Endo-robotic resection of the submandibular gland in a cadaver model

BACKGROUND: By means of a prospective, nonrandomized investigation, we evaluated the feasibility of performing endo-robotic resection of the submandibular gland in a cadaver model and compared the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique. METHODS: Procedural times were recorded in a consecutive series of 11 endoscopic submandibular gland resections using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) and a modified endoscopic surgical approach previously developed in a porcine model. The presence of neurovascular injury was assessed postoperatively, and the specimens were examined histologically. RESULTS: Eleven endo-robotic submandibular gland resections were successfully performed in six cadavers (no conversions to open resection were necessary). The median duration of the procedures was 48 minutes (range, 33-82 minutes). Creation of the operative pocket took an average (+/-SD) of 12.2 +/- 5.3 minutes, assembly of the robot required 9.3 +/- 4.1 minutes, and the mean time for submandibular gland resection was 29.4 +/- 8.9 minutes. The time required for robotic assembly was offset by the reduced operative time necessary compared with conventional endoscopic resection. Histologic examination confirmed the presence of normal glandular architecture, without evidence of excessive mechanical or thermal injury. There were no cases of apparent neurovascular injury. CONCLUSIONS: Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.     

Minimally invasive total hip arthroplasty with the anterior approach

Background:

Total hip athroplasty with the anterior surgical approach is advised because the dissection is entirely within intermuscular planes. In this report we describe a minimally invasive technique of anterior total hip arthroplasty, with the early outcomes.

Materials and Methods:

The technique of minimally invasive total hip arthroplasty with anterior approach (Smith-Petersen) is described. We reviewed data on 100 consecutive patients who underwent anterior total hip arthroplasty with uncemented components. Mean patient age was 61 years (range 33-91). Mean patience BMI 29.8 (range 18.1-51.8).

Results:

Minumum follow up duration is 10 months. The mean duration of surgery was 53 min (range 34-87) with mean blood loss 185 cc (range 65-630), and the mean incision length was 10.4 cm. Clinical and radiographic outcomes were similar to historical outcomes of standard total hip arthroplasty.

Conclusions:

With proper surgeon training, minimally invasive total hip replacement with the anterior surgical interval is safe and efficacious.     

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 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 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 and maximally safe approach to cardiac surgery

Background Minimally invasive approaches in cardiac surgery have been introduced in an attempt to limit post operative pain, allow prompt recovery, and reduce the cosmetic impact of the scar. We describe a surgical technique of limited skin incision with complete median sternotomy. Patients & Methods A comparative study was performed using two groups of 35 patients each in which a minimally invasive incision (Group I) was compared to a routine incision (Group II). Surgical procedures included atrial septal defect closure, mitral, aortic and tricuspid valve surgery. Results Incision length ranged from 6.9cm to 7.5cm (mean 7.1±0.2cm) in Group I and from 16.5cm to 21cm (mean 19.4 ±1.2cm) in Group II (Group I vs Group II, p<0.01). The operating time, cardiopulmonary bypass time, aortic cross clamp time were not significantly different in both the groups. Similarly, post-operative drainage was also not significantly different. The mean hospital stay of patients in Group I was 5.7±1.0 days operative mortality or morbidity. Conclusion This technique provides full, safe and easy access to all cardiac structures with acceptable cosmetic results. No special instruments are required.     

Minimally invasive adrenalectomy: a cohort study of surgical approach and outcomes

Background

In the context of minimally invasive adrenal surgery, there remains debate about whether the transperitoneal adrenalectomy (TPA) and posterior retroperitoneoscopic adrenalectomy (PRA) approach have equivalent indications. This study aims to examine complication and conversion rates associated with three surgical approaches for adrenal tumours over the last 17 years in a specialized endocrine surgical unit.

Methods

All adrenalectomy cases performed in the period 2005–2021 were identified within a prospectively maintained surgical database. A retrospective cohort study was undertaken with patients divided into two cohorts (2005–2013 and 2014–2021). Surgical approach (open adrenalectomy (OA), TPA, PRA), tumour size, histopathology, complication and conversion rates were compared.

Results

During the study period, 596 patients underwent adrenalectomy with 31 and 40 cases each year per cohort. The dominant surgical approach per cohort significantly changed from TPA (79% versus 17%) to PRA (8% versus 69%, P < 0.001), whilst the frequency of OA remained stable (13% versus 15%). TPA removed larger tumours (3.0 ± 2.9 cm) than PRA (2.8 ± 2.2 cm, P = 0.02), with the median size increasing from 3.0 ± 2.5 to 4.5 ± 3.5 cm per cohort (P < 0.001). The maximum tumour sizes treated by TPA and PRA were 15 and 12 cm, respectively. Adrenocortical adenoma was the commonest pathology treated by either laparoscopic technique. Complication rates were greatest for OA (30.1%) with no significant difference between minimally invasive approaches (TPA 7.3%, PRA 8.3%, P = 0.7). Both laparoscopic techniques had equivalent conversion rates (3.6%). PRA was preferably converted to TPA (2.8%) over OA (0.8%).

Conclusion

This study demonstrates the transition from TPA to PRA, offering similarly low complication and conversion rates.     

Minimally invasive endoscopic surgeryof the lumbar spine

The usefulness of endoscopic techniques in orthopaedics as well as in general surgical, gynecologic, urologic, andthoracic procedures is well established. Endoscopic techniques in coronary bypass surgery are being developed. The development of the minimally invasive endoscopic approach to the thoracic and lumbar spine is a technique prompted by the surgeons desire to increase access to the spine while decreasing morbidity. In this article, we address the laparoscopic and retroperitoneal approaches to the lumbar spine. Discussion focuses on indications and applications of the procedures as well as operative setup. Finally, surgical experience is reviewed.     

微创外科——不断发展的技术与理念

自1991年国内开展第1例腹腔镜胆囊切除术以来,在外科的每一个领域,微创外科手术无论是技术还是理论都取得迅速和广泛的发展。腹腔镜肝切除术已不再是梦想,且已成为现实,国外已报告2804例腹腔镜肝切除术。腹腔镜切除术已成为胰腺良性肿瘤的一种治疗方式,更是用于重症急性坏死性胰腺炎及平时危重疾病控制损伤的处理。目前自然腔道外科（NOTES）和机器人手术获得了越来越多的关注。影像学?内镜?腹腔镜?机器人?N0TES的“结盟”,将给传统的外科学带来极大的震撼。外科的明天可能会越来越数字化。     

The anterior approach to hip arthroplasty: the short, single minimally invasive incision

A modified anterior approach to the hip developed by the senior author has been utilized in performing over 7,000 hip replacement operations in the past three decades. It can be readily applied to both primary and revision surgery, and involves muscle splitting and sparing of the major hip muscles, their innervation, and their function. Since the late 1970s, Yale orthopaedic residents have been taught this minimally invasive anterior approach using 1, 2, or 3 mini-incisions without fluoroscopy, special operating room tables, or special retractors. Our overall experience has documented a very low incidence of dislocation and minimal perioperative complications. While a smaller skin incision is desirable for cosmetic reasons and decreased healing time, what goes on beneath the skin is far more important. A well-placed total hip replacement should never be compromised. While many of our patients can ambulate the same or first postoperative day quite well, we do not advocate outpatient total hip arthroplasty. Bone is still cut, tissues bleed, clots can form, and the traditional complications of arthroplasty, while reduced, can still occur.     

微创全膝关节置换术的早期临床疗效分析

目的比较不干扰股四头肌（QS）微创全膝置换术与标准全膝关节置换术的早期临床结果。方法2005年3月至2006年3月,采用QS微创全膝置换术完成26例单侧全膝关节置换术（QS组）,观察切口长度、手术时间、出血量、关节屈曲活动度,视觉模拟（VAS）疼痛评分、膝关节协会评分（KSS）、下肢胫股角和直腿抬高时间等,并与同期33例标准髌旁内侧入路TKA比较（标准组）。结果术后平均随访17个月（12～23个月）。平均切口长度QS组为（9．5±1．5）cm,标准组为（14．0±2．3）cm（P〈0．05）。止血带时间QS组为（83±16）min,标准组为（55±11）min（P〈0．05）。平均胫股角QS组为外翻（5．7±1．5）°,标准组为（6．0±1．4）°（P〉0．05）。VAS评分术后1、3和7dQS组明显低于标准组,术后6周VAS评分无差异。膝关节主动屈曲活动度术后1周QS组可达到（107±12）°,标准组为（95±11）°（P〈0．05）,术后6周和3个月组间差异有统计学意义（P〈0．05）,术后12个月平均屈曲度组间差异无统计学意义（P〉0．05）。直腿抬高术后1周QS组为23例（88％）,而标准组为21例（64％）（P〈0．05）。术后6周膝关节评分QS组为78±15,标准组为71±20（P〈0．05）。QS组1例出现有症状的深静脉血栓,标准组3例;QS组1例伤口愈合不良。所有病例未发现深部感染,神经血管损伤等并发症。结论采用QS微创全膝置换,术后疼痛轻,有利于早期伸膝功能和活动度的恢复,但手术技术要求高,应严格掌握手术适应证。     

急性坏死性胰腺炎的微创治疗进展

对于继发感染的急性坏死性胰腺炎,其治疗策略应该是保证患者治愈的同时,把并发症的发病率与病死率控制到最低。目前的标准治疗方法仍然是开腹行坏死感染组织清除术或引流术,近来有文献报道了经皮穿刺引流术、内镜治疗、腹腔镜治疗等微创治疗方法。本文就各种微创治疗方法的作用以及治疗策略的选择作一综述。     

微创手术治疗Pilon骨折

目的 介绍一种治疗高能量Plion骨折的微创手术方法，并观察其效果。方法 采用微创手术治疗12例Pilon骨折，随访7例。根据Ruedi—Allgower分型，Ⅱ型4例，Ⅲ型3例。均采用三叶草型支持接骨板经皮内固定，术后第2天开始功能锻炼，不采用任何外固定。结果 随访时间3～9个月，平均4．5个月：7例创口愈合良好，无骨折延迟愈合和不愈合：按Mazur等踝关节症状和功能评分系统进行疗效评定，优4例，良2例，可1例。结论 微创手术是治疗高能量Plion骨折的有效方法。     

The advantages of submandibular gland resection in anterior retropharyngeal approach to the upper cervical spine

Anterior surgery to the upper cervical spine, although rare, several successful approaches were described in the literature. To avoid the risks and limitations of transoral approach, the anterior retropharyngeal approach was developed. In this study, we describe our experience with anterior retropharyngeal approach to the upper cervical spine and discuss the significance of resecting the submandibular gland. From July 2001 to July 2004, we performed six anterior prevascular retropharyngeal approaches to the upper cervical spine. The series included five males and one female, ranging in age from 26 to 60 years (mean = 46). All six patients were intubated with nasotracheal cannula. The submandibular gland was mobilized and removed in all patients allowing adequate exposure of the arch of C1, C2, and C3 vertebral bodies. The anterior retropharyngeal approach permitted an adequate access to anteriorly situated lesions from C1 to C3 in all six patients, without the risks and limitations of transmucosal surgery. This approach allowed us to perform decompression of the spinal cord and reconstruction of the anterior column of the spine with bone graft and internal fixation. Careful removal of the submandibular gland provided better visualization of the arch of C1 and C2. No facial nerve palsy was seen in any of the six patients. Anterior retropharyngeal approach to the upper cervical spine combined with removal of the submandibular gland permits exposure of the anterior spine similar to that obtained by the transmucosal route, and provides a safe simultaneous arthrodesis and instrumentation during the primary surgical procedure without the potential contamination of the oropharyngeal cavity. Removal of the submandibular gland allows better exposure with less retraction and thus avoids severe injury to the mandibular branch of the facial nerve.