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The disposable surgical glove can serve as a model for toe-to-hand transfer, as a template for flap design, and as a ring tourniquet for the finger. The low cost, effectiveness, and easy handling of the glove warrant its role in reconstructive microsurgery.
Seventy-five patients with sessile adenomas or early carcinomas of the rectum or rectosigmoid were operated on with the new technique "transanal endoscopic microsurgery" Employing a newly developed complex endoscopic operating system, complete removal of sessile adenomas can be accomplished up to a distance of 25 cm from the anal verge, accurately and non-invasively. Complications occurred in three cases, with no resulting mortality. In the follow-up period we discovered only one adenomatous recurrence that required operative treatment. The superior accuracy of preparation, a short average stay in hospital, and low recurrence and complication rates are the advantages of this transanal endoscopic operative technique.
Considerably greater precision in operative manipulation during endolaryngeal microsurgery can be obtained by inserting a steel wire-grid in the lumen of the laryngoscope. Lever movements are possible for two instruments simultaneously, with a precision gain of 3:1. There is no visual impairment when looking through the microscope focused on the glottis.
Pathologic alterations of the turbinates are common in infectious diseases of the nose and paranasal sinuses. Over 300 patients were treated for paranasal sinuses disease from 1986 to 1989 by endonasal microsurgery. One-third of the patients were found intraoperatively to have alterations of the middle and inferior turbinate causing obstruction and functional disorders of the nose and sinuses. Our concept comprises a step-by-step microsurgical approach to the turbinates. The technique and the results are presented.
Out of a total of 295 cases in which endonasal microsurgery of the nasal cavity and the paranasal sinuses was performed, 221 were submitted to a detailed analysis. Compared with transfacial sinus surgery, the rate of complications was significantly lower. Further advantages of the transnasal microsurgical technique are better functional results, considerably fewer complaints during the postoperative period, and a reduced duration of hospitalization.
The birth of the first baby following in-vitro fertilisation and embryo transfer (IVF/ET) in 1978 and the introduction of gamete intrafallopian transfer (GIFT) in 1984 have increased the treatment modalities in operative reproductive medicine. In tubal pathology, there are besides micro-surgery now so-called additive methods available for treating infertility. With regard to the indications, there has been severe confusion, and it is therefore imperative to define special indications for IVF/ET, microsurgery and GIFT. We do not consider these treatment modalities as alternative methods. Reproductive centres should offer all these treatments to guarantee an appropriate individual programme for each couple. Therefore, knowledge of pregnancy rates is a prerequisite for the doctor. The aim of this paper is, to define the optimal therapy while taking into account the individual problems of each couple.
The authors describe a concept of converting microsurgical instruments into endoscopes and demonstrate prototype devices. These instruments combine the benefits of microsurgery (multiple instruments, tactile feedback, bimanual manipulation, magnification) with those of endoscopy (minimally invasiveness, indirect line of vision).
The operation microscope was equipped with two small camera heads on both sides, with a 35-mm still camera, and with or without a binocular observer tube. These camera heads were connected with a 3-dimensional (3D) converter. The operator can observe the 3D images of the operation field on a TV monitor through polarization glasses. The microscope with two camera heads is easy to handle because these camera heads are small and light. This is a promising monitoring system for microsurgery.
Mammalian somatic-cell hybrids can be formed in a direct and precise manner by microsurgery. Fusion of cells brought about in this way permits selection of specific, identifiable cells of the same or different types or species and their fusion at telophase.
Microsurgical free tissue transfer has become a gold standard in a wide range of clinical situations. Thrombosis at the anastomotic site is not only the most common cause of failure of microsurgical operations, but it is also one of the factors resulting in microcirculatory intravascular thrombosis in free flaps. All conditions of thrombus formation, defined by Virchow in 1856, are encountered in free flap surgery. This literature review concerns the problem of thromboprophylaxis in microsurgery. All citations published this last ten years (1996-2005) concerning this problem are noted. Data are confronted with other specialties, particularly vascular surgery, or with large retrospective studies. Protocol used in our institution is presented at the end of this lecture.
BACKGROUND: Transanal endoscopic microsurgery (TEM) is a newly developed, minimally invasive technique for the local resection of rectal tumours. Its place needs to be defined. METHODS: Literature review. RESULTS: Local excision of rectal tumours is associated with low mortality and morbidity. It is indicated in adenomas for curation and in rectal cancer for palliation. Transanal resection is used most frequently, but its use is limited. Other local techniques have no added value and are used sparingly. TEM is a newly developed, minimally invasive technique. Its technical characteristics allow an excellent view also in larger and more proximal tumours. Compared to other local techniques, mortality and morbidity are minimal and a laparotomy is more often preventable. Proper histological examination is possible and free margins are almost always observed. In adenomas it results in hardly any recurrences and in rectal cancer it can be adequately used for palliation. The results following local resection for rectal cancer with curative intent are promising, but they are only described anecdotally. CONCLUSIONS: TEM is an elegant technique with excellent results. It imposes itself as a method of choice for the local resection of rectal adenomas and of rectal cancer for palliation. If curation is intended in rectal carcinomas, TEM should be exercised with caution. Proper judgement over existing local techniques and TEM is being impeded by a lack of scientific argumentation.
The purpose of this study was to make public our results using endoscopic microsurgery in herniated cervical discs. This technique allows us to avoid complications due to conventional exposure, as is the case in traditional approaches. This study was carried out from January 1991 to January 1998. One hundred and seventy-one patients should have undergone traditional surgery for 296 herniated cervical discs. They were, instead, treated by using endoscopic microsurgical techniques. In 273 herniations the surgical procedure was performed by a paramidline right anterior approach, and in 23 herniations by a paramidline posterior approach, with a working sleeve of 4.6 mm outer diameter in both cases. In the anterior approach the tube was firmly placed against the anterior longitudinal ligament and the edge of the anterior part of the vertebral bodies. The neurovascular structures were placed lateral to the working sleeve and the visceral structures were placed medial to the working sleeve. Then, under endoscopic coaxial control, removal of the herniated part was performed, through the intervertebral discs, with microsurgical instruments. In the posterior approach, the tube was placed instead between the inferior and superior lamina, then under the nerve root up to the herniation, which was removed. This posterior approach was used only in the lateral disc herniations. There were no incidents or major complications following these operations. After one month the success rate was 94.7%, after three months 95.9%, after six months 96.4% and after one year 97%. There were no cases of relapse during the follow-up period of these patients. This study suggests that for herniated cervical discs, the endoscopic microsurgical technique is an extremely advantageous and safe method. Moreover, longer follow-up periods and an increased number of patients treated with this procedure should further confirm the usefulness of this technique.
The results of transsphenoidal microsurgery for growth hormone (GH)-secreting pituitary adenomas in a series of 47 patients are presented. A modified transsphenoidal approach with lateral rhinotomy was employed for the access to the sphenoid sinus. Remission, defined as mean GH concentration less than 2.5 ng/ml, was achieved in 79% of the patients. Macroadenoma size of the tumour and a GH concentration more than 50 ng/ml were factors unfavourable for the outcome. The experience of the lateral rhinotomy approach in transsphenoidal surgery of acromegaly has been favourable. The distance from the incision to the sella is shorter than in rhinoseptal approaches, where the depth of the operative field is determined by the distance from the nasal spine to the sella. The lateral rhinotomy also allowed an exposure of the sella of adequate width in all patients. These aspects of the procedure facilitated adenoma removal.
BACKGROUND: Rectourethral fistula is a rare complication of radical prostatectomy. Transanal endoscopic microsurgery (TEM) is a minimally invasive technique available for its surgical correction, although currently, TEM is used more commonly for excision of adenomas and stage T(1) carcinomas of the rectum. PATIENTS AND METHODS: We report two patients with rectourethral fistulae after laparoscopic radical prostatectomy in whom TEM was used for closure. The surgical procedure included microscopic full-thickness excision of the rectal wall around the fistula with a 1-cm margin and endoscopic suturing of the defect in the urethral and rectal walls. RESULTS: In one case, the rectourethral fistula was closed using TEM. In the other patient, the procedure, performed after failure of a graciloplasty, was difficult because of extensive scar tissue, and the fistula persisted. CONCLUSIONS: The TEM procedure is a minimally invasive technique that may be considered for surgical repair of rectourethral fistulae.
An endotracheal tube for use during anaesthesia for microsurgery of the larynx was made from a plastic endotracheal tube and an angiography connecting tube. It cannot be occluded, requires a minimum of space, and allows jet ventilation of the anaesthetized and paralysed patient. The value of a nitrous oxide-oxygen mixing valve in association with the tube is described.
We present an unusual case of hypercapnia and surgical emphysema during transanal endoscopic microsurgery, which led to delayed post-operative ventilatory failure. The hypercapnia and surgical emphysema were secondary to rectal insufflation with carbon dioxide used to facilitate visualization and resection of a rectal tumour. Despite a return to wakefulness after surgery, the patient's level of consciousness deteriorated in the recovery area as a result of hypercapnia. The PaCO2 rose to 16.8 kPa because of absorption of carbon dioxide from the surgical emphysema. On close examination, surgical emphysema was identified in unusual areas, including the anterior abdominal wall, both loins, both groins and the left thigh. Reventilation was required until these unusual carbon dioxide stores had dissipated. We discuss the need for prolonged post-operative vigilance in patients with surgical emphysema secondary to carbon dioxide insufflation, and the risk of delayed ventilatory failure.
The aim of this study was to evaluate the prognosis for the patients after the treatment of infertility resulting from proximal tubal blockage using microsurgical tubocornual anastomosis and in-vitro fertilization (IVF) and embryo transfer complementarily. A total of 59 microsurgical operations (1986-1992) for infertility resulting from pathological proximal tubal lesions were analysed. The cumulative live birth rate was 52% for tubocornual anastomosis, 58% for bilateral operations and 28% for two-site operations. In all, 35 singleton babies were born. Of the 32 operated patients who did not deliver within 2 years of surgery, 21 were treated by 66 IVF cycles; 12 babies were born. The live birth rate was 18% per cycle and 57% per patient. Combining both treatment methods the cumulative live birth rate was improved up to 69% in the group of tubocornual anastomoses, up to 75% in the group of bilateral operations, and up to 57% in the group of two-site operations. Complementary use of microsurgery and IVF and embryo transfer improves the prognosis for selected infertile patients with pathological proximal tubal blockage. In the absence of pregnancy, IVF and embryo transfer should be commenced 1 year after surgery.
Microsurgery has a growing influence in all surgical specialties as well as in the field of reconstructive surgery. Current experimental work and clinical experience of microvascular surgery are reviewed.