This work was supported by the third batch of the Ningbo Health Youth Technical Cadre program (Dr. Binbin Zhu), and the Zhejiang Medical Association Clinical Research Fund Project (Dr. Bin Gao) (2018ZYC-A66).

The study was approved by the Ethics Committee of the Affiliated Hospital of Ningbo University School of Medicine (KY20181215) on December 10, 2018.
1. Inclusion criteria
<ol>
	<li>Include all patients (aged &#62;18 years) undergoing pulmonary bullae resection, pulmonary wedge resection, or lobectomy.</li>
</ol>
2. Exclusion criteria
<ol>
	<li>Exclude patients based on an American Society of Anesthesiologists (ASA) physical status classification of &#62;315.</li>
	<li>Exclude patients with a body mass index (BMI)16 &#62;30 kg/m2.</li>
	<li>Exclude patients with oesophageal cancer, total pneumonectomy, and open-heart surgery with resection of the ribs.</li>
	<li>Exclude patients with a previous medical history of bronchiectasis, destroyed lung, or chronic obstructive pulmonary disease (COPD).</li>
	<li>Exclude patients with definite multiple pulmonary infections or inflammation prior to surgery, as well as other severe systemic diseases.</li>
	<li>Exclude patients with coagulation disorders and severe psychiatric or neurological disorders.</li>
</ol>
3. Preparation before the anesthesia
<ol>
	<li>Fast the patient for 8 h before the surgery.</li>
	<li>Adjust the operating room temperature to be between 24 &#176; C and 26 &#176; C.</li>
	<li>Insert a 20 G top-winged infusion needle into the non-surgical dorsal vein of the hand.</li>
	<li>Monitor the electrocardiography, blood pressure, pulse oxygen saturation (SpO2), and respiratory rate of the patient.</li>
	<li>Apply a bispectral index (BIS) quatro sensor to the forehead of each patient. 
	NOTE: Continuously monitor the radial arterial pressure and central venous pressure, if necessary.</li>
</ol>
4. Ultrasound-guided thoracic paravertebral blockade
<ol>
	<li>Place the patient in a lateral decubitus position.</li>
	<li>Place the ultrasound probe directly above the spinous processes of the third thoracic and seventh thoracic vertebrae, and obtain a cross-sectional image of the spinous processes. 
	NOTE: In the middle of the image is the hyperechoic spinous process with a posterior acoustic shadow, and the bony structures with a posterior acoustic shadow on either side of the spinous process are, in order, the vertebral plate and the transverse process.</li>
	<li>Move the ultrasound probe laterally to show the transverse process in its entirety.</li>
	<li>Move the ultrasound probe outward to visualize the transverse process, transverse rib joints, and ribs.</li>
	<li>Move the ultrasound probe caudally until the transverse process, the pleura, and the thoracic paravertebral space between them are detected in the image.</li>
	<li>Locally anesthetize the skin by injecting 2 mL of 1% lidocaine.</li>
	<li>Insert the block needle from lateral to medial with the in-plane approach under ultrasound guidance.</li>
	<li>Carefully increase the aspiration before the injection. Ensure that no blood reflux is observed. 
	&#8203;NOTE: The purpose of this step is to prevent systemic toxicity from the local anesthetic.</li>
	<li>Inject 2 mL of saline, and then visualize the anterior displacement of the pleura and the widening of the thoracic paravertebral space with the ultrasound.</li>
	<li>Inject 15 mL of 0.375% ropivacaine at the levels of T3 and T7.</li>
</ol>
5. Anesthetic induction
<ol>
	<li>Spray 1% levobupivacaine (3 mL) onto the throat.</li>
	<li>Inject 1.5 &#181;g/kg of fentanyl and 1-1.5 mg/kg of propofol.</li>
	<li>For continuous oxygen administration, place a facial mask, or insert a laryngeal mask airway (double-tube mask; #3 for 30-50 kg, #4 for 50-70 kg, #5 for 70-100 kg). Oxygen enters the patient&#39;s airway via the facial mask or laryngeal mask. 
	&#8203;NOTE: Adjust the injection dose to achieve a BIS value between 40-6016.</li>
</ol>
6. Maintenance of anesthesia
<ol>
	<li>Maintain an oxygen flow rate of 0.5-1 L/min.</li>
	<li>Maintain the concentration of sevoflurane at 1.5%-2.0% after the artificial pneumothorax. 
	NOTE: Inject 0.5 &#181;g/kg of fentanyl if the intraoperative spontaneous respiratory rate is higher than 20 breaths/min or when there is mediastinal flutter or coughing. Sevoflurane enters the patient&#39;s airway via the facial mask or laryngeal mask.</li>
	<li>Monitor the inhaled oxygen concentration and the end-tidal carbon dioxide (ETCO2&#160;&#60; 60 mmHg).</li>
	<li>Monitor the body temperature. Monitor the level of consciousness, and maintain a BIS value of 40-6016,17.</li>
	<li>Inject 20&#181;g/kg of atropine if the patient develops sinus bradycardia (HR &#8804; 50 beats/min).</li>
	<li>Continuously perfuse 2 &#181;g/kg/h of norepinephrine using an infusion pump if the systolic blood pressure is lower than 30% or 90 mmHg.</li>
	<li>Perform arterial blood gas analysis 15 min before the end of the surgery.</li>
	<li>Inject 1 mg/kg of flurbiprofen 30 min before the end of the surgery.</li>
</ol>
7. Thoracoscopic vagal block techniques and pleural infiltration anesthesia
<ol>
	<li>Use a 24 G top-winged infusion needle to produce an infiltration of 0.375% ropivacaine (3 mL) near the vagus nerve at the level of the lower trachea when performing right-sided procedures.</li>
	<li>Use a 24 G top-winged infusion needle to produce an infiltration of 0.5% ropivacaine (3 mL) near the vagus nerve at the level of the aortopulmonary window when performing left-sided procedures.</li>
	<li>Spray 10 mL of 2% lidocaine onto the surface of the visceral pleura using a 10 mL syringe.</li>
</ol>
8. Conversion from non-intubated anesthesia to intubated general anesthesia
<ol>
	<li>Convert the non-intubated anesthesia to intubated general anesthesia if the patient meets one of the following conditions: 
	-Severe hypoxemia (pulse oximetry &#60; 80%) 
	-Severe hypercapnia (PaCO2 &#62; 80 mmHg) 
	-Hemodynamic instability: intractable arrhythmias and right ventricular failure 
	-Persistent coughing resulting in surgery becoming difficult or impossible 
	-Intraoperative bleeding requiring thoracotomy</li>
</ol>
9. Post-operative care
<ol>
	<li>After fully waking, ask the patient to take a deep breath and cough to re-expand the collapsed lung.</li>
	<li>Connect a patient-controlled intravenous analgesia (PCA) pump to the intravenous catheter with a 100 mL solution in a PCA reservoir bag (containing 1 &#181;g/kg of sufentanil and a 0.9% sodium chloride injection), and titrate 2 mL/h of the PCA solution.</li>
	<li>Remove the chest drain when there is no air leak on coughing, no obvious fluid pneumothorax on the review of the chest X-ray, and a 24 h drainage of &#60;300 mL.</li>
</ol>

A Non-Intubation Protocol for Video-Assisted Thoracoscopic Surgery with Preserved Autonomic Breathing

The authors have nothing to disclose.

The advantages of this protocol are as follows: (i) providing a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery; (ii) minimizing over-sedation while providing a safe and pain-free operating environment for patients undergoing thoracic surgery; (iii) minimizing the patient&#39;s spontaneous breathing and mediastinal oscillations during the procedure, taking into account the associated technical challenges. This was achieved by providing pre-emptive intraoperative local ane...

In the past decade, non-intubated video-assisted thoracic surgery (NIVATS) anesthesia has gradually been accepted in clinical practice1,2,3. Although this novel strategy enhances the rapid recovery of patients and avoids the complications of general anesthesia (GA) and one-lung ventilation4, many surgeons regard this approach as less desirable than the traditional lung isolation technique.
Blood oxygen levels decline with age, and some patients may have decreased or borderline pulmonary function. GA may be associated with an increased risk of complications in such patients, including delayed emergence from anesthesia, airway complications, hoarseness, hypoxia, and arytenoid dislocation5,6,7,8,9. In contrast, multiple studies have documented shorter hospital stays among patients managed with NIVATS, as well as a reduction in respiratory complications compared to general anesthesia among low-risk patients10; additionally, successful surgery has even been reported in high-risk patients with very poor pulmonary function11,12,13.
Spontaneous ventilation during surgery is achieved with carefully administered local anesthesia or a regional nerve block supplemented with sedation, but the cough reflex with unexpected lung movement can be problematic during NIVATS. There is little emphasis on and no standard treatment for mediastinal flutter, irritating cough, or tachypnoea, which may disrupt a surgical procedure. In preliminary observations, the results showed that sevoflurane could decrease the respiratory rate and the occurrence of mediastinal flutter during NIVATS while maintaining spontaneous breathing14. Therefore, it could be hypothesized that sevoflurane inhalation may prevent coughing and reduce the requirement for mechanical ventilation, thereby reducing post-operative pulmonary complications (PPCs).
Firstly, this report presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. Secondly, a retrospective study was conducted to investigate the potential benefits of non-intubated anesthesia on post-operative outcomes.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>20-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383012</td>
			<td>Puncture with a 20-G top-winged infusion needle into the dorsal vein of the non-operative side of the hand.</td>
		</tr>
		<tr>
			<td>24-G top-winged infusion needle</td>
			<td>BD Intima II</td>
			<td>383033</td>
			<td>Thoracoscopic vagal block techniques</td>
		</tr>
		<tr>
			<td>Anesthesia&#160;machine</td>
			<td>Drager</td>
			<td>A300</td>
			<td>Maintenance of respiratory function; Inhalation anesthesia; Monitor for electrocardiography, blood pressure, pulse oxygen saturation (SpO2), end-tidal carbon dioxide and respiratory rate</td>
		</tr>
		<tr>
			<td>Atropine</td>
			<td>Jiuquan Dadeli Pharma</td>
			<td>H62020772</td>
			<td>Control of heart rate</td>
		</tr>
		<tr>
			<td>BIS</td>
			<td>COVIDIEN</td>
			<td>B277243</td>
			<td>Monitor the level of consciousness</td>
		</tr>
		<tr>
			<td>Disposable nerve block needle</td>
			<td>Tuoren Medical Device&#160;</td>
			<td>202303007</td>
			<td>Nerve block</td>
		</tr>
		<tr>
			<td>Facial mask</td>
			<td>Emedica</td>
			<td>EM01-105S</td>
			<td>Provides an effective non-invasive breathing circuit</td>
		</tr>
		<tr>
			<td>Fentanyl.</td>
			<td>Renfu Pharma</td>
			<td>21D04021</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Flurbiprofen</td>
			<td>Daan Pharma</td>
			<td>H20183054</td>
			<td>Analgesia</td>
		</tr>
		<tr>
			<td>Laryngeal mask&#160;</td>
			<td>Ambu Aura-i</td>
			<td>2012-2664652</td>
			<td>Airway management to preserve voluntary breathing</td>
		</tr>
		<tr>
			<td>Levobupivacaine</td>
			<td>Rundu Pharma</td>
			<td>H20050403</td>
			<td>Local Anaesthesia</td>
		</tr>
		<tr>
			<td>Lidocaine</td>
			<td>Kelun Pharma</td>
			<td>F221129C</td>
			<td>Local skin infiltration</td>
		</tr>
		<tr>
			<td>Norepinephrine</td>
			<td>Lijun Pharma</td>
			<td>H61021666</td>
			<td>Control of blood pressure</td>
		</tr>
		<tr>
			<td>Portable color doppler ultrasound</td>
			<td>SonoSite</td>
			<td>M-Turbo</td>
			<td>Guided nerve block</td>
		</tr>
		<tr>
			<td>Propofol</td>
			<td>Guorui Pharma</td>
			<td>H20030114</td>
			<td>Sedation and hypnosis</td>
		</tr>
		<tr>
			<td>Ropivacaine</td>
			<td>Aspen Pharma</td>
			<td>6091403219940</td>
			<td>Paravertebral nerve block</td>
		</tr>
		<tr>
			<td>Saline</td>
			<td>Kelun Pharma</td>
			<td>c221201E1</td>
			<td>Assisted subsonic localisation</td>
		</tr>
		<tr>
			<td>Sevoflurane</td>
			<td>&#160;Shanghai Hengrui Pharmaceutical Co.,Ltd</td>
			<td>9081931</td>
			<td>Anesthesia induction and maintenance</td>
		</tr>
		<tr>
			<td>Sufentanil</td>
			<td>Jiangsu Enhua Pharmaceutical Co., Ltd</td>
			<td>H20203650</td>
			<td>Postoperative analgesia</td>
		</tr>
	</tbody>
</table>

non-intubated video-assisted thoracoscopic surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the lung, and lobectomy. However, there is a high incidence of pulmonary complications arising from general anesthesia with tracheal intubation. Non-intubation with the preservation of voluntary breathing is an alternative to anesthesia. Non-intubation procedures minimize the adverse effects of tracheal intubation and general anesthesia, such as intubation-related airway trauma, ventilation-induced lung injury, residual neuromuscular blockade, and post-operative nausea and vomiting. However, the steps for non-intubation procedures are not detailed in many studies. Here, we present a concise non-intubated protocol for the performance of video-assisted thoracoscopic surgery with preserved autonomic breathing. This article identifies the conditions necessary to convert from non-intubated to intubated anesthesia and also discusses the advantages and limitations of non-intubated anesthesia. In this work, this intervention was performed on 58 patients. In addition, the results of a retrospective study are presented. Compared with intubated general anesthesia, patients in the non-intubated video-assisted thoracic surgery group had lower rates of post-operative pulmonary complications, shorter operative times, less intraoperative blood loss, shorter PACU stays, a lower number of days to chest drain removal, less post-operative drainage, and shorter hospital stays.

Clinical data were retrospectively collected on 58 consecutive patients undergoing non-intubated video-assisted thoracoscopic surgery from January 2016 to December 2022. The patients were given a preoperative visit by the anesthesiologist and provided with a detailed explanation of the contents of the anesthesia informed consent form prior to the anesthesia. The patients were allowed to choose one of the two groups (the NIVATS group or GA group) of anesthesia, and they signed an informed consent form.
<p class="jove_...

Watch this Scientific Journal Video about A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia at JoVE.com

Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Here, we present a non-intubated protocol for performing video-assisted thoracoscopic surgery with preserved autonomic breathing.

Non-Intubated Video-Assisted Thoracoscopic Surgery

Double-lumen intubation under general anesthesia is currently the most commonly performed intubation technique for pneumonectomy, wedge resection of the ...

This research presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. The protocol of NIVATS is based on multimodal analgesia, including ultrasound-guided thoracic paravertebral blockade. A thoracoscopic make a block, and plural infiltration anesthesia.Multimodal analgesia effectively relieves intraoperative pain and inhibits the cough reflex. This protocol provides a sevoflurane inhalation anesthesia regimen to reduce the cough reflex during thoracoscopic surgery, minimizes oversedation, while providing a safe and a pain-free operating environment for patients. We maintain the patient's spontaneous breathing and minimize mediastinal oscillations during the procedure, while taking into account the associated aided technical challenges.

non-intubated-video-assisted-thoracoscopic-surgery

Research

JoVE Journal

Medicine

1.1K Views.  Second Affiliated Hospital of Zhejiang University School of Medicine. This research presents a step-by-step protocol detailing the execution of non-intubated video-assisted thoracoscopic surgery. The protocol of NIVATS is based on multimodal analgesia, including ultrasound-guided thoracic paravertebral blockade. A thoracoscopic make a block, and plural infiltration anesthesia.Multimodal analgesia effectively relieves intraoperative pain and inhibits the cough reflex. This protocol provides a sevoflurane inhalation anesthesia regimen to reduce the cough r...

Video: Author Spotlight: A Non-Intubated Video-Assisted Thoracoscopic Surgery with Multimodal Analgesia and Sevoflurane Inhalation Anesthesia 

Murine Flexor Tendon Injury and Repair Surgery

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers and general hand function. Injuries to the FTs are common, and satisfactory healing is often impaired due to excess scar tissue and adhesions between the tendon and surrounding tissue. However, little is known about the molecular and cellular components of FT repair. To that end, a murine model of FT repair that recapitulates many aspects of healing in humans, including impaired range of motion and decreased mechanical properties, has been developed and previously described. Here an in-depth demonstration of this surgical procedure is provided, involving transection and subsequent repair of the flexor digitorum longus (FDL) tendon in the murine hind paw.&#160;This technique can be used to conduct lineage analysis of different cell types, assess the effects of gene gain or loss-of-function, and to test the efficacy of pharmacological interventions in the healing process. However, there are two primary limitations to this model: i) the FDL tendon in the mid-portion of the murine hind paw, where the transection and repair occur, is not surrounded by a synovial sheath. Therefore this model does not account for the potential contribution of the sheath to the scar formation process. ii) To protect the integrity of the repair site, the FT is released at the myotendinous junction, decreasing the mechanical forces of the tendon, likely contributing to increased scar formation. Isolation of sufficient cells from the granulation tissue of the FT during the healing process for flow cytometric analysis has proved challenging; cytology centrifugation to concentrate these cells is an alternate method used, and allows for generation of cell preparations on which immunofluorescent labeling can be performed. With this method, quantification of cells or proteins of interest during FT healing becomes possible.

Flexor tendons in the hand are commonly injured, leading to impaired hand function. However, the scar-tissue healing response is not well characterized. A murine model of flexor tendon healing is demonstrated here. This model can enhance overall understanding of the healing process and assess therapeutic approaches to improve healing.

Tendon connects skeletal muscle and bone, facilitating movement of nearly the entire body. In the hand, flexor tendons (FTs) enable flexion of the fingers ...

Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of a robotic system. In traditional robotic training for surgeons, a brief web based overview of performing an emergency undocking is provided during initial introductory training to the robotics system. During such a process, there is no training in delineation of interdisciplinary roles for operating room (OR) personnel. The training presented here uses formative simulation and debriefing followed by a lecture. For the simulation, a modified gynecologic simulator is draped in a steep trendelenburg position consistent with most gynecologic laparoscopic surgery. The training torso is modified using tubing hooked to pressure bags of red food colored IV fluid used to simulate a catastrophic vessel injury on demand. Positioned throughout the operating room setting is an interprofessional team consisting of embedded standardized persons (ESPs) to fulfill the roles of a circulating nurse, scrub nurse, anesthesiologist, and bedside assist surgeon. Robotic surgeons are presented a case scenario necessitating emergency undocking, and given control of the robotic instruments. The scenario is terminated following either successful completion of an emergency undock, or at five minutes due to the emergent nature of the case. A debriefing session with hands on training of the steps to emergency undocking, necessary equipment, troubleshooting techniques, and operating room personnel roles follows the simulation. The learners are presented with a short lecture reemphasizing the material presented in the debriefing for their own self-study. This training results in improved time accessing the patient, improved knowledge, confidence, and completion of critical actions, and can be replicated in most institutions. All robotic surgeons should be able to demonstrate competence in this crucial intervention. A limitation of the curriculum is ability to access the in-situ environment for training purposes.

This training platform is designed to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of the robotic system. Training includes the utilization of the technology and equipment to perform an emergency undocking, as well as delineation of roles for such a scenario.

The following is a training platform to allow robotic surgeons to develop the skills necessary to lead an interprofessional team in emergency undocking of ...

Intraoperative Ultrasound in Spinal Surgery

Since the 1980s, there have been several reports for the use of intraoperative ultrasound as a useful adjunct in spinal surgery. However, with the advent of newer cutting-edge imaging modalities, the use of intraoperative ultrasound in spine surgery has largely fallen out of favor. Despite this, intraoperative ultrasound continues to provide several advantages over other intraoperative techniques such as magnetic resonance imaging and computed tomography including being more cost-effective, efficient, and easy to operate and interpret. Additionally, it remains the only method for the real-time visualization of soft tissue and pathologies. This paper focuses on the advantages of using intraoperative ultrasound, especially in cases of intradural lesions and lesions ventral to the thecal sac when approaching posteriorly.

Here, we present a protocol on the use of intraoperative ultrasound in spinal surgery, particularly in cases of intradural lesions and lesions in the ventral spinal canal when using a posterior approach.

Since the 1980s, there have been several reports for the use of intraoperative ultrasound as a useful adjunct in spinal surgery. However, with the advent ...

Electromagnetic Navigation Transthoracic Nodule Localization for Minimally Invasive Thoracic Surgery

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or excision. Many of these nodules are identified and excised via minimally invasive thoracic surgery; however, subcentimeter and subsolid nodules are frequently difficult to identify intra-operatively. This can be mitigated by the use of electromagnetic transthoracic needle localization. This protocol delineates the step-by-step process of electromagnetic localization from the pre-operative period to the postoperative period and is an adaptation of the electromagnetically guided percutaneous biopsy previously described by Arias et al. Pre-operative steps include obtaining a same day CT followed by the generation of a three-dimensional virtual map of the lung. From this map, the target lesion(s) and an entry site are chosen. In the operating room, the virtual reconstruction of the lung is then calibrated with the patient and the electromagnetic navigation platform. The patient is then sedated, intubated, and placed in the lateral decubitus position. Using a sterile technique and visualization from multiple views, the needle is inserted into the chest wall at the prechosen skin entry site and driven down to the target lesion. Dye is then injected into the lesion and, then, continuously during needle withdrawal, creating a tract for visualization intra-operatively. This method has many potential benefits when compared to the CT-guided localization, including a decreased radiation exposure and decreased time between the dye injection and the surgery. Dye diffusion from the pathway occurs over time, thereby limiting intra-operative nodule identification. By decreasing the time to surgery, there is a decrease in wait time for the patient, and less time for dye diffusion to occur, resulting in an improvement in nodule localization. When compared to electromagnetic bronchoscopy, airway architecture is no longer a limitation as the target nodule is accessed via a transparenchymal approach. Details of this procedure are described in a step-by-step fashion.

Presented here is a protocol for lung nodule localization using dye marking via electromagnetically navigated transthoracic needle access. The technique described here can be accomplished in the peri-operative period to optimize nodule localization and to successful resection when performing minimally invasive thoracic surgery.

The increased use of chest computed tomography (CT) has led to an increased detection of pulmonary nodules requiring diagnostic evaluation and/or ...

Learning Modern Laryngeal Surgery in a Dissection Laboratory

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is almost completely reserved to a few referral centers that deal with a large proportion of this pathology. Practice on human specimens is not always possible for ethical, economic, or availability reasons. The aim of this study is to provide a reproducible method for the organization of a laryngeal laboratory on ex vivo animal models where it is possible to approach, learn, and refine laryngeal techniques. Porcine and ovine larynges are ideal, affordable, models to simulate laryngeal surgery given their similarity to the human larynx in their anatomical layout and tissue composition. Herein, the surgical steps of transoral laser surgery, open partial horizontal laryngectomy, and total laryngectomy are reported. The merging of endoscopic and exoscopic views guarantees an inside-out perspective, which is vital for the comprehension of the complex laryngeal anatomy. The method was successfully adopted during three sessions of a dissection course &#34;Lary-Gym&#34;. Further perspectives on robotic surgical training are described.

The purpose of this paper is to illustrate how to organize a reproducible laboratory for laryngeal surgery on affordable and closely similar animal laryngeal models in order to improve anatomical and surgical knowledge and skills.

Surgery for laryngeal malignancies requires millimetric accuracy from the different endoscopic and open techniques available. Practice of this surgery is ...

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 ...

Indocyanine Green-Guided Intraoperative Imaging to Facilitate Video-Assisted Retroperitoneal Debridement for Treating Acute Necrotizing Pancreatitis

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing pancreatitis, if it does not resolve or is accompanied with infected necrosis in the retroperitoneum. As there are rarely any visually clear separating surface in white light image between necrotic debris and adjacent inflammatory normal tissues due to extensive retroperitoneal adhesions, VARD is accompanied with the risk of vascular injury, external pancreatico-cutaneous or enterocutaneous fistulae. In view of the above disadvantages, we apply real-time intraoperative near-infrared fluorescence imaging with indocyanine green (ICG) during VARD, which enables visualization of the well-perfused adjacent normal tissues. This modified technique (ICG-guided VARD) can provide a clear separating surface during debridement and reduce the risk of vascular or enteric injury. ICG-guided VARD may facilitate surgeons to perform safer debridement in treating severe acute necrotizing pancreatitis.

This protocol presents Indocyanine Green-guided video-assisted retroperitoneal debridement (ICG-guided VARD) for treating severe acute necrotizing pancreatitis.

Video-assisted retroperitoneal debridement (VARD) is a feasible, minimally invasive necrosectomy method for treating severe acute necrotizing ...

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. ...

Reoperative Hiatal Hernia Repair

Technical Considerations and Approach to Redo Foregut Surgery

Foregut surgical techniques have advanced significantly over the years and have become increasingly popular. However, new challenges and technical considerations have arisen when dealing with reoperation for complications or surgical failure. This study focuses on the technical considerations and approach when dealing with reoperative foregut surgery, particularly redo&#160;hiatal hernia repair. We describe our approach starting from the preoperative workup to the procedural steps of the surgery. The present study describes the main steps for robotic reoperative hiatal hernia repair in a patient who had previously undergone laparoscopic hiatal hernia repair with Nissen fundoplication but did not present a recurrence of reflux and dysphagia symptoms. The patient is positioned supine with arms out and a footboard for steep Trendelenburg. We place six trocars, including an assistant port and a liver retractor port,&#160;to facilitate visualization and retraction. After docking the robot, we use a combination of electrocautery and sharp dissection&#160;to free the hernia sac and reduce the hiatal hernia. The previous fundoplication is then taken down carefully and the esophagus is mobilized through a transhiatal approach with a combination of blunt and sharp dissection until at least 3 cm of intra-abdominal esophageal length is achieved, after which a leak test is performed. We then perform a crural repair to reapproximate the hiatus with two posterior stitches and one anterior stitch. Lastly, a redo Nissen fundoplication is performed over a bougie, and endoscopy is used to confirm a loose stack-of-coin appearance. By emphasizing the crucial steps of redo hiatal hernia repair, including preoperative evaluation, our goal is to provide an approach for the foregut surgeon to maximize patient outcomes.

Author Spotlight: Recent Advancements in Reoperative Foregut Surgery

Redo foregut surgery is associated with increased patient morbidity and presents a technical challenge for the surgeon. We describe our approach and considerations when performing a redo hiatal hernia repair to provide a guide for other surgeons and improve patient outcomes.