|
Speciality Spotlight
-
C. Gaelyn Garrett, MD, and Robert H, Ossoff, DMD, MD From the Department of Otolaryngology, Vanderbilt Voice The Otolaryngologic Clinics of North America
Phonomicrosurgery II: Surgical Techniques
Volume 33, Number 5, October 2000, Pg. 1063-1070
Vocal fold stripping almost always results in the removal of normal epithelium and a significant portion of the superficial layer of the lamina propria [SLLP]. Frequently, the vocal fold heals with significant scarring within the lamina propria tethering the mucosal cover to the underlying vocal ligament. Vocal fold vibration is hampered.
In the treatment of benign nonneoplastic lesions, vocal fold stripping techniques should therefore be abandoned in favor of treatments that spare epithelial and mucosal tissue.
Newer microlaryngeal techniques attempt adequate excision of the lesion without removing surrounding normal tissue.
The CO2 laser causes tissue ablation to a depth of approximately 200 mm at optimal laser settings.
It has hemostatic properties for the microcirculation [vessels < 50mm], making it ideal for lesions such as palilloma that are highly vascular and involve the epithelium.
Unfortunately, laser energy causes thermal damage to surroundings normal tissue, including the epithelial layer and deeper portions of the lamina propria, unnecessarily increasing the risk for postoperative scarring.
Therefore, do not routinely use the laser for excision of benign nonneoplastic vocal fold lesions when sparing of the mucosal cover is indicated.
Surgical Approach
Phonomicrosurgical techniques have been developed to preserve as much as possible the cover-body vibration of the true vocal fold. These techniques have been described as microflap or mini-microflap approaches.
They take advantage of a natural surgical plane within the mostly avascular Superficial Layer of the Lamina Propria SLLP.
Clinical reviews have reported excellent results with the microflap technique. The goal of the dissection is to excise the lesion within the SLLP without injuring the overlying epithelium and underlying vocal ligament.
Postoperative Care
Patients are placed on strict voice rest for 1 to 2 weeks gradual resumption of voice use under the guidance of the surgeon and a speech and language pathologist. Most complaint patients can expect to achieve 90% or more of their premorbid voice by 3 months following surgery.
-
Kiviluoto T, Siren J, Luukkonen P, et al [Helsinki Univ Central Hosp]
Randomised Trail of Laparoscopic versus Open Cholecystectomy for Acute and Gangrenous Cholecystitis.
Lancer 351-325, 1998, Pg. 235
Laproscopic cholecystectomy [ LC] is the surgical approach of choice for elective cholecystectomy. Use of LC in acute cholecystitis is controversial. Postoperative complications were higher in open cholycystectomy than laperoscopic cholecystectomy. Laparoscopic cholecystactomy in patients with acute gangrenous cholecystitis is technically demanding and in experienced hands and in experienced hands, LC can be safe and effective procedure without increase in mortality and morbidity.
-
Robert H Fletcher, Harvard Medical school, Boston
The End of Barium Enemas ?
The New Eng J Med., June 15, 2000; Vol.342(24), p. 1823-1824.
For many years, barium enema was the only way to obtain a complete structural examination of the colon, short of surgery.
With the advent of fiberoptic technology and the widespread use of colonoscopy in the 1970’s, the role of barium enema came into question.
Whether or not colonoscopy is a better way to examine the colon, it has been replacing barium enemas in recent years.
For surveillance and diagnosis, barium enema should be used only when colonoscopy is not available or is contraindicated.
-
R Lehner, R Wenzi, et al (Univ of Vienna; Hosp Lainz, Vienna)
Influence of Delayed Staging Laparotomy After Laparoscopic Removal of Ovarian Masses Later Found Malignant.
Obstet Gynecol 92: 967-971, 1998
Seventy patients were reviewed who had undergone attempted laparoscopic excision of a suspected benign ovarian mass, which was later proved by tissue and biopsy specimens to be malignant. In 22 patients, laparotomy was performed immediately after laparoscopy (immediate laparotomy group). Of the remaining patients, 22 underwent laparotomy 17 days or less after the initial examination and in 24 the delay between laparoscopy and laparotomy was more than 17 days.
Findings: Early-stage ovarian cancer was significantly more prevalent among patients in the immediate and early laparotomy groups compared with those in the late laparotomy group (59% and 71%, respectively).
Conclusions – Patients whose laparotomy was delayed more than 17 days after laparoscopy had a significantly increased risk of more advanced disease, probably because of tumor cell dissemination caused by the laparoscopy.
Dr. Ingle’s comment: I have not understood why the authors have kept such an odd number of 17 days as cut-off line, probably this was appropriate for their particular group of patients
-
GB Thompson, CS Grant, JA van Heerden et al (Mayo Found, Rochester, Minn):
Laparoscopic versus open posterior adrenalectomy: A case control study of 100 patients.
Surgery 122: 1132-1136, 1997.
Few large studies have compared laparoscopic adrenalectomy (LA) with conventional open anterior or posterior adrenalectomy (PA).
Laparoscopic adrenalectomy is a safe and effective procedure that is superior to PA with respect to patient satisfaction, length of hospital stay, return to normal activities, analgesic requirements and late complications. Compared with PA, LA operating times and hospital stays are slightly longer. LA is more expensive and technically more demanding.
-
D. Boerma, E.A.J. Rauws T.M. van Gulik, K. Huibregtse, H. Obertop and D.J. Gouma [ Department of Surgery and Gastroenterology, Academic Medical Centre, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
Br. Jour. of Sur. Volume 87, No.11, November 2000, Pgs- 1506-1509
Spontaneous closure of an external pancreatic fistula is unlikely when a concomitant downstream obstruction of the pancreatic duct inhibits downstream flow. ERCP and stent insertion may aid fistula closure.
15 patients of pancreatic fistula developed after operative necrosectomy and debridement of the pancreas [ seven men and eight women; ages 25-68 years] were evaluated after endoscopic stenting.
Results – The median drainage dropped from 50-800 ml/day [amylase content of 21,000 to 493000 U/L] to nil. ERCP was done after a median time of 35 days and revealed a leak with obstruction in all cases. An endoprosthesis was inserted beyond the site of obstruction. In one patient drainage failed and a pancreaticojejunostomy had to be done. During follow-up [2-55 months] 3 patients required resection of the pancreatic tail because of psedocyst formation.
Early ERP stenting enhances fistula closure, facilitates wound care and surgery is postponed or even avoided.
-
MS Abdou, AR Cohen (Case Western Reserve Univ, Cleveland, Ohio) :
Endoscopic Treatment of colloid Cysts of the third Ventricle: Technical Note and Review of the Literature.
J Neurosurg 89:1062-1068, 1998.
In some patients, colloid cysts may obstruct the foramina of Monro, resulting in hydrocephalus, intracranial hypertension and neurologic dysfunction. A technique for endoscopic management of colloid cysts and its outcomes were reported.
Endoscopic surgery allows wide fenestration of the capsule and aspiration of the cyst contents under direct vision, with minimal disruption of the cortex and other normal brain structures. The endoscope is the ideal instrument for exploring fluid-filled cavities. The intraventricular location of colloid cysts makes these lesions especially accessible.
-
T Menovsky, JA Grotenhuis, J de Vries, et al (Univ Hosp of Nijmegen, The Netherlands)
Endoscope-assisted Supraorbital Craniotomy for Lesions of the Interpeduncular Fossa.
Neurosurgery 44: 106-112, 1999.
The supraorbital approach is accepted for lesions in the anterior fossa, the sellar region and the anterior part of the circle of Willis. However, for lesions in the interpeduncular fossa, this approach has not been widely used. The use of an endoscope allows a bright and excellent view into the interpeduncular fossa, necessary for a minimally invasive supraorbital approach.
With this technique, the surgical route is nearly perpendicular, the amount of dissection and brain retraction minimized, and the surgical incision is small
-
JA Cadeddu, Y Ono, RU Clayman, et al (John Hopkins Med. Institutions, Baltimore, Md; Washington Univ, St. Louis; Univ of Soskatchawan, Soskatoon, Canada; et al)
Laparoscopic Nephrectomy for Renal Cell Cancer: Evaluation of Efficacy and Safety: A Multicentre Experience.
Urology 52; 773-777, 1998.
Introduction : Concerns with laparoscopic procedure include possibility of tumor spillage and trocar site implantation.
Methods: Multicentric study included 157 patients who had undergone Laparoscopic radical nephrectomy between Feb.1991 and June 1997. All were clinical stages T1-2, No, Mo.
Results: 9.6% had perioperative complications and there was 1 intraoperative death. 6 patients needed to be converted to open surgical procedure for difficult dissection or bleeding. No case of implantation at Trocar site. 5 yr actuarial disease free rate was 91%.
Conclusion : Laparoscopic Radical Nephrectomy can be safely performed in patients with Renal Cell Carcinoma.
Although longer follow-up is needed to determine the true 5 and 10 yr survival rates, early data indicate that the laparoscopic procedure is comparable to open surgery in rates of actuarial. Long term freedom from disease and cancer specific survival.
-
IS Gill, AC Novick; JJ Soble, et al (Cleveland Clinic Found, Ohio)
Laparoscopic Renal Cryoablation : Initial Clinical Series.
Urology 52: 543-551, 1998.
Introduction : Select patients with small (<4cm) unilateral localised renal carcinoma can be successfully treated with Nephron sparing surgery, but the technique is associated with potential morbidity.
Method : 10 patients with 11 tumors were selected. Mean tumor size was 2.3 cm on C.T. Nephron sparing surgery was selected because tumor was small, it was a solitary functioning unit, there was renal dysfunction, or suspected renal metastasis.
Entire renal surface was exposed laparoscopically. Needle biopsy was performed with 15 G needle. Doppler probe passed through 12mm port to guide the biopsy.
Post-operative follow-up included biochemical, radiological, histological, CT and MRI. The ice ball was monitored so that it was felt to extend 1cm beyond the tumor.
Results : Minimal bleeding at puncture site when the probe was removed.
Mean surgical time 2.4 hrs. Blood loss 75ml. 9 of 10 patients discharged in 23 hrs. Convalescence 2 weeks. All kidneys functioned post operatively.
Conclusion: In carefully, selected patients short-term outcome suggests that renal cryoablation is a safe and feasible technique.
-
HN Winfield, BD Hamilton, EL Bravo, et al (Cleveland Clinic Found; Ohio)
Laparoscopic Adrenalectomy: The Preferred Choice ? A comparison to open adrenalectomy.
J Urol 160; 325-329, 1998
Laparoscopic adrenalectomy is an excellent treatment choice for patients with tumors of less than 6cm.
With this procedure patients are able to return to full diet earlier and can leave the hospital sooner. They have reduced anlagesic requirements.
-
L R Hickok (Seattle, Washington)
Hysteroscopic treatment of the uterine septum: A clinician’s experience
Am J Obstet Gynecol 2000; 182: 1414-20
Objective: The author reviewed his experience with the diagnosis and hysteroscopic treatment of uterine septa.
Study Design: This article is a retrospective review of cases from 1992-1999. A septate uterus was diagnosed in a total of 40 patients, and all were treated by hysteroscopic resection.
Results: The rate of preoperative pregnancy loss was 77.4%, and the uncomplicated delivery rate was 6.5%. After hysteroscopic septum resection 21 patients reported a total of 22 pregnancies with an 18.2% miscarriage rate and a 77.3% uncomplicated delivery rate.
Conclusion: Hysteroscopic treatment of uterine septa is a safe, simple and effective procedure. It can be used for all types of uterine septa, it attains optimal obstetric outcomes, and it should be undertaken whenever a uterine septum is diagnosed.
Discussion: Dr. Lorna A Marshall – Like every other report on this topic, this one is limited by its design. It compares a group of women who are examined because of failed reproduction with these same women after treatment. We know that a certain number of women will have a successful pregnancy in the presence of a uterine septum. In fact, that number may increase with each subsequent pregnancy in the untreated patient. There is currently no published clinical trial on uterine septa that compares pregnancy rate and pregnancy outcome in a treated and an untreated group. The ability to perform such a clinical trial has been limited by the need to do a laproscopy to provide reassurance that the uterus is externally unified.
Electrocautery may cause thermal damage that may negatively affect endometrial development or result in a weakened myometrium and uterine rupture in a subsequent pregnancy. In addition, uterine perforation during cauterization may entail a risk of severe thermal damage to intra-abdominal structures.
Uterine rupture during a subsequent pregnancy has been reported after hysteroscopic metroplasty complicated by perforation with microscissors. It has also been reported after an uncomplicated procedure with the KTP laser used to excise the septum. No cases of uterine rupture after resectoscopic removal of a septum have been reported.
Surgery for a septate uterus should not be substituted for other treatments for infertility.
Dr. Robert Israel comments that it is unnecessary to resect the septum; incising the septum is quite straightforward.
At present there is no substitute for diagnostic laparoscopy with regard to ascertaining the type of uterine anomaly or the condition of other pelvic organs or in identifying uterine perforations promptly, should they occur.
-
M. I. Shamonki, W F Ziegler, et al (Burlington, Vermont)
Prediction of endometrial ablation success according to perioperative findings
Am J Obstet & Gynecol, 2000; 182: 1005-7
Objective : The aim of this study was to determine which factors in the perioperative period influence the success of endometrial ablation in alleviating menorrhagia.
Study Design: The authors performed a retrospective chart review of 120 women aged 27 to 49 years who underwent endometrial ablation after 2 months of preoperative treatment with danazol (Danocrine, 800mg/d orally) or leuprolide (Lupron 3.75mg in one intramuscular injection each month). Patients who required medical management or additional operations to control the vaginal bleeding during follow-up (median follow-up, 37 weeks) were considered to have ablation failures.
Results: Sixty-three percent of patients (76/120) had a successful procedure. The chance of success was greater if a cavity of normal appearance was found (odds ratio, 2.3; P=.04). The finding of an intramural fibroid before the procedure resulted in a reduced trend toward success (odds ratio, 0.4; P=.06). The use of danazol pretreatment improved the rate of success overall (odds ratio, 2.2; P=.05) and especially among women <40 years old (P =.01).
Conclusion: Perioperative findings may provide useful information in counseling patients regarding endometrial ablation. Success is greater among patients with a normal intrauterine cavity and after preoperative treatment with danazol.
-
JA Cadeddu, Y Ono, RU Clayman, et al (John Hopkins Med. Institutions, Baltimore, Md; Washington Univ, St. Louis; Univ of Soskatchawan, Soskatoon, Canada; et al)
Laparoscopic Nephrectomy for Renal Cell Cancer: Evaluation of Efficacy and Safety: A Multicentre Experience.
Urology 52; 773-777, 1998.
Introduction : Concerns with laparoscopic procedure include possibility of tumor spillage and trocar site implantation.
Methods: Multicentric study included 157 patients who had undergone Laparoscopic radical nephrectomy between Feb.1991 and June 1997. All were clinical stages T1-2, No, Mo.
Results: 9.6% had perioperative complications and there was 1 intraoperative death. 6 patients needed to be converted to open surgical procedure for difficult dissection or bleeding. There was no case of implantation at Trocar site. 5 yr actuarial disease free rate was 91%.
Conclusion : Laparoscopic Radical Nephrectomy can be safely performed in patients with Renal Cell Carcinoma.
Although longer follow-up is needed to determine the true 5 and 10 yr survival rates, early data indicate that the laparoscopic procedure is comparable to open surgery in rates of actuarial, long term freedom from disease and cancer specific survival.
-
IS Gill, AC Novick; JJ Soble, et al (Cleveland Clinic Found, Ohio)
Laparoscopic Renal Cryoablation : Initial Clinical Series.
Urology 52: 543-551, 1998.
Introduction : Select patients with small (<4cm) unilateral localised renal carcinoma can be successfully treated with Nephron sparing surgery, but the technique is associated with potential morbidity.
Method : 10 patients with 11 tumors were selected. Mean tumor size was 2.3 cm on C.T. Nephron sparing surgery was selected because tumor was small, it was a solitary functioning unit, there was renal dysfunction, or suspected renal metastasis.
Entire renal surface was exposed laparoscopically. Needle biopsy was performed with 15 G needle. Doppler probe passed through 12mm port to guide the biopsy.
Post-operative follow-up included biochemical, radiological, histological, CT and MRI. The ice ball was monitored so that it was felt to extend 1cm beyond the tumor.
Results : Minimal bleeding at puncture site when the probe was removed.
Mean surgical time 2.4 hrs. Blood loss 75ml. 9 of 10 patients discharged in 23 hrs. Convalescence 2 weeks. All kidneys functioned post operatively.
Conclusion: In carefully, selected patients short-term outcome suggests that renal cryoablation is a safe and feasible technique.
-
HN Winfield, BD Hamilton, EL Bravo, et al (Cleveland Clinic Found; Ohio)
Laparoscopic Adrenalectomy: The Preferred Choice ? A comparison to open adrenalectomy.
J Urol 160; 325-329, 1998
Laparoscopic adrenalectomy is an excellent treatment choice for patients with tumors of less than 6cm.
With this procedure patients are able to return to full diet earlier and can leave the hospital sooner. They have reduced anlagesic requirements.
-
J.-P. Mcfarlane, C. Cowan, S.J. Holt and M.J. Cowan [ Departments of ‘Urology and Radiology. The Churchill Hospital, Oxford, UK]
Outpatient Ureteric Procedures : A New Method for Retrograde Ureteropyelography and Ureteric Stent Placement
BJU International, volume 87, Number 1, January 2001, Pg.Nos. 172-176
Patients and Methods -Procedures were undertaken using a flexible cystoscope and digital C-arm fluroscopy in outpatients under sedoanalgesia. The flexible cystoscope was used to identify the ureteric orifice, a straight 0.9 mm hydrophilic guidewire inserted and passed into the renal pelvis under fluroscopic guidance. A 4 F general purpose catheter was passed over the wire and ureteropyelography performed. Stenting was done over a ultra-stiff wire after exchange.
Results -Of the 723 procedures, 643 were technically successful. Failure was most commonly due to failure to cannulate the ureteric orifice. Immediate complications occurred in 3%. 282 of 300 procedures were reported to be acceptable.
Conclusion -Retrograde ureterography and ureteric stent placement may be satisfactorily undertaken with the patient under sedoanalgesia on an outpatient basis. This technique can reduce costs, hospital admissions, general anaesthetic use, demands on theatre time and complication rates.
