates and blood pressures were recorded throughout.

The breath samples were examined using a technique known as gas chromatography-mass spectrometry, and then statistically analyzed and compared to a library of compounds.

Two compounds in the breath – 2-methylpentadecane and indole – increased following the stress exercise which, if confirmed, the researchers believe could form the basis of a rapid test.

A further four compounds were shown to decrease with stress, which could be due to changes in breathing patterns.

“What is clear from this study is that we were not able to discount stress. It seems sensible and prudent to test this work with more people over a range of ages in more normal settings,” Prof Thomas said.

“We will need to think carefully about experimental design in order to explore this potential relationship further as there are ethical issues to consider when deliberately placing volunteers under stress. Any follow up study would need to be led by experts in stress.”

Breath profiling has become an attractive diagnostic method for clinicians and most recently researchers have found biomarkers associated with tuberculosis, multiple cancers, pulmonary disease and asthma. It is still unclear how to best manage external factors, such as diet, environment and exercise, which can affect a person’s breath sample.

“It is possible that stress markers in the breath could mask or confound other key compounds that are used to diagnose a certain disease or condition, so it is important that these are accounted for.”

The researchers hope that the findings could lead to a quick, simple and non-invasive test for measuring stress; however, the study, which involved just 22 subjects, would need to be scaled-up to include more people, over a wider range of ages and in more ‘normal’ settings, before any concrete conclusions can be made.

Source: /www.sci-news.com

 

 

Incidence of and risk factors for superior facet violation in minimally invasive versus open pedicle screw placement during transforaminal lumbar interbody fusion: a comparative analysis.

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A reported risk factor for adjacent-segment disease is injury to the superior facet joint from pedicle screw placement. Given that the facet joint is not typically visualized during percutaneous pedicle screw insertion, there is a concern for increased facet violation (FV) in minimally invasive fusion procedures. The purpose of this study was to analyze and compare the incidence of FV among patients undergoing minimally invasive transforaminal lumbar interbody fusion (MITLIF) and open transforaminal lumbar interbody fusion (TLIF). The impact of O-arm navigation compared with traditional fluoroscopy on FV in MITLIF is also assessed, as are risk factors for FV.

Methods

The authors identified a consecutive population of patients who underwent MITLIF with percutaneous pedicle screw placement, as well as a matched cohort of patients who underwent open TLIF. Postoperative CT imaging was assessed to determine intraarticular FV due to pedicle screw placement. Patients were stratified into minimally invasive and open TLIF groups. Within the MITLIF group, the authors performed a subanalysis of image guidance methods used in cases of FV. Two-tailed Student t-test, ANOVA, chi-square testing, and logistic regression were used for statistical analysis.

Results

A total of 282 patients were identified, with a total of 564 superior pedicle screw placements. The MITLIF group consisted of 142 patients with 284 screw insertions. The open TLIF group consisted of 140 patients with 280 screw insertions. Overall, 21 (7.4%) of 282 patients experienced FV. A total of 21 screws violated a facet joint for a screw-based FV rate of 3.7% (21 of 564 screws). There were no significant differences between the MITLIF and open TLIF groups in the percentage of patients with FV (6.3% vs 8.6%) and or the percentage of screws with FV (3.2% vs 4.3%) (p = 0.475 and p = 0.484, respectively). Further stratifying the MI group into O-arm navigation and fluoroscopic guidance subgroups, the patient-based rates of FV were 10.8% (4 of 37 patients) and 4.8% (5 of 105 patients), respectively, and the screw-based rates of FV were 5.4% (4 of 74 screws) and 2.4% (5 of 210 screws), respectively. There was no significant difference between the subgroups with respect to patient-based or screw-based FV rates (p = 0.375 and p = 0.442, respectively). The O-arm group had a significantly higher body mass index (BMI) (p = 0.021). BMI greater than 29.9 was independently associated with higher FV (OR 2.36, 95% CI 1.65–8.53, p = 0.039).

Conclusions

The findings suggest that minimally invasive pedicle screw placement is not associated with higher rates of FV. Overall violation rates were similar in MITLIF and open TLIF. Higher BMI, however, was a risk factor for increased FV. The use of O-arm fluoroscopy with computer-assisted guidance did not significantly decrease the rate of FV.

Source: Journal of Neurosurgery

 

 

New approaches to thyroidectomy prompt discussion.

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During an academic debate held here, two presenters focused on the pros and cons of conventional vs. minimally invasive approaches to thyroidectomy.

In the process, some of the concerns that patients now harbor, particularly in terms of cosmetic effects, came to the forefront.

“The frontiers of thyroidectomy today focus on minimizing pain and maximizing cosmesis and preventing long hospital stays,” Carmen C. Solorzano, MD, professor of surgery and director of the Vanderbilt Endocrine Surgery Center, said during a presentation at the American Thyroid Association 82nd Annual Meeting.

‘Gold standard‘

Conventional thyroidectomy consists of a Kocher incision and requires elevation of large flaps, often with the use of a surgical drain, to allow complete exposure of the thyroid gland, according to Solorzano, whereas a minimally invasive approach involves an incision in the cervical area that is small and requires less extensive dissection. These approaches include minimally invasive video-assisted thyroidectomy (MIVAT), minimal incision and endoscopic minimally invasive thyroidectomy, but not remote approaches to the thyroid gland, such as the robotic facelift thyroidectomy.

Solorzano, who spoke in favor of the conventional approach, noted that a meta-analysis showed that the rate of recurrent nerve palsy between the two approaches was the same, although cosmetic satisfaction and pain scores were better in the minimally invasive thyroidectomy group. The conventional approach, however, was associated with shorter operative times, lower cost and wider applicability, she said. Additionally, conventional thyroidectomy remains the standard approach for Graves’ disease, which usually involves very large glands, and bulky cancer, as these would be difficult to remove through small incisions.

“The fact remains that one of the drawbacks to the minimally invasive approach is that it is only appropriate in about 5% to 30% of cases,” Solorzano said. “Major limitations are thyroid size, thyroiditis or toxic glands and cancer or adenopathy.”

Nevertheless, patients can still experience the benefits associated with minimally invasive surgery, according to Solorzano, as long as surgeons adapt by considering cosmesis with smaller incisions in the skin crease, using magnification and lighting, and paying attention to the edges of the wound.

“The conventional thyroidectomy remains the gold standard approach to removing the thyroid gland,” Solorzano said. “The minimally invasive approach remains an option but is limited by thyroid size and pathology.”

For select patients

Although not appropriate for all, according to Maisie L. Shindo, MD, FACS, patients and physicians may benefit from the MIVAT approach, which is similar to a laparoscopic procedure in which a high definition camera is used that allows the surgeon to dissect using a monitor.

“An advantage of the high definition camera is you can really see the nerve in magnified view and then just take out the thyroid,” Shindo, who is director of thyroid and parathyroid surgery at Oregon Health & Science University, said.

She also cited data from several studies suggesting that patients who underwent MIVAT experienced somewhat better outcomes vs. those who underwent conventional thyroidectomy. In a 2002 prospective study comparing post-operative pain at 24 and 48 hours after the procedure, for instance, indicated that post-operative pain was better in the MIVAT group. Similarly, a 2004 study showed that patients in the MIVAT group experienced better cosmetic and pain results than those in the conventional approach group.

Additionally, a study comparing minimally invasive thyroidectomy without video with mini-incision revealed that pain was significantly lower among patients who underwent surgery with the minimally invasive approach, according to Shindo.

She expressed concern, however, about the use of MIVAT in patients with thyroid cancer where the surgeon would likely be performing a total thyroidectomy and potentially removing lymph nodes as well, and noted that becoming skilled in using MIVAT requires time.

“My argument is that MIVAT is safe with the appropriate patient selection,” Shindo said. “It does provide a small incision and less pain, but there is a learning curve like with any other laparoscopic procedure. You have to be very experienced because there can be anatomic variations, so you have to be aware of that.”

Perspective

 

David J. Terris

  • I thought both of the speakers made very balanced and informed presentations. It’s always a challenge assessing new technology and new procedures, and I thought they both did a great job of presenting fair arguments about the procedures.

Much of the discussion was about minimally invasive techniques, but there was mention of robotic surgery, and it was clear that neither speaker was necessarily supportive of that approach. I think they drew an important distinction between minimally invasive surgery and robotic remote access surgery conventional techniques because sometimes the lines get blurred by the uninformed who may think that robotic surgery must be minimally invasive. For other procedures, such as robotic prostatectomy, it is. In many respects, it is minimally invasive, but when we refer to thyroid surgery and remote locations like the armpit or behind the ear, there’s more dissection involved just to get to where the thyroid gland is. The reason the robot is so valuable in those cases is because you’re working down a long tunnel and you can use these very minitaturized instruments to a) provide tremendous 3-D visualiation and b) the maneuverability of the instruments in that small space is so superior that if you’re going to do remote access surgery, it’s much easier if you use the robot. But the overall technique itself, the remote access techniques, is more invasive, but I was pleased to see that each of the speakers kind of emphasized that point.

Source: Endocrine Today.

 

Frontal bur hole through an eyebrow incision for image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage.

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Surgical evacuation of spontaneous intracerebral hemorrhage (sICH) remains a subject of controversy. Minimally invasive techniques for hematoma evacuation have shown a trend toward improved outcomes. The aim of the present study is to describe a minimally invasive alternative for the evacuation of sICH and evaluate its feasibility.

Methods

The authors reviewed records of all patients who underwent endoscopic evacuation of an sICH at the UCLA Medical Center between March 2002 and March 2011. All patients in whom the described technique was used for evacuation of an sICH were included in this series. In this approach an incision is made at the superior margin of the eyebrow, and a bur hole is made in the supraorbital bone lateral to the frontal sinus. Using stereotactic guidance, the surgeon advanced the endoscopic sheath along the long axis of the hematoma and fixed it in place at two specific depths where suction was then applied until 75%–85% of the preoperatively determined hematoma volume was removed. An endoscope’s camera, then introduced through the sheath, was used to assist in hemostasis. Preoperative and postoperative hematoma volumes and reduction in midline shift were calculated and recorded. Admission Glasgow Coma Scale and modified Rankin Scale (mRS) scores were compared with postoperative scores.

Results

Six patients underwent evacuation of an sICH using the eyebrow/bur hole technique. The mean preoperative hematoma volume was 68.9 ml (range 30.2–153.9 ml), whereas the mean postoperative residual hematoma volume was 11.9 ml (range 5.1–24.1 ml) (p = 0.02). The mean percentage of hematoma evacuated was 79.2% (range 49%–92.7%). The mean reduction in midline shift was 57.8% (p < 0.01). The Glasgow Coma Scale score improved in each patient between admission and discharge examination. In 5 of the 6 patients the mRS score improved from admission exam to last follow-up. None of the patients experienced rebleeding.

Conclusions

This minimally invasive technique is a feasible alternative to other means of evacuating sICHs. It is intended for anterior basal ganglia hematomas, which usually have an elongated, ovoid shape. The approach allows for an optimal trajectory to the long axis of the hematoma, making it possible to evacuate the vast majority of the clot with only one pass of the endoscopic sheath, theoretically minimizing the amount of damage to normal brain.

Source: Journal of Neurosurgery.

 

 

 

Endoscopic approaches to the trigeminal nerve and clinical consideration for trigeminal schwannomas: a cadaveric study.

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The course of the trigeminal nerve straddles multiple fossae and is known to be very complex. Comprehensive anatomical knowledge and skull base techniques are required for surgical management of trigeminal schwannomas. The aims of this study were to become familiar with the endoscopic anatomy of the trigeminal nerve and to develop a minimally invasive surgical strategy for the treatment of trigeminal schwannomas.

Methods

Ten fresh cadavers were studied using 5 endoscopic approaches with the aid of 4-mm 0° and 30° endoscopes to identify surgical landmarks associated with the trigeminal nerve. The endoscopic approaches included 3 transcranial keyhole approaches (the extradural supraorbital, extradural subtemporal, and retrosigmoid approaches), and 2 endonasal approaches (the transpterygoid and the transmaxillary transpterygoid approaches).

Results

The trajectories of the extradural supraorbital, transpterygoid, and extradural subtemporal approaches corresponded with the course of the first, second, and third divisions of the trigeminal nerve, respectively. The 3 approaches demonstrated each division in intra- and extracranial spaces, as well as the Meckel cave in the middle cranial fossa. The interdural space at the lateral wall of the cavernous sinus was exposed by the extradural supraorbital and subtemporal approaches. The extradural subtemporal approach with anterior petrosectomy and the retrosigmoid approach visualized the trigeminal sensory root and its neighboring neurovascular structures in the posterior cranial fossa. The transmaxillary transpterygoid approach revealed the course of the third division in the infratemporal fossa.

Conclusions

The 5 endoscopic approaches effectively followed the course of the trigeminal nerve with minimal invasiveness. These approaches could provide alternative options for the management of trigeminal schwannoma.

Source: Journal of Neurosurgery.