Name: endoscopic septoplasty with limited two-line resection: minimally invasive surgery for septal deviation
Uploaded: 2018-06-20T13:30:00.000+00:00
Duration: 6 min 13 s
Description: Watch this Scientific Journal Video about Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation at JoVE.com

This work was funded by the National Nature Science Foundation of China for Young Scholars (No. 81300810), the Shanghai Young Doctor Training Program (No. 20141057), the Shanghai Natural Science Foundation (No. 16ZR1405100), and the Shanghai Municipal Commission of Health and Family Planning (No. 201740187). We would like to thank LetPub (www.letpub.com) for providing linguistic assistance during the preparation of this manuscript.

This procedure, which involved human subjects, was approved by the Institutional Review Board of the Eye and ENT Hospital, Fudan University, China. All the enrolled patients provided written informed consent.
1. Preparation for Surgery
<ol>
	<li>Before surgery, examine the patient&#39;s nasal cavity with anterior rhinoscopy, endoscopy, and computed tomography (CT) scans to confirm and locate the deviations and to identify the indications15.</li>
	<li>Ask the patient to assess the patency of their nose as a whole and to indicate this on a visual analog scale (VAS) before surgery. 
	NOTE: The total length of the scale was 10 cm, with one extreme being an entirely clear nose (i.e., 0 cm scoring 0%), the other extreme a completely blocked nose (10 cm scoring 100%), and the center a nose with a 50% blockage.</li>
	<li>Remove the vibrissae in both nasal vestibules 1 day before surgery.</li>
	<li>On the day of the surgery, administer general anesthesia to the patient after placing them on the operating table16. 
	NOTE: Induce anesthesia with 2 - 2.5 mg/kg of propofol, 0.2 &#181;g/kg of sulfentanyl, and 0.6 of mg/kg rocuronium. Maintain the anesthesia with a continuous intravenous infusion of remifentanil of 0.1 &#181;g/kg/min and an inhalation of sevoflurane (0.8 minimal alveolar concentration).</li>
	<li>Tilt the operating table 30&#176; (to the dorsal elevated position) and put the patient&#39;s head in a neutral position (neither flexed nor extended).</li>
</ol>
2. Surgical Procedure
NOTE: Use a 0-degree endoscope during the entire operation.
<ol>
	<li>Steep 8 pieces of gauze (6 cm x 60 cm) with a mixed solution of 20 mL of 1% tetracaine and 4 mL of 0.1% epinephrine. Put 1 soaked piece of gauze into each nasal cavity for 5 min to shrink the nasal mucosa.</li>
	<li>Put the inferior turbinate toward the lateral wall of the nasal cavity with the elevator at the end of the procedure.</li>
	<li>Infiltrate the septum using a needle attached to a 5 mL syringe with several milliliters of a mixed solution of 20 mL of 0.9% NaCl and 0.05 mL of 0.1% epinephrine in the subperichondrial and subperiosteal planes of both sides of the septum. 
	NOTE: If the septum was deviated to both sides, we defined the convex side as the side of the anterior deviation.</li>
	<li>Make a Killian incision at the mucocutaneous junction ipsilaterally on the side of the maximal deviation (i.e., the convex side) of the septal cartilage with a No. 15 blade. Start the vertical incision on the septum as high as possible, continue to the floor of the nasal cavity, and curve posteriorly as it reaches the floor of the nasal cavity. 
	NOTE: The incision needs to penetrate the mucous-perichondrium of the nasal septum.</li>
	<li>Raise the mucosal flap in the subperichondrial plane with the suction elevator in case of bleeding. Without bleeding, raise the flap with a 2 mm or 5 mm elevator. Extend the elevation as high as possible upwards and to the floor of the nasal cavity downwards to fully expose the cartilaginous and bony septum on the convex side.</li>
	<li>Make a vertical incision using the sharp end of the 2-mm elevator or a number 15 blade on the cartilage inferior to the dorsum and anterior to the junction of the quadrangular cartilage and perpendicular plate of the ethmoid bone (i.e., the first line of the 2LoRs). Likewise, make a horizontal incision on the cartilage superior to the junction of the quadrangular cartilage, vomer bone, and maxillary crest (i.e., the second line) (Figure 2A). 
	NOTE: In this way, the septal cartilage is mobilized from its posterior and inferior attachment to the bony septum, and the anterior and superior attachment is kept intact.</li>
	<li>Elevate the contralateral mucoperiosteum to expose the bony septum bilaterally with the suction elevator.</li>
	<li>Resect two strips of the posterior and inferior margins of the septal cartilage and the adjacent bony septum (Figure 1B).
	<ol>
		<li>Resect 1/4 to 1/3 (occasionally 1/3 to 1/2) of the original width of the cartilage in the anteroposterior dimension on the first line (Figure 2B).</li>
		<li>Resect 1/4 to 1/3 (occasionally 1/3 to 1/2) of the original height of the cartilage in the vertical dimension on the second line (Figure 2C).</li>
	</ol>
	</li>
	<li>Remove the thickening bony septal deviations and perform&#160;a partial fracture displacement to move the deviation back to the midline.&#160; 
	NOTE: The extensive removal of the posterior and inferior bony septum is to clear all of the thickness and deformities in this region.</li>
	<li>Control any intraoperative bleeding by electrocoagulation.</li>
	<li>Approximate the mucosal flaps by two interrupted sutures with absorbable materials (Figure 2D).
	<ol>
		<li>Start the sutures posterior to the incision, pass them through the septum to the opposite side, and then pull them back from the skin anterior to the incision site.</li>
		<li>Knot the sutures on themselves, respectively. Place the two sutures parallel, one above the other.</li>
	</ol>
	</li>
</ol>
3. Procedure and Assessment After Surgery
<ol>
	<li>Pack the nasal cavity with nasopore.</li>
	<li>Review the patient 1 week after the surgery to check if there is a hematoma or infection of the septum.</li>
	<li>Examine the nasal cavity with anterior rhinoscopy and 0-degree endoscopy and ask the patient to assess the patency of their nose with VAS 6 months after the surgery.</li>
	<li>Record postoperative septum hematoma, transient dental pain, hypesthesia, synechiae, epistaxis, septum abscess, septum swing, septal perforation, and dorsum collapse as surgical complications.</li>
</ol>

<ol>
	<li>Chung, B. J., Batra, P. S., Citardi, M. J., Lanza, D. C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+septoplasty:+revisitation+of+the+technique,+indications,+and+outcomes.">Endoscopic septoplasty: revisitation of the technique, indications, and outcomes.</a> The American Journal of Rhinology. 21 (3), 307-311 (2007).</li><li>Hwang, P. H., McLaughlin, R. B., Lanza, D. C., Kennedy, D. W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+septoplasty:+indications,+technique,+and+results.">Endoscopic septoplasty: indications, technique, and results.</a> Otolaryngology-Head and Neck Surgery. 120 (5), 678-682 (1999).</li><li>Fettman, N., Sanford, T., Sindwani, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Surgical+management+of+the+deviated+septum:+techniques+in+septoplasty.">Surgical management of the deviated septum: techniques in septoplasty.</a> Otolaryngologic Clinics of North America. 42 (2), 241-252 (2009).</li><li>Killian, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+submucous+window+resection+of+the+nasal+septum.">The submucous window resection of the nasal septum.</a> Annals of Otology, Rhinology &amp; Laryngology. 14, 363-393 (1905).</li><li>Freer, O. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+correction+of+deflections+of+the+nasal+septum+with+a+minimum+of+traumatism.">The correction of deflections of the nasal septum with a minimum of traumatism.</a> The Journal of The American Medical Association. 38, 636-642 (1902).</li><li>Aaronson, N. L., Vining, E. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Correction+of+the+deviated+septum:+from+ancient+Egypt+to+the+endoscopic+era.">Correction of the deviated septum: from ancient Egypt to the endoscopic era.</a> International Forum of Allergy &amp; Rhinology. 4 (11), 931-936 (2014).</li><li>Bloom, J. D., Kaplan, S. E., Bleier, B. S., Goldstein, S. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Septoplasty+complications:+avoidance+and+management.">Septoplasty complications: avoidance and management.</a> Otolaryngologic Clinics of North America. 42 (3), 463-481 (2009).</li><li>Rettinger, G., Kirsche, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Complications+in+septoplasty.">Complications in septoplasty.</a> Facial Plastic Surgery. 22 (4), 289-297 (2006).</li><li>Cottle, M. H., Loring, R. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Newer+concepts+of+septum+surgery;+present+status.">Newer concepts of septum surgery; present status.</a> Eye, Ear, Nose &amp; Throat Monthly. 27 (9), 403-406 (1948).</li><li>Gibson, T., Davis, W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+distortion+of+autogenous+cartilage+grafts:+Its+causes+and+prevention.">The distortion of autogenous cartilage grafts: Its causes and prevention.</a> British Journal of Plastic Surgery. 10, 257-274 (1958).</li><li>Kenedi, R. M., Gibson, T., Abrahams, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mechanical+characteristics+of+skin+and+cartilage.">Mechanical characteristics of skin and cartilage.</a> Human Factors. 5, 525-529 (1963).</li><li>Stenstroem, S. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+&amp;#34;natural&amp;#34;+technique+for+correction+of+congenitally+prominent+ears.">A &amp;#34;natural&amp;#34; technique for correction of congenitally prominent ears.</a> Plastic and Reconstructive Surgery. 32, 509-518 (1963).</li><li>Fry, H. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Interlocked+stresses+in+human+nasal+septal+cartilage.">Interlocked stresses in human nasal septal cartilage.</a> British Journal of Plastic Surgery. 19 (3), 276-278 (1966).</li><li>Wang, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+modified+septoplasty+with+three+high+tension+lines+resection.">A modified septoplasty with three high tension lines resection.</a> Acta Oto-Laryngologica. 130 (5), 593-599 (2010).</li><li>Trimarchi, M., Bellini, C., Toma, S., Bussi, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Back-and-forth+endoscopic+septoplasty:+analysis+of+the+technique+and+outcomes.">Back-and-forth endoscopic septoplasty: analysis of the technique and outcomes.</a> International Forum of Allergy &amp; Rhinology. 2 (1), 40-44 (2012).</li><li>Kilicaslan, A., Acar, G. O., Tekin, M., Ozdamar, O. I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Assessment+the+long-term+effects+of+septoplasty+surgery+on+olfactory+function.">Assessment the long-term effects of septoplasty surgery on olfactory function.</a> Acta Oto-Laryngologica. 136 (10), 1079-1084 (2016).</li><li>Meeuwis, J., Verwoerd-Verhoef, H. L., Verwoerd, C. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Normal+and+abnormal+nasal+growth+after+partial+submucous+resection+of+the+cartilaginous+septum.">Normal and abnormal nasal growth after partial submucous resection of the cartilaginous septum.</a> Acta Oto-Laryngologica. 113 (3), 379-382 (1993).</li><li>Lopatin, A. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Do+laws+of+biomechanics+work+in+reconstruction+of+the+cartilaginous+nasal+septum.">Do laws of biomechanics work in reconstruction of the cartilaginous nasal septum.</a> European Archives of Oto-Rhino-Laryngology. 253 (4-5), 309-312 (1996).</li><li>D'Ascanio, L., Manzini, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Quick+septoplasty:+surgical+technique+and+learning+curve.">Quick septoplasty: surgical technique and learning curve.</a> Aesthetic Plastic Surgery. 33 (6), 814-818 (2009).</li></ol>

The authors have nothing to disclose.

The 2LoRs procedure is based on embryological and anatomic knowledge of deviated nasal septa. The nasal septum consists of three different components: the anterior membrane, cartilage in the middle, and posterior and inferior bone. During the development of the nasal septum, the different components ossify in different time sequences. It is commonly held that the bone finishes its extension while the cartilage still grows. Therefore, stresses accumulate on the margins of the cartilage adjacent to the osseous septum, resu...

Endoscopic septoplasty is a commonly performed surgical procedure in otolaryngology to treat nasal airway obstruction caused by nasal septal deviation1. The purpose of the septoplasty with the indication of nasal airway obstruction is to provide a functional improvement in nasal airway patency, and the principle is to correct the septal deviation with a minimal surgical invasion2.
The beginning of septoplasty, a procedure that is still used today, traces back to the technique that Freer and Killian published in the early 20th century, which was called submucous resection (SMR)3. SMR is characterized by its direct removal of a nasal cartilaginous deviation in a subperichondrial plane, leaving an L-shaped strut to structurally support the appearance of the nose4,5. SMR showed advantages over the previous techniques at its time, so it gradually gained acceptance. In the 1990s, endoscopy was applied to septoplasty1. The illumination and visualization of the surgical field were highly improved, and the resection could be performed directly and precisely6. Thereafter, the indications of SMR were extended, and various septoplasty techniques were developed. While these techniques may be diversified in incision, flap elevation, excision, suture, or packing, the essence of direct removal has not changed. Therefore, once the cartilage was significantly resected, complications such as large septal perforations or a saddle nose deformity would occur7,8.
As Cottle and Loring suggested in 1948, the resection of deviated cartilage should be conservative9. Different from the direct removal of cartilaginous deviation, the biomechanics of cartilage as applied to septoplasty require the utilization of the inherent elastic property of cartilage to straighten the cartilaginous deviation by a limited surgical intervention, such as partial incisions (e.g., scratches or thin slices) and full incisions (e.g., full cuts or wedges). In 1958, Gibson and Davis first reported that cartilage has an internal self-locked stress system as a result of its growth pattern10. Partial incisions on the concave side would release the stress, thereby decreasing the bowing of the cartilage, while the incisions on the convex side would increase the bowing. In 1963, Kenedi, Gibson, and Abrahams further demonstrated the self-locked stress system through a series of studies on mapping the force distribution in a cross-section of rib cartilage11. In the same year, Stenstrom verified the effect of partial incisions on the antihelix12. A few years later, Fry published results on the human nasal septal cartilage that were consistent13. In other words, the biomechanics of cartilage can be used to alter the morphology of cartilage by releasing the forces within the cartilage. Based on this theoretical foundation, a surgical procedure that takes advantage of the biomechanical features of cartilage was developed14.
Combining previous surgical procedures with the embryologic and anatomic knowledge of the nasal septum, here, a modified endoscopic septoplasty procedure with the technique of limited two-line resection (2LoRs) at the posterior and inferior junction of the cartilaginous and bony septum (Figure 1) is presented in detail. This procedure is recommended to correct deviated nasal septa when external nasal deformities are absent, to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate as a preoperative operation. This procedure may also be used in children to correct septal deviation because of its minimally invasive approach.

<table><tbody><tr><td>Nasal Endoscopy (0&lt;sup&gt;o&lt;/sup&gt;)</td><td>Karl Storz-Endoskope</td><td>7230 AA</td><td></td></tr><tr><td>Tetracaine</td><td>Eye &amp;amp; ENT Hospital of Fudan University</td><td>180130</td><td></td></tr><tr><td>Epinephrine Hydrochloride Injection</td><td>Shanghai Harvest Pharmaceutical Co., Ltd</td><td>10170405</td><td></td></tr><tr><td>Number 15 blade</td><td>Shanghai Pudong Jinhuan Medical Products Co., Ltd</td><td>35T1205</td><td></td></tr><tr><td>Suction Elevator</td><td>Zhejiang Tian Song Medical Products Co., Ltd</td><td>B2117.1</td><td>Width: 4 mm</td></tr><tr><td>Electrocoagulation</td><td>Shanghai Hutong Electronics. Co.,Ltd</td><td>GD350-B5</td><td></td></tr><tr><td>4-0 Brided Absorbable Suture</td><td>Covidien Healthcare</td><td>SL-691</td><td></td></tr><tr><td>Rongeur forcep</td><td>Zhejiang Tian Song Medical Products Co., Ltd</td><td>B2300.3</td><td></td></tr><tr><td>Nasopore</td><td>Nasopore, Stryker, USA</td><td></td><td>Lengh: 8 cm</td></tr><tr><td>Gauze</td><td>Ningbo Shenyuan Medical Material Co., Ltd</td><td></td><td>6 cm x 60 cm</td></tr><tr><td>5mm Elevator</td><td>Zhejiang Tian Song Medical Products Co., Ltd</td><td>B2067</td><td>Width: 5 mm</td></tr><tr><td>2mm Elevator</td><td>Shanghai Medical Instruments (Group) Ltd., Corp. Surgical Instruments Factory</td><td>HBL020</td><td>Width: 2 mm</td></tr></tbody></table>

endoscopic septoplasty with limited two-line resection: minimally invasive surgery for septal deviation

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal deviation. It has a long history with multiple variations. In this article, a modified endoscopic septoplasty procedure using the limited two-line resection (2LoRs) technique at the posterior and inferior junction of the cartilaginous and bony septum is presented based on embryologic and anatomic knowledge of the nasal septum and the biomechanics of cartilaginous behavior. With this procedure, the quadrangular cartilage can be preserved as much as possible, which is helpful in retaining the supporting framework and rigidness of the septum. 2LoRs has been proven effective and sound for the correction of nasal septal deviation with rare complications. This modified procedure can be applied to correct the deviated nasal septum in the absence of any external nasal deformity to improve nasal patency or to improve access to the middle meatus or to the axillary region of the middle turbinate. It may also be used to expand the indications of septoplasty to children and adolescents because of its minimally invasive approach.

Adult patients (&gt;18 years of age) with nasal septal deviation were included in this study. Patients with nasal septal deviation accompanied by chronic rhinosinusitis, sinonasal tumors, external nose deformities, and those with a previous surgical history of septoplasty were excluded. Patients with a straight dorsum but who had caudal cartilage dislocated off the greater alar which had protruded into one of the nasal vestibules were excluded as well.
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Watch this Scientific Journal Video about Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation at JoVE.com

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic septoplasty is a time-honored surgical procedure with multiple variations. This paper focuses on a step-by-step surgical approach to perform a modified septoplasty procedure known as limited two-line resection. This surgical technique can be applied to correct a deviated nasal septum in the absence of an external nasal deformity.

Endoscopic septoplasty is a surgical procedure in otolaryngology that is commonly performed to treat nasal airway obstruction caused by nasal septal ...

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16.6K Views.  Fudan University. Endoscopische septoplasty is een aloude chirurgische ingreep met meerdere variaties. Dit document richt zich op een stapsgewijze chirurgische benadering uit te voeren van een procedure van de gewijzigde septoplasty bekend als beperkt twee-line resectie. Deze chirurgische techniek kan worden toegepast om een afwijkende neustussenschot bij gebrek aan een externe nasale misvorming te corrigeren.

Video: Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

Endoscopic Endonasal Trans-sphenoidal Approach: Minimally Invasive Surgery for Pituitary Adenomas

Endoscopic endonasal trans-sphenoidal surgery has become the gold standard for the surgical treatment of pituitary adenomas and many other pituitary lesions. Refinements in surgical techniques, technological advancements, and incorporation of neuronavigation have rendered this surgery minimally invasive. The complication rates of this surgery are very low while excellent results are consistently obtained through this approach.
This paper focuses on the step-by-step surgical approach to pituitary adenomas, which is based on personal experience, and details the results obtained with this minimally invasive surgery.

The aim of this paper is to describe the different steps of the endoscopic endonasal approach to the sella turcica.

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Combined Endoscopic and Transoral Approach for Total Maxillectomy

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The technique of maxillectomy has been revised since it was first described in the 1820s. During the past decade, the endoscopic approach has been widely ...

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

The Microscopic Transcanal Approach in Stapes Surgery Revisited

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the external auditory canal, the middle ear, and epitympanon. Such an approach avoids a retroauricular or endaural skin incision; however, working through a narrow space needs angled microsurgical instruments and specific training in otologic surgery. The transcanal approach restricts the working space; however, it offers a binocular microscopic vision into the middle ear without extended skin incisions and thus, reducing post-operative pain and bleeding. In addition, this minimally invasive approach avoids scar tissue complications, hypoesthesia of the auricle, and potential protrusion of the pinna. Despite its numerous advantages, this method is still not routinely performed by otologic surgeons. Since this minimally invasive technique is more challenging, there is a need for extensive training in order for it to be widely adopted by otologic surgeons. This article provides step-by-step surgical instructions for stapes surgery and reports possible indications, pitfalls, and limitations using this microscopic transcanal technique.

This article describes the microscopic transcanal technique for stapes surgery, providing step-by-step surgical instructions for familiarizing surgeons with this approach.

The microscopic transcanal (aka transmeatal) surgical approach was first described in the 60s, offering a minimally invasive means of reaching the ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Full-Endoscopic Decompression for Thoracic Ossification of the Ligamentum Flavum Combined with Dural Ossification

Ossification of the ligamentum flavum (OLF) can result in spinal stenosis. Thoracic spinal cord compression due to spinal stenosis is a common cause of progressive thoracic myelopathy in Asian countries. The incidence of complications is high in open decompression surgeries for thoracic OLF. With dural ossification (DO), the risk of complications is even higher in thoracic OLF. We introduce a full-endoscopic decompression surgery for thoracic OLF combined with DO under local anesthesia. Hemilaminectomy is performed using a high-speed burr under the endoscopy first, and then decompression of the contralateral spinal canal is completed using an "over the top" technique. DO resection uses the eggshell technique; after the base of the DO is cut from the lamina, forceps or lamina rongeurs are typically used for removal. The dural defect left after resection does not need repair. Neurological function was improved, and no complications such as hematoma or neck pain occurred. On imaging, no pseudodural cyst, cerebrospinal fluid leakage, or wound complications were observed after the operation. Endoscopic surgery causes less damage to the posterior ligament complex, so no cases of persistent back pain complaints or secondary internal fixation requirements were found in this study. Full-endoscopic decompression can achieve good imaging and clinical effects in the treatment of thoracic OLF with DO.

We describe a minimally invasive surgery using a full-endoscopy system for the single segmental thoracic ossification of the ligamentum flavum, combined with dural ossification, at Hebei General Hospital.

Ossification of the ligamentum flavum (OLF) can result in spinal stenosis. Thoracic spinal cord compression due to spinal stenosis is a common cause of ...

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Technical advances and increased experience in full-endoscopic spinal surgeries enable these procedures to be performed with minimal incision, muscle retraction, and bone removal.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Endoscopic Balloon Dilatation of the Eustachian Tube via the Soft Palate Approach in Miniature Pigs

The eustachian tube (ET) is one of the most complex organs in the human body, and its dysfunction may lead to a variety of diseases. In recent years, an increasing number of scholars have opted to conduct ET-related studies using large experimental animals such as miniature pigs or sheep, yielding promising results. Typically, conventional endoscopic procedures are performed through the nasal approach for large experimental animals. However, due to the elongated and narrow nasal cavity in these animals, transnasal surgeries are challenging. 
To address this issue, we explored an ET surgery approach via the soft palate. The animal was placed in a supine position. After endotracheal intubation under general anesthesia, a mouth opener was used to fully expose the upper palate. Local infiltration with diluted adrenal fluid was performed for anesthesia of the area. A sickle knife was then used to make a longitudinal soft palate incision at the junction of the soft and hard palates. After hemostasis, an endoscope was inserted into the nasopharynx cavity, allowing the visualization of the pharyngeal opening of the ET on the posterior lateral wall of the nasal cavity. 
Subsequently, a specialized pusher was used to insert a balloon into ET. The balloon was inflated, maintained at 10 bar for 2 min, and then removed. The incision in the soft palate was then sutured to ensure proper alignment. The soft palate healed well after the operation. This surgical approach is suitable for ET-related procedures in large experimental animals (e.g., miniature pigs, sheep, and dogs). The surgical procedure is simple, with a short surgical time, and wound healing is rapid. Under endoscopy, the pharyngeal opening of the ET is visible, and it is thus a good choice for procedures such as balloon dilation of the ET.

In this study, we present a protocol to explore an eustachian tube surgery approach via the soft palate in miniature pigs. The surgical procedure is simple, with short surgical time, and wound healing is rapid; it is thus a good choice for procedures such as balloon dilation of the eustachian tube.

The eustachian tube (ET) is one of the most complex organs in the human body, and its dysfunction may lead to a variety of diseases. In recent years, an ...

Surgical Management of Persistent or New Symptoms After Hiatal Hernia Repair

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. These may include recurrent reflux, dysphagia, regurgitation, weight loss, or deteriorating quality of life. While nonoperative management can be pursued in some patients, reoperation may be the only option in select patients. A thorough preoperative workup, including a repeat esophagram, upper endoscopy, +/- chest computed tomography (CT) scan, manometry, pH probe, and/or gastric emptying study, is warranted to better understand the pathophysiology of the presenting symptoms. If a recurrent hernia, slipped, or migrated wrap is identified, surgery is considered. Pseudoachalasia must also be ruled out if obstructive symptoms are observed at the hiatus. Such an exhaustive workup is indeed necessary to ensure accurate diagnosis and optimal outcome. In addition, an understanding of the factors that may have led to the recurrence will increase the chances of a successful reoperation. Although a technically demanding procedure, redo hiatal hernia repair utilizing a minimally invasive approach is increasingly being employed with promising outcomes. Herein, the steps of a redo hiatal hernia repair via a minimally invasive approach will be outlined and detailed.

Redo foregut surgery is challenging in today's clinical practice and is fraught with increased morbidity and reportedly a lower 'success' rate than the index procedure. Here, we present a protocol for a redo hiatal hernia repair via a minimally invasive approach.

Following a hiatal hernia repair, patients can present with recurrent or new symptoms. Symptoms can occur anywhere from weeks to years after surgery. ...

Endoscopic Septoplasty with Limited Two-line Resection: Minimally Invasive Surgery for Septal Deviation

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