Minimally Invasive Surgery The latest articles from Hindawi Publishing Corporation © 2014 , Hindawi Publishing Corporation . All rights reserved. Transforaminal Approach in Thoracal Disc Pathologies: Transforaminal Microdiscectomy Technique Tue, 15 Apr 2014 11:36:09 +0000 Objective. Many surgical approaches have been defined and implemented in the last few decades for thoracic disc herniations. The endoscopic foraminal approach in foraminal, lateral, and far lateral disc hernias is a contemporary minimal invasive approach. This study was performed to show that the approach is possible using the microscope without an endoscope, and even the intervention on the discs within the spinal canal is possible by having access through the foramen. Methods. Forty-two cases with disc hernias in the medial of the pedicle were included in this study; surgeries were performed with transforaminal approach and microsurgically. Extraforaminal disc hernias were not included in the study. Access was made through the Kambin triangle, foramen was enlarged, and spinal canal was entered. Results. The procedure took 65 minutes in the average, and the mean bleeding amount was about 100cc. They were mobilized within the same day postoperatively. No complications were seen. Follow-up periods range between 5 and 84 months, and the mean follow-up period is 30.2 months. Conclusion. Transforaminal microdiscectomy is a method that can be performed in any clinic with standard spinal surgery equipment. It does not require additional equipment or high costs. Sedat Dalbayrak, Onur Yaman, Kadir Öztürk, Mesut Yılmaz, Mahmut Gökdağ, and Murat Ayten Copyright © 2014 Sedat Dalbayrak et al. All rights reserved. Prospective Comparison of Nonnarcotic versus Narcotic Outpatient Oral Analgesic Use after Laparoscopic Appendectomy and Early Discharge Mon, 14 Apr 2014 09:35:44 +0000 Purpose. To compare narcotic versus nonnarcotic outpatient oral pain management after pediatric laparoscopic appendectomy. Methods. In a prospective study from July 1, 2010, to March 30, 2011, children undergoing laparoscopic appendectomy on a rapid discharge protocol were treated with either nonnarcotic or narcotic postoperative oral analgesia. Two surgeons in a four-person faculty group employed the nonnarcotic regimen, while the other two used narcotics. Days of medication use, time needed for return to normal activity, and satisfaction rate with the pain control method were collected. Student’s t-test was used for statistical analysis. Results. A total of 207 consecutive children underwent appendectomy for acute, nonperforated appendicitis or planned interval appendectomy. The age and time to discharge were equivalent between the nonnarcotic () and narcotic () groups. Both had an equivalent number of medication days and similar times of return to normal activity. Ninety-seven percent of the parents of children in the nonnarcotic group stated that the pain was controlled by the prescribed medication, compared to 90 percent in the narcotic group (). Conclusion. This study indicates that after non-complicated pediatric laparoscopic appendectomy, nonnarcotic is equivalent to narcoticbased therapy for outpatient oral analgesia, with higher parental satisfaction. Fuad Alkhoury, Colin Knight, Steven Stylianos, Jeannette Zerpa, Raquel Pasaron, JoAnne Mora, Alexandra Aserlind, Leopoldo Malvezzi, and Cathy Burnweit Copyright © 2014 Fuad Alkhoury et al. All rights reserved. Erratum to “Minimally Invasive Treatment of the Thoracic Spine Disease: Completely Percutaneous and Hybrid Approaches” Sun, 06 Apr 2014 06:57:16 +0000 Francesco Ciro Tamburrelli, Laura Scaramuzzo, Maurizio Genitiempo, and Luca Proietti Copyright © 2014 Francesco Ciro Tamburrelli et al. All rights reserved. Video-Assisted Thoracic Surgery for Tubercular Spondylitis Thu, 03 Apr 2014 13:36:41 +0000 The present study evaluated the outcome of video-assisted thoracic surgery (VATS) in 9 patients (males = 6, females = 3) with clinico-radiological diagnosis of tubercular spondylitis of the dorsal spine. The mean duration of surgery was 140.88 ± 20.09 minutes, mean blood was 417.77 ± 190.90 mL, and mean duration of postoperative hospital stay was 5.77 ± 0.97 days, Seven patients had a preoperative Grade A neurological involvement, while at the time of final followup the only deficit was Grade D power in 2 patients. In patients without bone graft placement (n = 6), average increase in Kyphosis angle was 16°, while in patients with bone graft placement (n = 3) the deformity remained stationary. At the time of final follow up, fusion was achieved in all patients, the VAS score for back pain improved from a pretreatment score of 8.3 to 2, and the function assessment yielded excellent (n = 4) to good (n = 5) results. In two patients minithoracotomy had to be resorted due to extensive pleural adhesions (n = 1) or difficulty in placement of graft (n = 1). Videoassisted thoracoscopic surgery provides a safe and effective approach in the management of spinal tuberculosis. It has the advantages of decreased blood loss and post operative morbidity with minimal complications. Roop Singh, Paritosh Gogna, Sanjeev Parshad, Rajender Kumar Karwasra, Parmod Kumar Karwasra, and Kiranpreet Kaur Copyright © 2014 Roop Singh et al. All rights reserved. National Trends in the Adoption of Laparoscopic Cholecystectomy over 7 Years in the United States and Impact of Laparoscopic Approaches Stratified by Age Thu, 20 Mar 2014 06:50:32 +0000 Introduction. The aim of this study was to characterize national trends in adoption of laparoscopic cholecystectomy and determine differences in outcome based on type of surgery and patient age. Methods. Retrospective cross-sectional study of patients undergoing cholecystectomy. Trends in open versus laparoscopic cholecystectomy by age group and year were analyzed. Differences in outcomes including in-hospital mortality, complications, discharge disposition, length of stay (LOS), and cost are examined. Results. Between 1999 and 2006, 358,091 patients underwent cholecystectomy. In 1999, patients aged ≥80 years had the lowest rates of laparoscopic cholecystectomy, followed by those aged 65–79, 64–50, and 49–18 years (59.7%, 65.3%, 73.2%, and 83.5%, resp., ). Laparoscopic cholecystectomy was associated with improved clinical and economic outcomes across all age groups. Over the study period, there was a gradual increase in laparoscopic cholecystectomy performed among all age groups during each year, though elderly patients continued to lag significantly behind their younger counterparts in rates of laparoscopic cholecystectomy. Conclusion. This is the largest study to report trends in adoption of laparoscopic cholecystectomy in the US in patients stratified by age. Elderly patients are more likely to undergo open cholecystectomy. Laparoscopic cholecystectomy is associated with improved clinical outcomes. Anahita Dua, Abdul Aziz, Sapan S. Desai, Jason McMaster, and SreyRam Kuy Copyright © 2014 Anahita Dua et al. All rights reserved. Laparoscopic Appendectomy in Children: Experience in a Single Centre in Chittagong, Bangladesh Tue, 11 Mar 2014 13:22:25 +0000 Background. Since the latter half of 1980s laparoscopy has become a well accepted modality in children in many surgical procedures including appendectomy. We present here the experience of laparoscopic appendectomy in children in a tertiary care hospital in Bangladesh.  Subjects & Methods. From October 7, 2005 to July 31, 2012, 1809 laparoscopic appendectomies were performed. Laparoscopy was performed in all the cases using 3 ports. For difficult and adherent cases submucosal appendectomy was performed. Feeding was allowed 6 h after surgery and the majority was discharged on the first postoperative day. The age, sex, operative techniques, operative findings, operative time, hospital stay, outcome, and complications were evaluated in this retrospective study. Results. Mean age was 8.17 ± 3.28 years and 69% were males. Fifteen percent were complicated appendicitis, 8 cases needed conversion, and 27 cases were done by submucosal technique. Mean operating time was 39.8 ± 14.2 minutes and mean postoperative hospital stay was 1.91 days. About 5% cases had postoperative complications including 4 intra-abdominal abscesses. Conclusions. Laparoscopic appendectomy is a safe procedure in children even in complicated cases. Md. Jafrul Hannan Copyright © 2014 Md. Jafrul Hannan. All rights reserved. Converting Potential Abdominal Hysterectomy to Vaginal One: Laparoscopic Assisted Vaginal Hysterectomy Wed, 05 Mar 2014 00:00:00 +0000 Background. The idea of laparoscopic assisted vaginal hysterectomy (LAVH) is to convert a potential abdominal hysterectomy to a vaginal one, thus decreasing associated morbidity and hastening recovery. We compared intraoperative and postoperative outcomes between LAVH and abdominal hysterectomy, to find out if LAVH achieves better clinical results compared with abdominal hysterectomy. Material and methods. A total of 48 women were enrolled in the study. Finally 17 patients underwent LAVH (cases) and 20 underwent abdominal hysterectomy (controls). All surgeries were performed by a set of gynecologists with more or less same level of surgical experience and expertise. Results.None of the patients in LAVH required conversion to laparotomy. Mean operating time was 30 minutes longer in LAVH group as compared to abdominal hysterectomy group (167.06 + 31.97 min versus 135.25 + 31.72 min; ). However, the mean blood loss in LAVH was 100 mL lesser than that in abdominal hysterectomy and the difference was found to be statistically significant (248.24 + 117.79 mL versus 340.00 + 119.86 mL; ). Another advantage of LAVH was significantly lower pain scores on second and third postoperative days. Overall complications and postoperative hospital stay were not significantly different between the two groups. Jyothi Shetty, Asha Shanbhag, and Deeksha Pandey Copyright © 2014 Jyothi Shetty et al. All rights reserved. Management of Gastroesophageal Reflux Disease: A Review of Medical and Surgical Management Mon, 17 Feb 2014 13:00:09 +0000 Background. Gastroesophageal reflux disease currently accounts for the majority of esophageal pathologies. This study is an attempt to help us tackle the diagnostic and therapeutic challenges of this disease. This study specifically focuses on patients in the urban Indian setup. Materials and Methods. This study was a prospective interventional study carried out at a teaching public hospital in Mumbai from May 2010 to September 2012. Fifty patients diagnosed with gastroesophageal reflux disease (confirmed by endoscopy and esophageal manometry) were chosen for the study. Results. Fifty patients were included in the study. Twenty patients showed symptomatic improvement after three months and were thus managed conservatively, while 30 patients did not show any improvement in symptoms and were eventually operated. Conclusion. We suggest that all patients diagnosed to have gastroesophageal reflux disease should be subjected to 3 months of conservative management. In case of no relief of symptoms, patients need to be subjected to surgery. Laparoscopic Toupet's fundoplication is an effective and feasible surgical treatment option for such patients, associated with minimal side effects. However, the long-term effects of this form of treatment still need to be evaluated further with a larger sample size and a longer followup. Nirali Shah and Sandhya Iyer Copyright © 2014 Nirali Shah and Sandhya Iyer. All rights reserved. Minimally Invasive Local Treatments for Bone and Pulmonary Metastases Tue, 11 Feb 2014 09:13:38 +0000 Surgery and chemotherapy have historically been the mainstay of treatment in patients with metastatic disease. However there are many alternative therapies available to relieve the symptoms and morbidity of metastases. In this paper, we review the role and highlight the advantages of minimally invasive techniques employed in patients with pulmonary and bone metastases. Meena Bedi, David M. King, and Sean Tutton Copyright © 2014 Meena Bedi et al. All rights reserved. Standardization of Laparoscopic Pelvic Examination: A Proposal of a Novel System Mon, 30 Dec 2013 08:27:17 +0000 Objective. Laparoscopic pelvic assessment is often performed in a nonstandardized fashion depending on the surgeon’s discretion. Reporting anatomic findings is inconsistent and lesions in atypical locations may be missed. We propose a method for systematic pelvic assessment based on anatomical landmarks. Design. Retrospective analysis. Setting. Tertiary care academic medical center. Intervention. We applied this system to operative reports of 540 patients who underwent diagnostic or operative laparoscopy for unexplained infertility between 2006 and 2012. The pelvis was divided into 2 midline zones (zone I and II) and right and left lateral zones (zone III and IV). All reports were evaluated for the comprehensiveness of description with respect to normal findings or pathology for each zone. Results. Of 540 surgeries, all reports commented on the uterus, tubes, and ovaries (100%), but only 17% (, 95% CI: 13.8–20.2) commented on the dome of the bladder and the anterior cul-de-sac. 24% (, 95% CI: 20.4–27.6) commented on the posterior cul-de-sac, and 5% (, 95% CI: 3.2–6.8) commented on the pelvic sidewall. Overall, 6% (, 95% CI: 4–8) reported near complete documentation of the pelvic zones. Conclusion. Implementation of a systematic approach for laparoscopic pelvic examination will enhance the diagnostic accuracy and provide better communication between care providers. In the absence of pelvic pathology, we recommend a minimum of 6 photographs of the 6 pelvic zones. Mohamed A. Bedaiwy, Rachel Pope, Drisana Henry, Kristin Zanotti, Sangeeta Mahajan, William Hurd, Tommaso Falcone, and James Liu Copyright © 2013 Mohamed A. Bedaiwy et al. All rights reserved. Endoscopic Transforaminal Thoracic Foraminotomy and Discectomy for the Treatment of Thoracic Disc Herniation Wed, 18 Dec 2013 18:28:06 +0000 Thoracic disc herniation is a relatively rare yet challenging-to-diagnose condition. Currently there is no universally accepted optimal surgical treatment for symptomatic thoracic disc herniation. Previously reported surgical approaches are often associated with high complication rates. Here we describe our minimally invasive technique of removing thoracic disc herniation, and report the primary results of a series of cases. Between January 2009 and March 2012, 13 patients with symptomatic thoracic disc herniation were treated with endoscopic thoracic foraminotomy and discectomy under local anesthesia. A bone shaver was used to undercut the facet and rib head for foraminotomy. Discectomy was achieved by using grasper, radiofrequency, and the Holmium-YAG laser. We analyzed the clinical outcomes of the patients using the visual analogue scale (VAS), MacNab classification, and Oswestry disability index (ODI). At the final follow up (mean: 17 months; range: 6–41 months), patient self-reported satisfactory rate was 76.9%. The mean VAS for mid back pain was improved from 9.1 to 4.2, and the mean ODI was improved from 61.0 to 43.8. One complication of postoperative spinal headache occurred during the surgery and the patient was successfully treated with epidural blood patch. No other complications were observed or reported during and after the surgery. Hong-Fei Nie and Kai-Xuan Liu Copyright © 2013 Hong-Fei Nie and Kai-Xuan Liu. All rights reserved. From the Idea to Its Realization: The Evolution of Minimally Invasive Techniques in Neurosurgery Tue, 17 Dec 2013 13:58:59 +0000 Minimally invasive techniques in neurosurgery evolved in two steps. Many minimally invasive concepts like neuronavigation, endoscopy, or frame based stereotaxy were developed by the pioneers of neurosurgery, but it took decades till further technical developments made the realization and broad clinical application of these early ideas safe and possible. This thesis will be demonstrated by giving examples of the evolution of four minimally invasive techiques: neuronavigation, transsphenoidal pituitary surgery, neuroendoscopy and stereotaxy. The reasons for their early failure and also the crucial steps for the rediscovery of these minimally invasive techniques will be analysed. In the 80th of the 20th century endoscopy became increasingly applied in different surgical fields. The abdominal surgeons coined as first for their endoscopic procedures the term minimally invasive surgery in contrast to open surgery. In neurrosurgery the term minimally invasive surgery stood not in opposiotion to open procedures but was understood as a general concept and philosophy using the modern technology such as neuronavigation, endoscopy and planing computer workstations with the aim to make the procedures less traumatic. P. Grunert Copyright © 2013 P. Grunert. All rights reserved. Minimally Invasive Treatment of the Thoracic Spine Disease: Completely Percutaneous and Hybrid Approaches Mon, 16 Dec 2013 14:26:01 +0000 The aim of the study was to evaluate the feasibility of a limited invasive approach for the treatment of upper thoracic spine disease. Seven patients with type-A thoracic fractures and three with tumors underwent long thoracic stabilization through a minimally invasive approach. Four patients underwent a completely percutaneous approach while the other three underwent a modified hybrid technique, a combination of percutaneous and open approach. The hybrid constructs were realized using a percutaneous approach to the spine distally to the spinal lesion and by open approach proximally. In two patients, the stabilization was extended proximally up to the cervical spine. Clinical and radiographic assessment was performed during the first year after the operation at 3, 6, and 12 months. No technically related complications were seen. The postoperative recovery was rapid even in the tumor patients with neurologic impairment. Blood loss was irrelevant. At one-year follow-up there was no loosening or breakage of the screws or failure of the implants. When technically feasible a completely percutaneous approach has to be taken in consideration; otherwise, a combined open-percutaneous approach could be planned to minimize the invasivity of a completely open approach to the thoracic spine. Tamburrelli Francesco Ciro, Scaramuzzo Laura, Genitiempo Maurizio, and Proietti Luca Copyright © 2013 Tamburrelli Francesco Ciro et al. All rights reserved. Laparoscopic-Assisted Single-Port Appendectomy in Children: It Is a Safe and Cost-Effective Alternative to Conventional Laparoscopic Techniques? Sun, 08 Dec 2013 10:15:25 +0000 Aim. Laparoscopic-assisted single-port appendectomy (SPA), although combining the advantages of open and conventional laparoscopic surgery, is still not widely used in childhood. The aim of this study was to evaluate the safety and the cost effectiveness of SPA in children. Methods. After institutional review board approval, we retrospectively evaluated 262 children who underwent SPA. The appendix was dissected outside the abdominal cavity as in open surgery. For stump closure, we used two 3/0 vicryl RB-1 sutures. Results. We identified 146 boys (55.7%) and 116 girls (44.3%). Median age at operation was 11.4 years (range, 1.1–15.9). Closure of the appendiceal stump using two sutures (cost: USD 15) was successful in all patients. Neither a stapler (cost: USD 276) nor endoloops (cost: USD 89) were used. During a follow-up of up to 69 months (range, 30–69), six obese children (2.3%, body mass index >95th percentile) developed an intra-abdominal abscess after perforated appendicitis. No insufficiency of the appendiceal stump was observed by ultrasound. Five of them were treated successfully by antibiotics, one child required drainage. Conclusion. The SPA technique with conventional extracorporal closure of the appendiceal stump is safe and cost effective. In our unit, SPA is the standard procedure for appendectomy in children. Sergio B. Sesia and Frank-Martin Haecker Copyright © 2013 Sergio B. Sesia and Frank-Martin Haecker. All rights reserved. Minimally Invasive Mitral Valve Procedures: The Current State Thu, 05 Dec 2013 08:18:32 +0000 Since its early days, cardiac surgery has typically involved large incisions with complete access to the heart and the great vessels. After the popularization of the minimally invasive techniques in general surgery, cardiac surgeons began to experiment with minimal access techniques in the early 1990s. Although the goals of minimally invasive cardiac surgery (MICS) are fairly well established as decreased pain, shorter hospital stay, accelerated recuperation, improved cosmesis, and cost effectiveness, a strict definition of minimally invasive cardiac surgery has been more elusive. Minimally invasive cardiac surgery started with mitral valve procedures and then gradually expanded towards other valve procedures, coronary artery bypass grafting, and various types of simple congenital heart procedures. In this paper, the authors attempt to focus on the evolution, techniques, results, and the future perspective of minimally invasive mitral valve surgery (MIMVS). Bhuyan Ritwick, Krishanu Chaudhuri, Gareth Crouch, James R. M. Edwards, Michael Worthington, and Robert G. Stuklis Copyright © 2013 Bhuyan Ritwick et al. All rights reserved. Relaparoscopic Treatment of Recurrences after Previous Laparoscopic Inguinal Hernia Repair Thu, 28 Nov 2013 18:28:20 +0000 Background. Relaparoscopic treatment of inguinal hernia recurrences has become a relatively new concept with favourable results. The purpose of this study was to examine a series of relaparoscopic repair, present technical experiences, and the clinical outcomes in this subset of patients. Patients and Methods. The medical records of five patients who underwent relaparoscopic repair (TAPP or TEP) for a recurrence between March 2005 and September 2012 were retrospectively reviewed. Results. All the patients were male with a mean age of 45 years. Technical failures in the previous repairs were the main factors contributing to recurrences. In two re-TEP cases with no previous mesh fixation, the old mesh remained on the peritoneal side during preperitoneal dissection and this greatly facilitated surgical manipulation. The mean operative time was 93 min (range, 45–120 min). There were no conversions, no intraoperative complications, and no morbidity or rerecurrence after a mean follow-up period of 17 months (range, 7–24 months). Conclusion. Relaparoscopic repair appears to be safe and effective in the treatment of recurrent inguinal hernia and repeated TEP could be a simpler approach than expected in the presence of no prior mesh fixation. Metin Ertem, Volkan Ozben, Hakan Gok, and Emel Ozveri Copyright © 2013 Metin Ertem et al. All rights reserved. Adnexal Masses Treated Using a Combination of the SILS Port and Noncurved Straight Laparoscopic Instruments: Turkish Experience and Review of the Literature Wed, 06 Nov 2013 11:53:24 +0000 Objective. To report our experience treating adnexal masses using a combination of the SILS port and straight nonroticulating laparoscopic instruments. Study Design. This prospective feasibility study included 14 women with symptomatic and persistent adnexal masses. Removal of adnexal masses via single-incision laparoscopic surgery using a combination of the SILS port and straight nonroticulating laparoscopic instruments was performed. Results. All of the patients had symptomatic complex adnexal masses. Mean age of the patients was 38.4 years (range: 21–61 years) and mean duration of surgery was 71 min (range: 45–130 min). All surgeries were performed using nonroticulating straight laparoscopic instruments. Mean tumor diameter was 6 cm (range: 5–12 cm). All patient pathology reports were benign. None of the patients converted to laparotomy. All the patients were discharged on postoperative d1. Postoperatively, all the patients were satisfied with their incision and cosmetic results. Conclusion. All 14 patients were successfully treated using standard, straight nonroticulating laparoscopic instruments via the SILS port. This procedure can reduce the cost of treatment, which may eventually lead to more widespread use of the SILS port approach. Furthermore, concomitant surgical procedures are possible using this approach. However, properly designed comparative studies with single port and classic laparoscopic surgery are urgently needed. Polat Dursun, Tugan Tezcaner, Hulusi B. Zeyneloglu, Irem Alyazıcı, Ali Haberal, and Ali Ayhan Copyright © 2013 Polat Dursun et al. All rights reserved. Neuroendoscopic Resection of Intraventricular Tumors: A Systematic Outcomes Analysis Thu, 26 Sep 2013 12:19:17 +0000 Introduction. Though traditional microsurgical techniques are the gold standard for intraventricular tumor resection, the morbidity and invasiveness of microsurgical approaches to the ventricular system have galvanized interest in neuroendoscopic resection. We present a systematic review of the literature to provide a better understanding of the virtues and limitations of endoscopic tumor resection. Materials and Methods. 40 articles describing 668 endoscopic tumor resections were selected from the Pubmed database and reviewed. Results. Complete or near-complete resection was achieved in 75.0% of the patients. 9.9% of resected tumors recurred during the follow-up period, and procedure-related complications occurred in 20.8% of the procedures. Tumor size ≤ 2cm (), the presence of a cystic tumor component (), and the use of navigation or stereotactic tools during the procedure () were each independently associated with a greater likelihood of complete or near-complete tumor resection. Additionally, the complication rate was significantly higher for noncystic masses than for cystic ones (). Discussion. Neuroendoscopic outcomes for intraventricular tumor resection are significantly better when performed on small, cystic tumors and when neural navigation or stereotaxy is used. Conclusion. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors of a particular morphology. Sean M. Barber, Leonardo Rangel-Castilla, and David Baskin Copyright © 2013 Sean M. Barber et al. All rights reserved. Fully Endoscopic Microvascular Decompression: Our Early Experience Tue, 03 Sep 2013 15:55:25 +0000 Background. Microvascular decompression (MVD) is a widely accepted treatment for neurovascular disorders associated with facial pain and spasm. The endoscope has rapidly become a standard tool in neurosurgical procedures; however, its adoption in lateral approaches to the posterior fossa has been slower. The endoscope is used primarily to assist conventional microscopic techniques. We are interested in developing fully endoscopic approaches to the cerebellopontine angle, and here, we describe our preliminary experience with this procedure for MVD. Methods. A retrospective review of our two-year experience from 2011 to 2012, transitioning from using conventional microscopic techniques to endoscope-assisted microsurgery to fully endoscopic MVD, is provided. We also reviewed our preliminary outcomes during this transition. Results. There was no difference in the surgical duration of these three procedures. In addition, the majority of procedures performed in 2012 were fully endoscopic, suggesting the ease of incorporating this solo tool into practice. Pain outcomes of fully endoscopic MVD appear to be very similar to those of both conventional and endoscope-assisted MVDs. Complications occurred in all groups at equally low rates. Conclusion. Fully endoscopic MVD is both safe and effective. By enhancing visualization of structures within the cerebellopontine angle, endoscopy may prove to be a valuable adjunct or alternative to conventional microscopic approaches. Casey H. Halpern, Shih-Shan Lang, and John Y. K. Lee Copyright © 2013 Casey H. Halpern et al. All rights reserved. Confocal Laser Endomicroscopy in Neurosurgery: A New Technique with Much Potential Sun, 28 Jul 2013 13:06:13 +0000 Technical innovations in brain tumour diagnostic and therapy have led to significant improvements of patient outcome and recurrence free interval. The use of technical devices such as surgical microscopes as well as neuronavigational systems have helped localising tumours as much as fluorescent agents, such as 5-aminolaevulinic acid, have helped visualizing pathologically altered tissue. Nonetheless, intraoperative instantaneous frozen sections and histological diagnosis remain the only method of gaining certainty of the nature of the resected tissue. This technique is time consuming and does not provide close-to-real-time information. In gastroenterology, confocal endoscopy closed the gap between tissue resection and histological examination, providing an almost real-time histological diagnosis. The potential of this technique using a confocal laser endoscope EndoMAG1 by Karl Storz Company was evaluated by our group on pig brains, tumour tissue cell cultures, and fresh human tumour specimen. Here, the authors report for the first time on the results of applying this new technique and provide first confocal endoscopic images of various brain and tumour structures. In all, the technique harbours a very promising potential to provide almost real-time intraoperative diagnosis, but further studies are needed to provide evidence for the technique’s potential. David Breuskin, Jana DiVincenzo, Yoo-Jin Kim, Steffi Urbschat, and Joachim Oertel Copyright © 2013 David Breuskin et al. All rights reserved. Endoscopic Third Ventriculostomy in Previously Shunted Children Wed, 24 Jul 2013 11:02:59 +0000 Endoscopic third ventriculostomy (ETV) is a routine and safe procedure for therapy of obstructive hydrocephalus. The aim of our study is to evaluate ETV success rate in therapy of obstructive hydrocephalus in pediatric patients formerly treated by ventriculoperitoneal (V-P) shunt implantation. From 2001 till 2011, ETV was performed in 42 patients with former V-P drainage implantation. In all patients, the obstruction in aqueduct or outflow parts of the fourth ventricle was proved by MRI. During the surgery, V-P shunt was clipped and ETV was performed. In case of favourable clinical state and MRI functional stoma, the V-P shunt has been removed 3 months after ETV. These patients with V-P shunt possible removing were evaluated as successful. In our group of 42 patients we were successful in 29 patients (69%). There were two serious complications (4.7%)—one patient died 2.5 years and one patient died 1 year after surgery in consequence of delayed ETV failure. ETV is the method of choice in obstructive hydrocephalus even in patients with former V-P shunt implantation. In case of acute or scheduled V-P shunt surgical revision, MRI is feasible, and if ventricular system obstruction is diagnosed, the hydrocephalus may be solved endoscopically. Eva Brichtova, Martin Chlachula, Tomas Hrbac, and Radim Lipina Copyright © 2013 Eva Brichtova et al. All rights reserved. Differences in Epidural and Analgesic Use in Patients with Apparent Stage I Endometrial Cancer Treated by Open versus Laparoscopic Surgery: Results from the Randomised LACE Trial Sun, 14 Jul 2013 10:19:02 +0000 Objectives. We compared postoperative analgesic requirements between women with early stage endometrial cancer treated by total abdominal hysterectomy (TAH) or total laparoscopic hysterectomy (TLH). Methods. 760 patients with apparent stage I endometrial cancer were treated in the international, multicentre, prospective randomised trial (LACE) by TAH () or TLH () (2005–2010). Epidural, opioid, and nonopioid analgesic requirements were collected until ten months after surgery. Results. Baseline demographics and analgesic use were comparable between treatment arms. TAH patients were more likely to receive epidural analgesia than TLH patients (33% versus 0.5%, ) during the early postoperative phase. Although opioid use was comparable in the TAH versus TLH groups during postoperative 0–2 days (99.7% versus 98.5%, ), a significantly higher proportion of TAH patients required opioids 3–5 days (70% versus 22%, ), 6–14 days (35% versus 15%, ), and 15–60 days (15% versus 9%, ) after surgery. Mean pain scores were significantly higher in the TAH versus TLH group one (2.48 versus 1.62, ) and four weeks (0.89 versus 0.63, ) following surgery. Conclusion. Treatment of early stage endometrial cancer with TLH is associated with less frequent use of epidural, lower post-operative opioid requirements, and better pain scores than TAH. Jannah Baker, Monika Janda, David Belavy, and Andreas Obermair Copyright © 2013 Jannah Baker et al. All rights reserved. The Supraorbital Keyhole Craniotomy through an Eyebrow Incision: Its Origins and Evolution Wed, 10 Jul 2013 09:12:58 +0000 In the modern era of neurosurgery, the use of the operative microscope, rigid rod-lens endoscope, and neuronavigation has helped to overcome some of the previous limitations of surgery due to poor lighting and anatomic localization available to the surgeon. Over the last thirty years, the supraorbital craniotomy and subfrontal approach through an eyebrow incision have been developed and refined to play a legitimate role in the armamentarium of the modern skull base neurosurgeon. With careful patient selection, the supraorbital “keyhole” approach offers a less invasive but still efficacious approach to a number of lesions along the subfrontal corridor. Well over 1000 cases have been reported in the literature utilizing this approach establishing its safety and efficacy. This paper discusses the nuances of this approach, including the benefits and limitations of its use described through our technique, review of the literature, and case illustration. D. Ryan Ormond and Costas G. Hadjipanayis Copyright © 2013 D. Ryan Ormond and Costas G. Hadjipanayis. All rights reserved. Robotically Assisted Hysterectomy versus Vaginal Hysterectomy for Benign Disease: A Prospective Study Sun, 07 Jul 2013 15:48:05 +0000 Objectives. A prospective study was carried out to compare vaginal hysterectomy (VH) and robotically assisted hysterectomy (RH) for benign gynecological disease. Materials and Methods. All patients who underwent hysterectomy from March 2010 to March 2012 for a benign disease were included. Patients’ demographics per and post surgery results were collected from medical files. A questionnaire was also conducted 2 months after surgery. Results. Sixty patients were included in the RH group and thirty four in the VH one. Operative time was significantly longer in the RH group ( versus  min; ). Blood loss and length of hospital stay were significantly reduced: versus  ml; , and versus days; , respectively. Less pain was reported at D1 and D2 by RH patients, and levels of analgesia were lower compared to those observed in the VH group. No differences were found regarding the rate of conversion to laparotomy, intra- or postoperative complications. Conclusion. Robotically assisted hysterectomy appears to reduce blood loss, postoperative pain, and length of hospital stay, but it is associated with longer operative time and higher cost. Specific indications for RH remain to be defined. M. Carbonnel, H. Abbou, H. T. N’Guyen, S. Roy, G. Hamdi, A. Jnifen, and J. M. Ayoubi Copyright © 2013 M. Carbonnel et al. All rights reserved. Neuroendoscopic Resection of Intraventricular Tumors and Cysts through a Working Channel with a Variable Aspiration Tissue Resector: A Feasibility and Safety Study Thu, 13 Jun 2013 10:16:29 +0000 Pure neuroendoscopic resection of intraventricular lesions through a burr hole is limited by the instrumentation that can be used with a working channel endoscope. We describe a safety and feasibility study of a variable aspiration tissue resector, for the resection of a variety of intraventricular lesions. Our initial experience using the variable aspiration tissue resector involved 16 patients with a variety of intraventricular tumors or cysts. Nine patients (56%) presented with obstructive hydrocephalus. Patient ages ranged from 20 to 88 years (mean 44.2). All patients were operated on through a frontal burr hole, using a working channel endoscope. A total of 4 tumors were resected in a gross total fashion and the remaining intraventricular lesions were subtotally resected. Fifteen of 16 patients had relief of their preoperative symptoms. The 9 patients who presented with obstructive hydrocephalus had restoration of cerebrospinal fluid flow though one required a ventriculoperitoneal shunt. Three patients required repeat endoscopic resections. Use of a variable aspiration tissue resector provides the ability to resect a variety of intraventricular lesions in a safe, controlled manner through a working channel endoscope. Larger intraventricular tumors continue to pose a challenge for complete removal of intraventricular lesions. Edjah Kweku-Ebura Nduom, Eric A. Sribnick, D. Ryan Ormond, and Costas G. Hadjipanayis Copyright © 2013 Edjah Kweku-Ebura Nduom et al. All rights reserved. Single-Incision Laparoscopic Colectomy for Cancer: Short-Term Outcomes and Comparative Analysis Sun, 19 May 2013 12:47:07 +0000 Introduction. Single-incision laparoscopic colectomy (SILC) is a viable and safe technique; however, there are no single-institution studies comparing outcomes of SILC for colon cancer with well-established minimally invasive techniques. We evaluated the short-term outcomes following SILC for cancer compared to a group of well-established minimally invasive techniques. Methods. Fifty consecutive patients who underwent SILC for colon cancer were compared to a control group composed of 50 cases of minimally invasive colectomies performed with either conventional multiport or hand-assisted laparoscopic technique. The groups were paired based on the type of procedure. Demographics, intraoperative, and postoperative outcomes were assessed. Results. With the exception of BMI, demographics were similar between both groups. Most of the procedures were right colectomies () and anterior resections (). There were no significant differences in operative time (127.9 versus 126.7 min), conversions (0 versus 1), complications (14% versus 8%), length of stay (4.5 versus 4.0 days), readmissions (2% versus 2%), and reoperations (2% versus 2%). Oncological outcomes were also similar between groups. Conclusions. SILC is an oncologically sound alternative for the management of colon cancer and results in similar short-term outcomes as compared with well-established minimally invasive techniques. Rodrigo Pedraza, Ali Aminian, Javier Nieto, Chadi Faraj, T. Bartley Pickron, and Eric M. Haas Copyright © 2013 Rodrigo Pedraza et al. All rights reserved. SILC for SILC: Single Institution Learning Curve for Single-Incision Laparoscopic Cholecystectomy Thu, 09 May 2013 14:08:31 +0000 Objectives. We report the single-incision laparoscopic cholecystectomy (SILC) learning experience of 2 hepatobiliary surgeons and the factors that could influence the learning curve of SILC. Methods. Patients who underwent SILC by Surgeons A and B were studied retrospectively. Operating time, conversion rate, reason for conversion, identity of first assistants, and their experience with previous laparoscopic cholecystectomy (LC) were analysed. CUSUM analysis is used to identify learning curve. Results. Hundred and nineteen SILC cases were performed by Surgeons A and B, respectively. Eight cases required additional port. In CUSUM analysis, most conversion occurred during the first 19 cases. Operating time was significantly lower (62.5 versus 90.6 min, P = 0.04) after the learning curve has been overcome. Operating time decreases as the experience increases, especially Surgeon B. Most conversions are due to adhesion at Calot’s triangle. Acute cholecystitis, patients’ BMI, and previous surgery do not seem to influence conversion rate. Mean operating times of cases assisted by first assistant with and without LC experience were 48 and 74 minutes, respectively (P = 0.004). Conclusion. Nineteen cases are needed to overcome the learning curve of SILC. Team work, assistant with CLC experience, and appropriate equipment and technique are the important factors in performing SILC. Chee Wei Tay, Liang Shen, Mikael Hartman, Shridhar Ganpathi Iyer, Krishnakumar Madhavan, and Stephen Kin Yong Chang Copyright © 2013 Chee Wei Tay et al. All rights reserved. Hybrid Coronary Revascularization as a Safe, Feasible, and Viable Alternative to Conventional Coronary Artery Bypass Grafting: What Is the Current Evidence? Wed, 03 Apr 2013 11:54:56 +0000 The “hybrid” approach to multivessel coronary artery disease combines surgical left internal thoracic artery (LITA) to left anterior descending coronary artery (LAD) bypass grafting and percutaneous coronary intervention of the remaining lesions. Ideally, the LITA to LAD bypass graft is performed in a minimally invasive fashion. This review aims to clarify the place of hybrid coronary revascularization (HCR) in the current therapeutic armamentarium against multivessel coronary artery disease. Eighteen studies including 970 patients were included for analysis. The postoperative LITA patency varied between 93.0% and 100.0%. The mean overall survival rate in hybrid treated patients was 98.1%. Hybrid treated patients showed statistically significant shorter hospital length of stay (LOS), intensive care unit (ICU) LOS, and intubation time, less packed red blood cell (PRBC) transfusion requirements, and lower in-hospital major adverse cardiac and cerebrovascular event (MACCE) rates compared with patients treated by on-pump and off-pump coronary artery bypass grafting (CABG). This resulted in a significant reduction in costs for hybrid treated patients in the postoperative period. In studies completed to date, HCR appears to be a promising and cost-effective alternative for CABG in the treatment of multivessel coronary artery disease in a selected patient population. Arjan J. F. P. Verhaegh, Ryan E. Accord, Leen van Garsse, and Jos G. Maessen Copyright © 2013 Arjan J. F. P. Verhaegh et al. All rights reserved. Transumbilical Laparo-Assisted Appendectomy: A Safe Operation for the Whole Spectrum of Appendicitis in Children—A Single-Centre Experience Wed, 27 Mar 2013 13:21:23 +0000 The paper reports the results of a retrospective review of the medical charts of 203 patients admitted to a pediatric surgical unit with a diagnosis of acute appendicitis between January 2006 and December 2010 when a transumbilical laparoscopic-assisted appendectomy (TULAA) was introduced as a new surgical technique. Among 203 admitted patients, 7 (3.5%) had a localized appendiceal abscess and were treated with antibiotics. All of them responded to antibiotics and underwent TULAA interval appendectomy 8 weeks later. 196 patients (96.5%) underwent immediate surgery. In 12/181 (6.6%) urgent cases, conversion to laparotomy was necessary, in 3 patients because of bowel distension and in 9 for retrocecal position of appendix. In all 181 TULAA completed procedures, one trocar was used in 151 cases (89.4%), two trocars in 16 (9.4%), and three trocars in 2 (1.2%). The mean operative time for single port TULAA was 52′ Complications included 5 wound infections and 5 intra-abdominal abscesses, all managed conservatively. In conclusion, TULAA is a safe, minimally invasive approach with acute appendicitis, regardless of the perforation status, and can be recommended in the pediatric urgical settings. D. Codrich, M. G. Scarpa, M. A. Lembo, F. Pederiva, D. Olenik, F. Gobbo, A. Giannotta, S. Cherti, and J. Schleef Copyright © 2013 D. Codrich et al. All rights reserved. Minimally Invasive Mitral Valve Surgery: A Systematic Review Wed, 27 Mar 2013 11:53:34 +0000 In the recent years minimally invasive mitral valve surgery (MIMVS) has become a well-established and increasingly used option for managing patients with a mitral valve pathology. Nonetheless, whether the purported benefits of MIMVS translate into clinically important outcomes remains controversial. Therefore, in this paper we provide an overview of MIMVS and discuss results, morbidity, mortality, and quality of life following mitral minimally invasive procedures. MIMVS has been proven to be a feasible alternative to the conventional full sternotomy approach with low perioperative morbidity and short-term mortality. Reported benefits of MIMVS include also decreased postoperative pain, improved postoperative respiratory function, reduced surgical trauma, and greater patient satisfaction. Finally, compared to standard surgery, MIMVS demonstrated comparable efficacy across a range of long-term efficacy measures such as freedom from reoperation and long-term survival. Fabiana Lucà, Leen van Garsse, Carmelo Massimiliano Rao, Orlando Parise, Mark La Meir, Calogero Puntrello, Gaspare Rubino, Rocco Carella, Roberto Lorusso, Gian Franco Gensini, Jos G. Maessen, and Sandro Gelsomino Copyright © 2013 Fabiana Lucà et al. All rights reserved.