Minimally invasive endoscopic thyroidectomy by a cervical approach

Background: The technique of thyroidectomy mandates adequate visualization of the operative field to identify pertinent anatomical structures. The purpose of this prospective review was to assess the feasability and safety of endoscopic thyroidectomy by a cervical approach. Methods: All patients who underwent endoscopic thyroidectomy were assessed by retrospective review of a prospective database. Results: Thirty-eight patients underwent endoscopic thyroidectomy by a cervical approach. Thirty-five of 38 cases were successfully completed endoscopically with a mean OR time of 190 min. One patient experienced a permanent recurrent laryngeal palsy. Conclusion: Endoscopic thyroidectomy by a cervical approach is a feasible procedure. As in conventional thyroid surgery, great care should be exercised when dissecting the recurrent laryngeal nerve.     

Minimally invasive approach to the cervical spine: a proposal

BACKGROUND and PURPOSE: During the last 3 years, a minimally invasive video-assisted approach for parathyroidectomy and thyroidectomy has been developed. Because of the good exposure of the cervical spine during these procedures, the authors decided to perform an anatomic-radiologic study in order to evaluate which cervical vertebrae could be reached by this minimally invasive approach. PATIENTS and METHODS: Three consenting patients, two undergoing minimally invasive parathyroidectomy and one a conventional operation for C4-C5 disc herniation, were selected for this study. The procedure was carried out through a single 1.5-cm central skin incision above the sternal notch. After opening of the cervical linea alba, dissection was performed under endoscopic vision, without using any CO2 insufflation or trocar. After exposure of the prevertebral fascia, an operative tube was introduced through the cervical incision in order to maintain the operative space without using conventional retractors. RESULTS: Through this operative tube, it was possible to introduce both a 5-mm (or 3-mm) endoscope and the surgical instruments. In our patients, we inserted a 1-mm metal probe to exactly localize during fluoroscopy the vertebrae reached by the dissection (C2-C7). CONCLUSIONS: This study shows the feasibility of an anterior minimally invasive approach to the cervical spine. Although the exact indications have to be verified, a video-assisted approach could add some advantages to the well-known benefits coming from the anterior approaches to the cervical spine, especially in terms of cosmetic results and postoperative course and recovery.     

Minimally invasive anterior contralateral approach for the treatment of cervical disc herniation

BACKGROUND: During the practice of ipsilateral approach to the offending lesion in anterior simple discectomy, the authors realized that it achieves better surgical exposure of the opposite foraminal area. In addition, it was also realized that routine procedures for better visualization of the foraminal area, such as stripping longus colli muscles, further excising of the anterior longitudinal ligament, or using a spreader, which cause more invasive surgery during the standard anterior approach, are not necessary because the contralateral approach already achieves sufficient exposure of the target foraminal area. OBJECTIVE: Evaluation of the results and effectiveness of this minimal invasive technique in patients with either soft or hard disc herniations. METHODS: Between January 1994 and April 2002, 216 patients underwent anterior contralateral microdiscectomy without fusion for cervical disc herniation at 1 or 2 adjacent levels. Anterior contralateral microdiscectomy is a less invasive technique than standard anterior simple discectomy in which longus colli muscles are not stripped, and the lateral part of annulus fibrosis at the side of intervention and ventrolateral part of it at the opposite side are not removed. In addition, a mini Zenker handheld retractor is used for retraction of paravertebral soft tissues and a spreader is not used during the discectomy procedure. There were 182 patients diagnosed with radiculopathy and 34 patients with myelopathy. Assessments of the neurological status of patients with radiculopathy were done by physical examinations, and of those with myelopathy according to the modified Japanese Orthopaedic Association cervical spine functional assessment scale. These neurological assessments were repeated in the 18th month after surgery. In the follow-up period, the outcomes of surgery were also assessed for all patients in 4 categories, from failure to excellent. RESULTS: Surgery outcomes generally have been good to excellent and none of the patients were made worse by the procedure. The outcomes were significantly better in the radiculopathy and soft disc herniation groups. Other positive outcome factors were short duration and sudden onset of symptoms, normal cervical curvature, and single-level disease. Follow-up radiological studies revealed fibrous healing with normal or slight loss of disc height in 199 (92.1%) patients and total obliteration of the involved disc space representing radiological fusion signs in 13 (6%) patients. The overall complications observed in this study were 2 spontaneous and 2 postinfection collapses of disc level, 1 excessive fibrosis of disc level, and 2 adjacent-level diseases. CONCLUSION: Anterior contralateral microdiscectomy without fusion achieves better exposure for resection of the offending foraminal or far lateral lesions, ventral osteophytes, or a disc fragment under direct microscopic visualization. Collapse and instability of the involved disc level can also be avoided via this less invasive technique.     

Minimally invasive cervical stenosis decompression

Cervical stenosis and cervical spondylotic myelopathy are common disorders seen by many spine surgeons. Presentation can range from asymptomatic to myelopathy or myeloradiculopathy to lower extremity and gait problems attributed to lumbar disease. Various surgical procedures are practiced in the surgical management of this disease. Posterior cervical laminectomy is a familiar procedure and is the treatment of choice for multilevel disease. With the development of newer instruments and access devices, it has become possible to treat this problem through a minimally invasive approach.     

Minimally invasive anterior approach to upper cervical spine: surgical technique

OBJECTIVE: The transoral approach of Spetzler is the classic anterior access to the upper cervical spine that provides direct exposure for anterior decompression of the spinal cord. The risks of infection, the limits in extension, and the postoperative recovery difficulties of transmucosal access suggest the use of an alternative anterior extraoral approach in upper cervical surgery. However, this approach results in complications from nerve palsy because of excessive retraction of the hypoglossal and the superior laryngeal nerves. The goal of this work was to provide anatomic data for an anterior retropharyngeal upper cervical approach through a minimally invasive window below the hypoglossal and the superior laryngeal nerves. METHODS: In two adult cadaveric cervical spines, the anterior approach using the Metrx tubular retractor system through a window between the hypoglossal nerve and the superior laryngeal nerve, as well as below these two nerves, is compared in the exposure of C1 and C2 anteriorly with the aid of an operating microscope. RESULTS: A maximum diameter of the internervous window for the tubular retractor is reached beyond which the superior laryngeal nerve will be excessively stretched. Conversely, the tubular retractor can retract the superior laryngeal nerve superiorly without undue tension. Better proximal exposure is also made possible by angling an end-beveled tubular retractor on the mandible without undue compression on the hypoglossal and superior laryngeal nerves, the marginal mandibular branch of the facial nerve, and the submandibular gland. CONCLUSION: This minimally invasive approach can replace transoral surgery, allowing direct anterior access to C1 and C2 while allowing extension to the lower cervical spine.     

Minimally invasive approaches to the cervical spine

Minimally invasive approaches and operative techniques are becoming increasingly popular for the treatment of cervical spine disorders. Minimally invasive spine surgery attempts to decrease iatrogenic muscle injury, decrease pain, and speed postoperative recovery with the use of smaller incisions and specialized instruments. This article explains in detail minimally invasive approaches to the posterior spine, the techniques for posterior cervical foraminotomy and arthrodesis via lateral mass screw placement, and anterior cervical foraminotomy. Complications are also discussed. Additionally, illustrated cases are presented detailing the use of minimally invasive surgical techniques.     

Minimally invasive ilioinguinal approach to the acetabulum

The classic ilioinguinal approach is a gold standard in acetabular surgery. We developed a modification, a minimally invasive method that entails a median lower abdominal approach with extraperitoneal dissection and exposure of the pubic symphysis. The second incision is lateral, next to the iliac crest. This allows an easy, safe and quick exposure of the anterior iliac ring as well as easy access to the posterior column and wall towards the sacroiliac joint. The iliac vessels and nerves are thereby protected, and no preparation of neurovascular structures is required. The technique was applied in 23 clinical cases and compared with the classic ilioinguinal approach in 9 similar cases over the same period.     

Minimally invasive posterior cervical arthrodesis and fixation

This article describes the use of minimally invasive posterior cervical arthrodesis and internal fixation for the subaxial cervical spine. Such systems vary by the angulation of their screws and in the degree of the constraint placed at the screw-rod interface. The polyaxial tulip or islet connectors of the screws are able to angle medially, laterally, and straight, with varying degrees of rotational freedom in each direction, thus making segmental fixation more easily achievable from a top-loading approach and allowing for the possibility of minimally invasive posterior cervical fixation.     

Minimally invasive approach to colorectal surgery

While the development of laparoscopic surgery over the last two decades was amazingly fast, its adoption was neither uniform nor universal. Some procedures, like laparoscopic cholecystectomy, rapidly became the standard of care throughout the surgical community. Laparoscopy for colorectal surgery gained much less acceptance. Factors such as technical complexity, cost, duration of surgery and concerns about oncologic safety influenced the hesitancy in performing this surgery, and it took the surgical community more than a decade to admit that the laparoscopic option is legitimate: it is safe, and it provides the patients with the advantages of minimally invasive surgery, without any surgical or oncologic compromise. This slow process of maturation had a significant advantage, as it allowed this kind of surgery to be thoroughly investigated. Its acceptance is now well based on multitude of data, available from many basic science and clinical studies. Not many procedures in the daily surgical practice are as evidence-based as is laparoscopic colon surgery. The aim of this review was to describe some general aspects of laparoscopic colorectal surgery, and examine the data supporting its use in different procedures for various pathologies, both benign and malignant.     

Minimally invasive parathyroidectomy in patients with previous endocrine surgery

Objective:

Previous endocrine neck surgery (PENS) in patients with sporadic primary hyperparathyroidism (PHP) is considered a contraindication for minimally invasive parathyroidectomy (MIP). The purpose of our study was to determine the effectiveness of MIP in such patients.

Methods:

From January 2004 to December 2009, 270 patients with PHP were treated in our department; 30 had had PENS in the past. Eighteen were selected to have MIP, while the other 12 had traditional neck explorations. Selection criteria for MIP were unilateral single- or double-gland disease localized preoperatively with at least 2 concordant imaging techniques and patient informed consent. Imaging studies included high-resolution neck ultrasound and sestamibi scan in most patients, and CT scan, selective venous sampling, and MRI in 7 patients. Unilateral explorations via a lateral approach with the patients under local (UALA in 13 patients), general (MIP in 4 patients), or local followed by general anesthesia (1 patient) were performed.

Results:

Sixteen of the 17 patients became normocalcemic after the operation. There was no conversion to traditional exploration. A single adenoma was found in 16 patients and hyperplasia in one. One patient underwent a successful parathyroidectomy 8 months later via mesothoracoscopy, because the parathyroid gland was localized correctly but was beyond access via neck. There were no postoperative complications. Mean duration of the procedure and length of stay were similar to MIP in patients without PENS. Mean follow-up of 33 months (range, 4 to 70) did not reveal any recurrence.

Conclusion:

These results illustrate that MIP is a valuable option in select patients with sporadic PHP and PENS. Localization with 2 or more concordant imaging techniques could avoid intraoperative sestamibi or qPTH testing with low morbidity (0%), high biochemical cure rate (100% in this series), rapid recovery, and finally substantially lower the cost of the procedure.     

Minimally invasive limited pericardiectomy: the hybrid approach

This communication describes our clinical experience with the hybrid method, a video-assisted anterior minithoracotomy approach developed for minimally invasive limited pericardiectomy to treat 8 patients with massive pericardial effusion. The average operating time was 37.2 minutes, and there was no procedure-related morbidity or mortality. The mean follow-up period was 5.6 months, and there have been no recurrences. The hybrid approach can be accomplished irrespective of pleural adhesions. It eliminates the need for hemipulmonary collapse, making it more advantageous than the totally port-access thoracoscopic approach.     

Minimally invasive approach in the management of childhood intussusception

Background: Intussusception is one of the most common causes of intestinal obstruction in infancy. Non‐operative reduction using air enema or other hydrostatic reduction methods has been the standard treatment in most cases. However, if the non‐operative method is not indicated or fails, open surgery is still necessary. With the tremendous development of the minimally invasive approach in handling surgical conditions in children in the last decade, this has been applied recently for the reduction of intussusception in children. We herein reviewed our experience of using the combined approach, namely, pneumatic reduction and, if failed, laparoscopic reduction in the management of childhood intussusception. Methods: We carried out a retrospective analysis of all children with intussusception managed at Prince of Wales Hospital between December 1998 and December 2004. The minimally invasive approach was used as far as possible. The method of reduction, success rate and the incidence of complication were analysed. Results: Over a 6‐year period, there were 146 patients with 167 episodes of intussusception. Pneumatic reduction was carried out in 160 occasions and was successful in 134 (83.8%). In 33 patients, operative reduction was required. Of these, laparoscopic reduction was attempted in 15 and was successful in 13 (86.7%). In those with either pneumatic or laparoscopic reduction, no procedure‐related complication was encountered and they had a significant shorter hospital stay (median 3.0 day) than those requiring laparotomy (median 8.0 day) (t‐test, P < 0.0001). Conclusion: The minimally invasive approach, that is, pneumatic and/or laparoscopic reduction, was successful in reducing intussusception in 88% of patients with minimal morbidity and shorter hospital stay.     

Minimally invasive surgical approach for the treatment of gastroparesis

Background

Gastroparesis is a chronic disorder resulting in decreased quality of life. The gastric electrical stimulator (GES) is an alternative to gastrectomy in patients with medically refractory gastroparesis. The aim of this study was to analyze the outcomes of patients treated with the gastric stimulator versus patients treated with laparoscopic subtotal or total gastrectomy.

Methods

A retrospective chart review was performed of all patients who had surgical treatment of gastroparesis from January 2003 to January 2012. Postoperative outcomes were analyzed and symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI).

Results

There were 103 patients: 72 patients (26 male/46 female) with a GES, implanted either with laparoscopy (n = 20) or mini-incision (n = 52), and 31 patients (9 male/22 female) who underwent laparoscopic subtotal (n = 27), total (n = 1), or completion gastrectomy (n = 3). Thirty-day morbidity rate (8.3 % vs. 23 %, p = 0.06) and in-hospital mortality rate (2.7 % vs. 3 %, p = 1.00) were similar for GES and gastrectomy. There were 19 failures (26 %) in the group of GES patients; of these, 13 patients were switched to a subtotal gastrectomy for persistent symptoms (morbidity rate 7.7 %, mortality 0). In total, 57 % of patients were treated with GES while only 43 % had final treatment with gastrectomy. Of the GES group, 63 % rated their symptoms as improved versus 87 % in the primary gastrectomy group (p = 0.02). The patients who were switched from GES to secondary laparoscopic gastrectomy had 100 % symptom improvement. The median total GCSI score did not show a difference between the procedures (p = 0.12).

Conclusion

The gastric electrical stimulator is an effective treatment for medically refractory gastroparesis. Laparoscopic subtotal gastrectomy should also be considered as one of the primary surgical treatments for gastroparesis given the significantly higher rate of symptomatic improvement with acceptable morbidity and comparable mortality. Furthermore, the gastric stimulator patients who have no improvement of symptoms can be successfully treated by laparoscopic subtotal gastrectomy.