The supraorbital approach—a minimally invasive approach to the superior orbit

Background  We present a minimally invasive approach to the superior orbit via an eyebrow incision with a small osteotomy, minimal orbital rim resection and small frontal craniotomy. Methods  This approach was used in 20 patients with a well-defined intra-and extraconal lesion superior to the optic nerve, who underwent surgery between 2000 and 2007. Results  This approach is purely extradural with minimal brain and orbital retraction. The size of the lesion was not a limiting factor. Sensory deficits in the territory of the supraorbital nerve resolved within 7 months on average. Conclusion  This approach presents a combination of an extra-and transcranial approach, which is indicated in all orbital lesions superior to the optic nerve. The clinical and cosmetic results are excellent.     

A “Modern” posterior approach: “The Back Is Back”

In recent years the direct anterior approach (DAA) to total hip arthroplasty has gained in popularity. This increased interest in the DAA took place at a time when surgeons using a traditional posterior approach were struggling with dislocation risks and slowed recovery due to now outdated, and largely abandoned, techniques combined with older style implants. However, at the same time that the DAA gained in popularity, the standard posterior approach was also being modified. It has been adapted to work with newer instrumentation and modern cementless implants which also offer an expanded array of sizing and dimensioning versatility. We present a contemporary, iliotibial band sparing, minimally invasive posterior approach that we believe achieves the same degree of soft tissue preservation, with similar early recovery benefits as compared to the DAA. This highly modified posterior approach offers a lower risk profile and the potential for stepwise adoption and a surgeon controlled learning curve.     

The “Swiss-cheese Doppler-guided laser tonsillectomy”: a new safe cribriform approach to intracapsular tonsillectomy

Outpatient laser ablation of palatine tonsils is a very interesting procedure that has been recently introduced as a routine in head and neck surgery departments. The aim of this study was to describe a new strategy using a Doppler-guided fibre optic neodymium-yttrium–aluminium–garnet (YAG) laser to remove up to 80 % of tonsillar tissue, as assessed in the long-term postoperative clinical evaluation of the volume of the tonsils at the follow-up, and leaving the capsule in place, thus avoiding any haemorrhagic complication and minimize pain. A total of 20 patients (men, n?=?13; women, n?=?7), aged between 6 and 63, were recruited for the procedure. They were affected by chronic hypertrophic tonsillitis with a recurrent fever and other symptoms that were related to oral inflammation. Among the 20 patients, no serious adverse events, including haemorrhage-related complications, were observed. Treatment was well tolerated, even in patients displaying an overall low pain threshold. No dropout or uncompleted procedure occurred in the present study. Minor complications included sore throat, moderate oedema, mild acute pharynx inflammation, slight peritonsillar exudate and local burning. The postoperative pain, measured by Scott–Huskisson visual analogue scale, was between 5 and 40 mm and was easily counteracted by means of external ice packages and nonsteroidal anti-inflammatory drugs, according to the individual patient’s need. During the 12–36-month follow-up patients showed improved symptoms (n?=?7) and complete recovery (n?=?13). A relapse episode was observed in two patients. This study supports fibre optic laser neodymium-YAG tonsil surgery, named “cribriform intracapsular tonsillectomy” or “Swiss-cheese laser tonsillectomy”, as an effective alternative to the traditional cold knife approach or electrosurgery. This approach could become the gold standard for tonsil surgery in the third millennium for safety reasons, acceptable cost–benefit ratio, the precise targeting of the beam across the affected tissues and the short- and long-term recovery.     

The “Kergin pneumonectomy”

Out of a series of 211 stage III (A and B) lung cancers radically resected with routine lymphadenectomy from 1971 to 1987, a total of 11 were squamous cell carcinomas invading the right main bronchus and lateral portion of the trachea. These patients were managed using a particular technique that we have always arbitrarily called, Kergin pneumonectomy, after the Toronto surgeon who described it in 1952. These patients, today, are staged III B. There was no operative mortality and only 2 minor complications. Two patients survived 3 years and 1 is alive and free of disease 7 years from surgery. This technique should be considered before embarking on more perilous surgery such as sleeve pneumonectomy, a procedure which still carries high mortality and morbidity rates and requires special equipment and intensive postoperative care.

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Resumen En una serie de 211 casos de cáncer pulmonar en estado III (A y B) sometidos a resección radical con linfadenectomía rutinaria entre 1971 y 1987, un total de 11 eran carcinomas escamocelulares que invadían el bronquio principal derecho y la porción lateral de la tráquea. Estos pacientes fueron manejados utilizando una técnica quirúrgica particular que arbitrariamente hemos denominado la neumonectomía de Kergin, según el cirujano de Toronto que la describió en 1952. Estos pacientes actualmente son estadificados como III B. No se presentó mortalidad operatoria y sólo hubo 2 complicaciones menores. Dos pacientes sobrevivieron 3 años y uno se encuentra vivo y libre de enfermedad 7 años después de la operación. Esta técnica debe ser considerada antes de embarcarse en operaciones más peligrosas taies como la neumonectomía en manga, un procedimiento que todavía conlleva elevadas tasas de mortalidad y morbilidad y que requiere equipo especial y cuidado intensivo postoperatorio.

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Résumé Dans une série de 211 cancers bronchopulmonaires de stade III (A et B), réséqués de façon radicale avec lymphadénectomie systématique, entre 1971 et 1987, 11 étaient des cancers épithéliaux envahissant la bronche souche droite et la partie latérale de la trachée. Les patients ont été opérés selon une technique que nous avons nommée arbitrairement la pneumectomie de Kergin, selon le nom du chirugien de Toronto qui l'a décrite pour la première fois en 1952. A présent, ces patients sont de stade III B. Il n'y a pas eu de mort à l'opération et il y a eu seulement 2 complications mineures. Deux patients ont survécu 3 ans et le troisème est vivant et sans récidive à 7 ans. Cette technique est à considérer avant d'envisager la pneumectomie avec enmanchonnage, technique encore accompagnée de mortalité et morbidité élevées et demandant des soins postopératoires intensifs spécifiques.

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Presented at the Société Internationale de Chirurgie in Toronto, Ontario, Canada, September, 1989.     

The “Unpleasant” smile

A simple procedure is described to correct what the authors call the unpleasant smile. The procedure consists of hiding the excessively visible upper arch mucosa exposed during smiling, and it usually solves the aesthetic problem in patients who reject a more complicated maxillofacial approach. Basically, the technique involves creating a synechia between the upper lip and the periosteum of the maxillary arch. This synechia eliminates overexcursion of the lip during smiling.Presented at the First Congress of the Sociedad Argentina de Cirugía Estética, Buenos Aires, November 1972.     

The direct anterior approach: First among equals—Opposes

The anterior approach is increasingly practiced throughout the United States. Advocates claim it is minimally invasive, tissue friendly with decreased dislocation rates, decreased hospital stay, and improved outcomes. Recent data however, indicates high complication rates; wound problems, fractures, femoral loosening, and dislocation rates similar to other approaches. The superior approach is modeled after an ideal approach to total hip arthroplasty that is tissue-preserving, inexpensive, and reduces complications of other techniques. Features of the superior approach include simple positioning, no dislocation of the femoral head, preservation of abductors, anterior and posterior capsule, and most, if not all of the external rotators.