Minimal access breast surgery

Minimal access procedures have great potential for providing patients with equal, if not superior, forms of breast cancer diagnosis and treatment. Many of these procedures are in a process of evolution. The reliability of each method probably depends heavily on the training, ability, and experience of the operator. Surgeons should be aware of the advantages and pitfalls of these techniques and exercise caution during the initial phases of their learning experience.     

Minimal access adrenal surgery

Laparoscopic adrenalectomy has become the preferred method for removal of most adrenal tumors. An important component in selecting patients for this operation is to understand the clinical presentation and diagnostic workup for the various functioning and nonfunctioning adrenal tumors. In this review, an overview of the key clinical and diagnostic aspects of the most common adrenal tumors is presented. The indications and contraindications for a laparoscopic approach are discussed and the technique for laparoscopic adrenalectomy is then presented with inclusion of video links to demonstrate the technique. A review of the results of laparoscopic adrenalectomy is then considered with regard to common outcome measures and complications. A current controversy in adrenal surgery is the role of laparoscopic adrenalectomy in the management of patients with large tumors and malignant or potentially malignant adrenal lesions and the literature on this topic is reviewed in detail. The article concludes with a discussion of the indications and technique for partial adrenalectomy. This article contains a supplementary video.     

Minimal access aortic surgery including re-operations.

OBJECTIVES: Safety and benefits of minimal access ascending aorta and aortic arch surgery, including for re-operations has not been reported. METHODS: Fifty-four patients undergoing minimal access operations were evaluated. Of the 54 patients, valve replacements were performed in 76% (41 patients) (including composite valve grafts), and re-operations in 33% (18 patients). Composite valve grafts were used in 28% (15 patients) patients, and elephant trunk type procedures in 6% (three patients). RESULTS: The survival rate was 96% (52 patients), stroke 3.7% (two patients), and neurocognitive deficit 1.8% (one patient). The circulatory arrest time was 20 min (SD 17), aortic crossclamp time 91 min (SD 45) and cardiopulmonary bypass time 132 min (SD 59). Intraoperative homologous blood transfusion was a mean of 1.3 units (SD 2.3). ICU and postoperative stay were 1.8 days (SD 1.9) and 6.7 days (SD 3.7), respectively. No patient died after re-operation, although one patient had a stroke. CONCLUSIONS: Minimal access aortic surgery does not appear to carry a greater risk and, although more demanding technically, is associated with a reasonable ICU and hospital stay. For re-operations, we particularly recommend the technique.     

Minimal access surgery in neonates and infants

Background

Minimal access surgery (MAS) in small infants carries an important consideration. The tolerance of these small babies and the assumed physiological effect of MAS, in addition to the required anesthetic and surgical skills, have made it difficult to perform these types of procedures in many international centers. The present article reviews our experience with MAS in neonates and infants in the first year of life.

Methods

The medical records of all neonates and infants (<1 year) who underwent MAS over a period of 3 years were retrospectively reviewed for demographic information, procedures, operative time, complications, outcomes, and follow-up. Most of the operations were performed with 3-mm instruments and scopes and mean insufflation pressure of 10 mm Hg (range, 4-15 mm Hg).

Result

Seventy neonates and infants were included in this study: 19 females and 51 males. The weight ranged from 1.3 to 8.2 kg (mean, 4.3 kg). The mean age was 93 days (range, 1 day to 12 months). Twenty-four (34%) were neonates (first 30 days of life). Procedures performed included repair of tracheoesophageal fistula, lobectomy, repair of diaphragmatic or hiatus hernias, pull-through for imperforated anus and Hirschsprung's disease, plication of the diaphragm, Kasai procedure, excision of choledochal cyst, pyloromyotomy, Ladd's procedure, and reduction of intussusceptions. There were 2 conversions, both in neonates with tracheoesophageal fistula. All patients tolerated the procedure very well, with lesser degrees in neonates undergoing thoracoscopic procedures. Two neonates had postoperative hypothermia (<35°C) and 1 neonate had high Pco₂ postoperatively. There was 1 mortality and no morbidities. The follow-up ranged from 1 month to 3 years (mean, 19 months).

Conclusion

Minimal access surgery in neonates and infants is safe and well tolerated. Intraoperative monitoring of end-tidal CO₂ and core temperature is essential in avoiding unwanted effects of performing these procedures, especially in neonates.     

Early definitive surgery for acute pancreatitis associated with cholelithiasis

Since the natural history of pancreatitis associated with cholelithiasis is one of recurrence, surgery for the biliary tract disease is mandatory. But appropriate timing of the surgery remains controversial. Seventy-eight patients have been treated with early surgery once a diagnosis of cholelithiasis associated pancreatitis was made. Eighteen patients had previous episodes of nonalcoholic pancreatitis. Utilizing Ranson's prognostic signs, 52 patients had mild pancreatitis and 26 severe. Sixty-eight patients (87%) had surgery within 72 hours after admission and ten patients (13%) within 5 days. All patients had a cholecystectomy and operative cholangiogram performed. Fifty-six (72%) positive operative cholangiograms were obtained and common bile duct exploration revealed choledocholithiasis in 42 patients (75%). No mortality occurred, and four had six complications including mild persistent pancreatitis (two), wound infection (one), urinary tract infection (one), cardiac arrhythmia (one) and heart block requiring permanent pacemaker (one). The average hospital stay was 10.4 days. T-tube cholangiogram done prior to discharge was normal in all patients, and there have been no episodes of recurrent pancreatitis. Early definitive surgery for pancreatitis associated with cholelithiasis is recommended and can be accomplished with minimal morbidity and mortality coupled with judicious utilization of hospital resources.     

Minimal access surgery in managing anterior lumbar disorders

Traditional anterior lumbar surgery usually requires a long and sometimes painful skin incision. The current study evaluated the feasibility and safety of minimal access surgery for anterior lumbar disorders, emphasizing indications, operative technique, and the minimum 2-year followup results. From May 1996 to December 1997, the authors used this technique on 25 patients whose indications for surgery included syndromes of failed back surgery, selected cases of lumbar disc herniations, tuberculous or pyogenic spondylitis, selected spondylolisthesis, and vertebral tumors. In 23 of 25 patients, the site of interest was approached through a left flank incision, regardless of the laterality of the lesion. The mean length of the main incision was 5 cm. There were no injuries to great vessels or any neurologic deterioration after the procedures. Solid interbody fusion could be identified radiographically between 3 and 6 months after surgery. At a mean followup of 39.6 months, nine patients had excellent clinical outcomes, 11 patients had good outcomes, two patients had fair outcomes, and one patient had a poor outcome. The authors think such minimal access surgery is simple, effective, and safe for anterior lumbar disorders. The merits of the current technique include no need for endoscopic, microscopic, or complex surgical instruments, a lower amount of radiation exposure during surgery, and a shortened learning curve because the approach is similar to the anterior open lumbar technique, although the skin incision is only 5 cm in length.     

Minimal access surgery for the repair of simple congenital heart defects

Objective: We reviewed our experience of minimal access surgery to elucidate the efficacy and safety of this approach and determine the factors affecting hospital stay. Methods: Seventy-seven patients (age, 11.8±11.0 years), with body weight of more than 10 kg, were operated using various forms of minimal access approach for repair of simple congenital heart defects [atrial septal defect (ASD) in 40, ventricular septal defect in 37]. These included lower partial sternotomy (n=68) and mini-thoracotomy (n=9, ASD only) with limited skin incision of 4–11 cm. The anesthetic protocol was modified to wean all patients from ventilator soon after operation. The protocol of discharge from hospital (critical pass) was 14 days in the early period (n=30) and 10 days in the late period (n=47). Results: There were no hospital or late death, and no hospital re-admission. None of patients required blood transfusion. The endotracheal tube was extubated in the operating room in 48 cases (62%). Twenty-four patients (31%) failed to fulfill conditions of the critical pass. Univariate analysis of factors affecting unfavorably the critical pass demonstrated that the median approach, retention of pericardia] effusion and social reasons were statistically significant, while an opened pleura and aortic cross-clamp time were marginally significant Multivariate analysis indicated that the retention of pericardial effusion was the only significant factor that failed critical pass [p=0.007, odds ratio (OR) 5.7,95% confidence interval (CI) 1.61–19.8]. In addition, a pericardio-pleural fenestration was the only significant factor that affected favorably the pericardial effusion (p=0.035, OR 0.2,95%CI 0.47–0.89) by multivariate analysis. Conclusions: Our experience demonstrated that minimal access surgery of the simple congenital heart defects provided excellent cosmetic results. Retention of pericardial effusion, possibly due to pericarditis, was a major risk factor of the prolonged hospital stay. The pericardio-pleural fenestration could reduce the risk of retention of effusion.     

小切口心脏瓣膜手术72例

目的探讨小切口行心脏瓣膜手术的可行性. 方法 1997年1月～2003年1月小切口行心脏瓣膜手术72例,其中经胸右前外侧切口行二尖瓣手术36例,单纯三尖瓣手术9例;经胸骨横断切口行主动脉瓣手术5例;经胸骨旁切口行主动脉瓣手术5例,二尖瓣手术2例;经胸骨下段劈开联合横断右半胸骨(倒L型)切口行二尖瓣手术15例. 结果术后早期(术后1个月)71例生存,1例术后急性肝、肾功能衰竭死亡.随访64例,时间6～60个月,平均13个月,64例术后6个月症状改善,心功能(NYHA)II级56例,III级8例,复查心脏彩超机械瓣和生物瓣启闭良好,患者均对切口较小且隐蔽表示满意.结论小切口心脏瓣膜手术可行,避免完全劈开胸骨,维护胸廓完整性,有利于术后恢复.     

Minimal access surgery and the future of interventional laparoscopy

Minimal access surgery is intended to minimize the trauma of access without compromising exposure of the operative field. Its major benefits include diminished cost of therapy due to a reduced hospital stay and accelerated recovery with early return to full activity. The approaches used in minimal access surgery are laparoscopic, endoluminal, perivisceral, intra-articular, and combined. Many abdominal and thoracic procedures are being adapted to the minimal access approach. Developmental requirements include improvements in light delivery systems; three-dimensional television imaging; better surgical instrumentation; ultrasound probes for internal and external scanning; stapling devices; and tunable, portable solid-state diode lasers. In addition, however, adequate prospective evaluation of laparoscopic procedures, established or new, must be undertaken in the major academic institutions.     

Minimal access surgery of pediatric inguinal hernias: a review

Inguinal hernia is a common problem among children, and herniotomy has been its standard of care. Laparoscopy, which gained a toehold initially in the management of pediatric inguinal hernia (PIH), has managed to steer world opinion against routine contralateral groin exploration by precise detection of contralateral patencies. Besides detection, its ability to repair simultaneously all forms of inguinal hernias (indirect, direct, combined, recurrent, and incarcerated) together with contralateral patencies has cemented its role as a viable alternative to conventional repair. Numerous minimally invasive techniques for addressing PIH have mushroomed in the past two decades. These techniques vary considerably in their approaches to the internal ring (intraperitoneal, extraperitoneal), use of ports (three, two, one), endoscopic instruments (two, one, or none), sutures (absorbable, nonabsorbable), and techniques of knotting (intracorporeal, extracorporeal). In addition to the surgeons’ experience and the merits/limitations of individual techniques, it is the nature of the defect that should govern the choice of technique. The emerging techniques show a trend toward increasing use of extracorporeal knotting and diminishing use of working ports and endoscopic instruments. These favor wider adoption of minimal access surgery in addressing PIH by surgeons, irrespective of their laparoscopic skills and experience. Growing experience, wider adoption, decreasing complications, and increasing advantages favor emergence of minimal access surgery as the gold standard for the treatment of PIH in the future. This article comprehensively reviews the laparoscopic techniques of addressing PIH.     

Minimal access surgery (MAS)-related surgeon morbidity syndromes

The benefits of minimal access surgery (MAS) in terms of accelerated recovery, reduced period of short-term disability, and patient outcome account for the widespread use of the laparoscopic approach by the majority of general surgeons. In adopting this approach with its current limitations and poor ergonomics, surgeons have been known to sustain surgery-related injuries encompassed by a spectrum best described as MAS-related surgeon morbidity syndromes, some of which are currently overlooked and poorly researched. Equivalent morbidities including the overuse syndrome (from overuse of certain muscle groups during long operations) have been documented in open surgery but are nowadays rare occurrences. As more advanced MAS operations are performed with long execution times, new patterns of neuromusculoskeletal injuries are being recognized. The surgical fatigue syndrome has also been described, though its complex nature is not fully understood. Virtually little is known on other long-term adverse effects on the surgeon following many years of operating from images displayed on a television monitor or LCD screen, and these include deterioration of visual acuity and function of the ocular muscles responsible for fixation–refixation of the eyeballs. The limited reported literature on the MAS-related surgeon morbidity syndromes identifies certain risk factors for these injuries pertaining to central and peripheral domains. Only improved knowledge of the etiology and underlying ergonomic factors based on investigative studies followed by improved instrumentation and operating room (OR) ergonomics will provide near- and long-term solutions.