Abdominal hydatids: a minimally invasive approach.

BACKGROUND: The conventional surgical procedures for managing abdominal hydatids, including those of the liver, have a very high morbidity rate in terms of hospital stay and wound complications. Less invasive procedures may thus be logical alternatives. METHOD: We enrolled 58 patients in the study. Using guided ultrasound aspiration followed by instillation of 15% saline, we were able to manage 16 patients as outpatients. In the remaining 42 patients, saline instillation was combined with laparoscopic aided percutaneous evacuation combined with partial pericystectomy. Omental packing was added in four patients. A pericystic drain tube was left in every patient managed laparoscopically. RESULTS: In the aspiration group, two sittings were required in 12 patients and more than two sittings (3 x) in two patients. Laparoscopic parameters showed an average IV infusion time of 12.3 hrs, drain removal time of 3.2 days, and discharge time of 3.2 days. Short-term complications included prolonged tube drainage for six days in one patient, intracystic bile collection in two, and intracystic pus in four patients. The aspiration group did not have any complications. Conversion to open evacuation was done in one patient. Fifty-four months of follow-up has been recurrence free. CONCLUSION: Minimally invasive management, including aspiration and laparoscopic intervention, appear to be viable alternatives to open surgery because they result in less morbidity.     

Trans-eyebrow mini-orbitozygomatic pterional approach for minimally invasive skull base surgery.

Surgical treatment of skull base pathologies remains one of the most challenging tasks to neurosurgeons. Advances in neuroimaging as well as the evolution of modern techniques and neurosurgical equipment have paved the way for a more precise diagnosis, a better selection of the surgical approach and have prompted the adaptation of minimally invasive concepts to different aspects of modern neurosurgical practice. The trans-eyebrow mini orbitozygomatic pterional approach is a tailored approach that provides multiple avenues to the target, minimizing retraction of the brain and affords better exposure of the pathology. It was performed on 16 patients with frontobasal or suprasellar tumors. The post-operative clinical outcome was excellent with smooth and fast recovery as well as satisfactory cosmetic results. It should be considered as part of the armamentarium to manage skull base lesions when indicated and not to replace other well recognized skull base approaches.     

Ethical and educational considerations in minimally invasive surgery training for practicing surgeons

There is an opportunity to improve the training of practicing surgeons in minimal access techniques. Such improvement is desirable because it would allow for the introduction of innovation in a way that maximizes the benefit for patients while minimizing the harm that can result from the introduction of new techniques after inadequate training. This goal is consistent with basic biomedical principles that govern the behavior of surgeons. Individuals who place themselves in the role of a teacher of surgeons accept another level of responsibility and are governed not only by biomedical ethics but also by the ethics of teaching. Adherence to these two different governing ethical principles compels these teachers to apply the best educational principles in the development of educational courses. Review of motor skill learning theory would suggest that effective feedback and adequate practice opportunities are essential for the acquisition of motor skill and should be integrated into all skills-type continuing medical educational courses. The present trend is toward more objectivity in skill evaluation although evidence that this actually improves evaluation is lacking. Curriculum development and evaluation of this specific type of training course should follow those general principles proposed for the development of effective continuing medical education.     

MicroHip: a minimally invasive procedure for total hip replacement surgery. A modified Smith-Peterson approach

Abstract: In this article we present the surgical technique of our anterior minimally invasive approach to the hip joint. This is aligned along an interneural plane and makes the approach truly minimally invasive. This technique is performed in a lateral decubitus position on a normal operating table; there is not a need for a specific orthopaedic or fracture table. As leg traction is not necessary, this enables the approach to be used routinely. Most of the instruments used for this procedure are standard instruments, only the acetabular reamers and positioners are angulated and specifically designed. The angled instruments (MI – minimally invasive) are especially useful when performing hip replacement in obese patients. An excellent view of both the acetabulum and the proximal femur can be obtained through an incision of only 6-8 cm, using this MI approach. The approach follows the interval between the tensor fascia lata muscle and the sartorius muscle using a section of the anterior iliofemoral approach described by Smith-Peterson. No tendon or muscle is cut or detached. The joint capsule is split and preserved in toto. The hip joint is not dislocated and we perform the osteotomy of the femoral neck in-situ. To date we have performed over 500 MicroHip™ operations. We have not observed any nerve lesions or fractures of the trochanter. Our experience to date shows that the method we have developed allows us to operate reliably on virtually any patient. Preliminary results also show that important factors like length of stay, pain, blood loss and return to work can be reduced significantly. The MicroHip™ technique is being used by more and more different clinics all over the world and can be applied with success after suitable training.     

Descending necrotizing mediastinitis: a minimally invasive approach using video-assisted thoracoscopic surgery

BACKGROUND: Descending necrotizing mediastinitis is a rare but serious disease. Aggressive surgical approaches have been emphasized rather than simple medical treatment. METHODS: Four patients with descending necrotizing mediastinitis were treated surgically in our institution between January 2001 and August 2002. Three had peritonsilar abscesses and one had an odontogenic abscess. Operative procedures included drainage and debridement through a Chamberlain incision and neck incision using video-assisted thoracic surgery. RESULTS: The mean duration from symptoms to operation was 5.3 days (range, 3 to 7) and mean hospital stay was 28.8 days (range, 14 to 47). There was no perioperative mortality. Postoperative complications were found in three patents: two with localized pleural effusion and one with a hydropneumothorax. CONCLUSIONS: Video-assisted thoracic surgery is feasible and effective as a less invasive method for the surgical management of patients with descending necrotizing mediastinitis, especially when applied early.     

Mick J. Perez-Cruet,Richard G. Fessler,Michael Y. Wang: An anatomic approach to minimally invasive Spine surgery

European Journal of Orthopaedic Surgery & Traumatology -     

Combined minimally invasive approach using microsurgery and thoracoscopic surgery for resecting a dumbbell-type thoracic schwannoma.

We present a case of a thoracic schwannoma with an intravertebral component, a so-called "dumbbell-type" tumor, that was resected with a combined minimally invasive approach using microsurgery and thoracoscopic surgery simultaneously. A 31-year-old man was admitted to our hospital for treatment of a thoracic schwannoma 45 mm in maximal diameter at the level of the third thoracic vertebra. After the tumor was separated from intravertebral structures by using a microsurgical technique via the posterior approach with a hemilaminectomy and minimal unilateral facetectomy, the mass was removed completely by using video thoracoscopy. We stress that this approach should be the most useful and less invasive technique for treating the dumbbell-type of thoracic neurogenic tumor compared with a single or combination technique involving thoracotomy, multi-level laminectomy and costotransversectomy. Below, we make some notes on this technique from the neurosurgeon's standpoint.     

关于微创理念与手术入路的断想与思考

外科医生治疗疾病的基本途径是手术.对于任何外科手术,首先必须"显露",黄志强院士曾经说过:"显露是解决战斗的一半",要达到理想的显露,关键在于手术入路.可以说,手术入路的选择是否合理,在很大程度上影响到整个手术的成败.     

关于微创理念与手术入路的断想与思考

外科医生治疗疾病的基本途径是手术.对于任何外科手术,首先必须"显露",黄志强院士曾经说过:"显露是解决战斗的一半",要达到理想的显露,关键在于手术入路.可以说,手术入路的选择是否合理,在很大程度上影响到整个手术的成败.     

关于微创理念与手术入路的断想与思考

外科医生治疗疾病的基本途径是手术.对于任何外科手术,首先必须"显露",黄志强院士曾经说过:"显露是解决战斗的一半",要达到理想的显露,关键在于手术入路.可以说,手术入路的选择是否合理,在很大程度上影响到整个手术的成败.     

Surgical considerations of entire lumbar spine hardware removal via a minimally invasive approach

A retrospective analysis of 13 patients who underwent endoscopic hardware removal to resolve residual foraminal stenosis issues was performed to determine the feasibility and validity of utilizing endoscopic techniques to entirely remove spinal hardware. Tubular retractors were utilized for the procedure with a diameter of 15 to 18 mm. Surgical times ranged from 58 to 268 minutes, with the largest time delay being the need to cut the crossbars in vivo due to stripped screws, bony overgrowth, or bent hardware. Entire hardware systems can be removed via an endoscopic approach. Blood loss averaged around 90 cc but surgical times were over an hour for most procedures. Endoscopic removal of entire hardware systems can be accomplished but it offers little advantage over conventional hardware removal. The main advantages include reduced trauma and the ability of the surgery to be performed on an outpatient basis.     

Liver tumors and minimally invasive surgery: a feasibility study.

Laparoscopic liver resection has not yet been established, although recent reports document that liver resection can be performed safely by the laparoscopic approach. Other interventional procedures like cryoablation have also been introduced in treatment of liver metastases. In this report 11 liver resections performed laparoscopically in eight patients are presented. Six patients had colorectal metastases, one a metastases from a malignant melanoma, and one patient had focal nodular hyperplasia. Two patients received synchronous cryoablation of remaining liver metastases. During follow up, two patients received percutaneous cryoablation of liver recurrences monitored by an open configuration magnetic resonance scanner. All except one of the tumors we attempted to remove had free resection margins (re-resection of new metastasis). No complications occurred except an atelectasis of the left lower pulmonary lobe in one patient. Median postoperative hospital stay was 3 days, and median postoperative opioid-dependent days was 1. The report demonstrates that minimally invasive techniques may safely be combined in hepatic intervention, and that the advantages of minimally invasive surgery, such as reduced hospital stay and less patient discomfort, also applies to liver resections.     

Critical design and validation considerations for the development of neonatal minimally invasive surgery simulators

Background/PurposePediatric surgical trainees have limited exposure to advanced minimally invasive surgery (MIS) during their clinical training, particularly for cases such as esophageal atresia/tracheoesophageal fistula (EA/TEF). Simulation on validated neonatal models offers an alternative means of training that may augment traditional forms of training; but to be useful, they must fulfill certain criteria.MethodologyReview of the currently available MIS, thoracoscopic and laparoscopic, simulators for pediatric surgery, and identification of those factors that contribute to their fidelity and validity as a training tool that must be incorporated in the design of future simulation models.ResultsThere are few neonatal laparoscopic and thoracoscopic models currently available, or in the research stage. To our knowledge, there is no commercially available, synthetic, high fidelity and low cost thoracoscopic model in existence. Use of animal tissue has disadvantages of ethical dilemmas, cost, and logistic and procurement issues. Newer synthetic models need to be validated for fidelity, to replicate those components of the operation that pose the greatest technical challenge, and incorporate means of measuring acquisition of technical expertise.ConclusionThis review describes the principles that need to be considered to develop low cost, validated high-fidelity MIS simulator that can be used for training, and that is capable of measuring the acquisition of the technical skills that can be applied to the repair of complex procedures such as esophageal atresia.Level of evidence III     

Treatment of urachal anomalies: a minimally invasive surgery technique.

BACKGROUND: Urachal disease is uncommon. The surgical treatment consists of the resection of the urachus throughout its entire length. Our objective is to demonstrate the use of minimally invasive surgery to treat this disease. METHODS: Six patients were studied and diagnosed. The technique used three 10-mm ports on the right hemi abdomen, through which the dissection of the urachus was performed from the umbilical extreme to the bladder. We evaluated the perioperative records to assess morbidity and outcome. RESULTS: Most patients suffered from episodes of umbilical discharge. The diagnosis was made mainly through clinical history and confirmed during the laparoscopic procedure. The urachus was resected throughout its entire length, and we did not perform a segmentary bladder resection in any patient. The average operative time was 66 minutes (range, 42 to 123), and no operative complications were associated with the technique. DISCUSSION: Minimally invasive surgery is a safe and effective procedure that allows the dissection of the urachus through its entire length, providing optimal postoperative results.     

Gaze-contingent control for minimally invasive robotic surgery.

OBJECTIVE: Recovering tissue depth and deformation during robotically assisted minimally invasive procedures is an important step towards motion compensation, stabilization and co-registration with preoperative data. This work demonstrates that eye gaze derived from binocular eye tracking can be effectively used to recover 3D motion and deformation of the soft tissue. METHODS: A binocular eye-tracking device was integrated into the stereoscopic surgical console. After calibration, the 3D fixation point of the participating subjects could be accurately resolved in real time. A CT-scanned phantom heart model was used to demonstrate the accuracy of gaze-contingent depth extraction and motion stabilization of the soft tissue. The dynamic response of the oculomotor system was assessed with the proposed framework by using autoregressive modeling techniques. In vivo data were also used to perform gaze-contingent decoupling of cardiac and respiratory motion. RESULTS: Depth reconstruction, deformation tracking, and motion stabilization of the soft tissue were possible with binocular eye tracking. The dynamic response of the oculomotor system was able to cope with frequencies likely to occur under most routine minimally invasive surgical operations. CONCLUSION: The proposed framework presents a novel approach towards the tight integration of a human and a surgical robot where interaction in response to sensing is required to be under the control of the operating surgeon.     

Comparison of outcomes of minimally invasive mitral valve surgery for posterior, anterior and bileaflet prolapse

Objective: We sought to compare the outcomes of minimally invasive mitral valve (MV) surgery for anterior (anterior mitral leaflet, AML), posterior (posterior mitral leaflet, PML) or bileaflet (BL) MV prolapse. Methods: Between August 1999 and December 2007, 1230 patients who presented with isolated AML (n = 156, 12.7%), isolated PML (n = 672, 54.6%) or BL (n = 402, 32.7%) MV prolapse underwent minimally invasive MV surgery. The preoperative mitral regurgitation (MR) grade was 3.3 ± 0.8, left ventricular ejection fraction (LVEF) was 62 ± 12% and mean age was 58.9 ± 13.0 years; 836 patients (68.0%) were male. Mean follow-up time was 2.7 ± 2.1 years, and the follow-up was 100% complete. Results: Overall, the MV repair rate was 94.0% (1156 patients). Seventy-four patients (6.0%) received MV replacement. MV repair for PML prolapse was accomplished in 651 patients (96.9%), for AML in 142 patients (91%) and for BL in 363 patients (90.3%). Repair techniques consisted predominantly of leaflet resection and/or implantation of neochordae, combined with ring annuloplasty. Concomitant procedures were tricuspid valve surgery (n = 56), atrial fibrillation ablation (n = 286) and closure of an atrial septal defect or patent foramen ovale (PFO) (n = 89). The overall duration of cardiopulmonary bypass was 127 ± 40 min and aortic cross-clamp time was 78 ± 33 min. The mean postoperative hospital stay was 11.6 ± 9.7 days for the overall group. Early echocardiographic follow-up revealed excellent valve function in the vast majority of patients, regardless of the repair technique, with a mean MR grade of 0.3 ± 0.5. For the overall group, 5-year survival rate was 87.3% (95% CI: 83.9–90.1) and 5-year freedom from cardiac reoperation rate was 95.6% (95% CI: 94.1–96.7). The log-rank test revealed no significant difference between the three groups regarding long-term survival or freedom from reoperation. Conclusions: Minimally invasive MV repair can be achieved with excellent results. Long-term outcomes and reoperation rates for AML prolapse are not significantly different from PML or BL prolapse.     

腰椎间盘突出症的微创外科治疗进展

近年来,微创脊柱外科发展迅速,微创治疗腰椎间盘突出症是其重要组成部分,有损伤小、恢复期短、疗效确切的优势.正确认识腰椎间盘微创手术,严格适应证和熟练的操作技巧是取得良好疗效的关键.本文将总结各种微创手术方法在临床应用的现状与进展.