Minimally Invasive Direct Access Surgical Technology - MIDAST(TM).

The minimally invasive direct access surgical technology (MIDAST) has grown out of previous experience applied in otolaryngology and endoscopic microsurgery. From the time of Ambroise Pare and for centuries surgeons have made large incisions to gain adequate access for manipulation with large, straight, bulky instruments and achieved adequate illumination by the sun and later by artificial lighting.

Familial paragangliomas: linkage to chromosome 11q23 and clinical implications.

Familial paragangliomas (PGL), or glomus tumors, are slow-growing, highly vascular, generally benign neoplasms usually of the head and neck that arise from neural crest cells. This rare autosomal-dominant disorder is highly penetrant and influenced by genomic imprinting through paternal transmission. Timely detection of these tumors affords the affected individual the opportunity to avoid the potential morbidity associated with surgical removal, and mortality that may accompany local and distant metastases. Linkage to two distinct chromosomal loci, 11q13.1 and 11q22.3-q23, has been reported, suggesting heterogeneity. We evaluated three multigenerational families with hereditary PGL, including 19 affected, and 59 unaffected and potentially at-risk individuals. Numerous microsatellite markers corresponding to each candidate region were tested in all members of the three families. Confirmation of linkage to 11q23 was established in all three families. The inheritance pattern was consistent with genetic imprinting. Using these data, we were able to provide presymptomatic diagnosis with subsequent removal of tumor from one individual, and to start several others on an MRI surveillance protocol.

A randomized comparison between minilaparotomy and conventional approach for aortoiliac reconstructive surgery.

To decrease the surgical stress on patients undergoing aortic surgery the authors developed a less extensive procedure utilizing minilaparotomy and videoendoscopy. From June 1993 through July 1996, patients undergoing surgery for aortoiliac occlusive disease were randomized comparing the minilaparotomy (ML) with conventional approach (CA). Sixty-two patients participated in this trial, with 37 in the ML group and 25 in CA group. There were no significant differences between the groups in terms of age, sex or comorbid conditions. The incidence of intraoperative complications was similar for both groups. After surgery, nasogastric drainage was significantly (p = 0.01) shorter, bowel movement and initiation of alimentation began earlier in ML group. Both groups of patients showed a significant decrease in vital capacity and forced exspiration volume postoperatively, but this depression was significantly higher (p = 0.05) in CA group. The ML group also had significantly shorter stay in the intensive care unit (p = 0.001) and the mean duration of the postoperative hospital stay was also significantly less (p = 0.05). Generally, the patients operated by ML method during the postoperative recovery period required less analgesia, and expressed better "overall satisfaction". In long-term follow-up (mean 21 months), there was no significant difference in survival rates between two groups.

Videotunneler for minimal and direct access aortoiliac reconstructive surgery.

UNLABELLED: Despite improvements in surgical practice and postoperative care, the large vertical midline or transverse transperitoneal approaches used in abdominal aortic surgery are still associated with a relatively high perioperative morbidity and mortality rate even in patients who are considered good risks for undergoing aortic surgery. This significant perioperative morbidity is partly caused by the major surgical trauma. To decrease the surgical stress on these patients we have developed a less-extensive procedure for this type of vascular reconstruction. TECHNIQUE: The abdominal aorta is explored using a special retractor through a short upper median minilaparotomy utilizing modified conventional surgical hand instruments. For an aortobifemoral graft implantation, a retroperitoneal tunnel is necessary. During the creation of this tunnel special care should be exercised to avoid troublesome hemorrhage with iliac and other vein lacerations. To overcome these difficulties, we have developed a new tunneling device, which allows us to have visual control of the tunneling procedure. This prototype device contains a semiflexible tube with an inflatable balloon and a flexible videoendoscope. It is introduced along the external iliac artery into the retroperitoneal space and creates a tunnel through step-by-step inflation of the balloon. After this, the graft is implanted in the usual manner. To date, 19 abdominal vascular reconstructions have been performed with this method.

Minimal and direct access aortoiliac reconstructive surgery.

Despite improvements in surgical practice and postoperative care, the large transperitoneal approaches used in elective aortic reconstructive surgery are still associated with a relatively high perioperative morbidity and mortality rate, even in patients who are good risks for undergoing aortic surgery.,,2This perioperative morbidity is partly caused by major surgical trauma.

Minimal access ureterolithotomy.

A new minimally invasive ureterolithotomy is herein described which utilizes a 3 cm long skin incision. Surgery is performed with the aid of a newly developed bivalve retractor endoscope (Jakoscope) which provides excellent illumination with built-in double fiberoptic light cables and high intensity light source. The new surgical technique can be utilized in the rare cases of ureteral stone when other standard modalities may not work or when the patient demands definitive rapid treatment, and cannot be followed postoperatively.

Minimal and direct access surgery in urology.

An alternative method to laparoscopic surgery has been developed for urological procedures. The surgery is minimal access because the length of the single skin incision ranges from 3-6 cm depending on the type of operation. It is direct access because the surgeon sees the operative area directly and stereoscopically by eye without video-optical support. The procedure requires a special open-lumen retractorscope (Jakoscope(TM)) with a high intensity fiberoptic light system and modified standard hand instruments. Among the procedures performed nephrectomy, ureterolithotomy, prostatic adenomectomy, spermatic vein ligation and others have been performed. The kidney procedures have been operated retroperitoneally through a minilumbotomy incision. The procedures are simple, rapid and the instruments are inexpensive. The postoperative pain and morbidity are comparable to the laparoscopic approach.

[Minimally invasive and direct approach for aorto-iliac reconstruction]. / Minimal-invasiver und direkter Zugang für Aorto-Iliakale Rekonstruktion.

Using a prospective, randomized trial, the authors compared the minilaparotomy (ML) with the conventional transabdominal approach (CTA) to the aorta for infrarenal aortic reconstruction. After surgery, nasogastric drainage was significantly (p < 0.01) shorter; bowel movement and initiation of alimentation began earlier in the ML group. Both groups of patients showed a significant decrease in vital capacity and forced expiration volume postoperatively, but this depression was significantly higher (p < 0.05) in the CTA group. The ML group also had significantly shorter stays in the intensive care unit and the mean duration of the postoperative hospital stay was also significantly less (p < 0.05).

Retractorscopic nephrectomy: initial report.

The authors describe a newly developed minimal access method for nephrectomy. The mini approach-a 5 cm skin incision-can be performed with a special retractorscope, which is an open lumen "scope" with fiberoptic light system.

[Video controlled, minimally invasive exposure of the abdominal aorta by retroperitoneal approach for aorto-iliac reconstructions]. / Videokontrollierte, "minimal-invasive" Freilegung der Bauchaorta durch retroperitonealen Zugang für aortoiliacale Rekonstruktionen.

The morbidity and mortality rate of aortoiliac reconstruction is significant even in patients who are at low risk undergoing aortic surgery. Beyond the general extent of vascular disease, the great surgical intervention using a large vertical midline or transverse abdominal incision is also responsible for this events. To decrease the surgical stress a new minimal retroperitoneal approach was developed. To exposure the infrarenal aortic segment a 7 cm left paramedian incision is used, a special retractor and modified surgical instruments combining direct visualization of the operation field with flexible videoendoscopic control. This new approach offers the possibility to decrease the operative stress and enables complete control if serious bleeding might occur. This 'minimally invasive' approach appears to diminish the catabolic response and is hopefully associated with accelerated recovery and virtual abolition of large wound-related complications.

Minimal and direct access ureterolithotomy.

Authors developed an alternative method to laparoscopic surgery for ureterolithotomy. The surgery is of minimal access because the length of the single skin incision ranges from 3 to 4 cm, depending on the type of exploration. It is of direct access because the surgeon sees the operative area directly and stereoscopically with his own two eyes without video-optical support. The procedure requires a special open-lumen retractorscope (Jakoscope) with a high intensity fiberoptic light system and modified standard hand instruments. Ureterolithotomy is operated retroperitoneally through a minilumbotomy incision. The procedures are simple, rapid and the instruments are inexpensive. The postoperative pain and morbidity are comparable to the laparoscopic approach.

Preliminary report: endoscopic laser-microsurgical removal of human gallbladder.

An alternative surgical instrumentation and technique to laser laparoscopic cholecystectomy (LLC) with a case report is presented. Thousands of patients have benefited from the conceptual and practical revolution brought about through LLC (i.e., minimal surgical trauma). The minimal invasiveness of this procedure also can help make surgical treatment more acceptable by the public. The instruments and technique presented are redesigns of ones used in laryngology for 30 years. Utilizing them would provide major cost reduction. Most hospitals around the world already have operating microscopes, electrocoagulation equipment, and CO2 lasers. Some of these are underutilized. The presented patient case shows that the procedure can have similar benefits to LLC, in some respects even more. This open endoscopic technique and instrumentation may be suitable to other abdominal or thoracic procedures.

MR imaging of laser-tissue interactions.

A new application of magnetic resonance (MR) imaging to map the spatial and temporal distribution of the effects of Nd:YAG lasers on tissues was studied. The temperature dependence of MR relaxation mechanisms and the high sensitivity of MR to changes in the mobility and distribution of tissue water make it particularly suitable for the demonstration and control of thermal energy deposition in tissues. In heterogeneous tissues, MR imaging does not follow changing temperatures directly because even in the case of reversible thermal interactions, there is a hysteresis in the dynamic relationship between MR signal intensity and temperature. Appropriate matching of the laser and MR pulse sequences can, however, optimize the detection of relatively small laser energy deposition, and reversible and irreversible tissue changes can be distinguished. There is a potential for the integration of MR imaging and lasers for three-dimensional control and monitoring of laser-tissue interactions.