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1.  Right Kocher’s incision: a feasible and effective incision for right hemicolectomy: a retrospective study 
Background
The choice of surgical incision is determined by access to the surgical field, particularly when an oncological resection is required. Special consideration is also given to other factors, such as postoperative pain and its sequelae, fewer complications in the early postoperative period and a lower occurrence of incisional hernias. The purpose of this study is to compare the right Kocher’s and the midline incision, for patients undergoing right hemicolectomy, by focusing on short- and longterm results.
Methods
Between 1995 and 2009, hospital records for 213 patients that had undergone a right hemicolectomy for a right- sided adenocarcinoma were retrospectively studied. 113 patients had been operated via a Kocher’s and 100 via a midline incision. Demographic details, operative data (explorative access to the peritoneal cavity, time of operation), recovery parameters (time with IV analgesic medication, time to first oral fluid intake, time to first solid meal, time to discharge), and oncological parameters (lymph node harvest, TNM stage and resection margins) were analyzed. Postoperative complications were also recorded. The two groups were retrospectively well matched with respect to demographic parameters and oncological status of the tumor.
Results
The median length of the midline incision was slightly longer (12 vs. 10 cm, p < 0.05). The duration of the surgery for the Kocher’s incision group was significantly shorter (median time 70 vs 85 min, p < 0.001). In three patients we performed wedge resection of liver metastasis and in one patient we performed a typical right hepatectomy that lasted 190 min. No major operative complications were noted. There was no immediate or 30- day postoperative mortality. The Kocher’s incision group had a significantly shorter hospital stay (median time 5 vs 8 days). All patients underwent wide tumor excision and clear resection margins were obtained in all cases. No significant difference was noted regarding analgesia requirements and early postoperative complications. Late postoperative complications included 2 incisional hernias and three patients presented with one episode of obstructive ileus, that resolved conservatively.
Conclusions
The Kocher’s incision approach for right- sided colon cancer is technically feasible, safe and overall very well tolerated. It can achieve the same standards of tumor resection and surgical field accessibility as the midline approach, while reducing postoperative recovery.
doi:10.1186/1477-7819-10-101
PMCID: PMC3482598  PMID: 22676778
Colonic adenocarcinoma; Midline incision; Right Kocher’s incision; Right hemicolectomy
2.  The minimally invasive open video-assisted approach in surgical thyroid diseases 
BMC Surgery  2005;5:9.
Background
The targets of minimally invasive surgery (MIVA) could be summarised by: achievement of the same results as those obtained with traditional surgery, less trauma, better post-operative course, early discharge from hospital and improved cosmetic results. The minimally invasive techniques in thyroid surgery can be described as either endoscopic "pure" approach (completely closed approach with or without CO2 insufflation), or "open approach" with central neck mini-incision or "open video-assisted approach". Traditionally, open thyroidectomy requires a 6 to 8 cm, or bigger, transverse wound on the lower neck. The minimally invasive approach wound is much shorter (1.5 cm for small nodules, up to 2–3 cm for the largest ones, in respect of the exclusion criteria) upon the suprasternal notch.
Patients also experience much less pain after MIVA surgery than after conventional thyroidectomy. This is due to less dissection and destruction of tissues.
Pathologies treated are mainly nodular goiter; the only kind of thyroid cancer which may be approached with endoscopic surgery is a small differentiated carcinoma without lymph node involvement.
The patients were considered eligible for MIVA hemithyroidectomy and thyroidectomy on the basis of some criteria, such as gland volume and the kind of disease. In our experience we have chosen the minimally invasive open video-assisted approach of Miccoli et al. (2002). The aim of this work was to verify the suitability of the technique and the applicability in clinical practice.
Methods
A completely gasless procedure was carried out through a 15–30 mm central incision about 20 mm above the sternal notch. Dissection was mainly performed under endoscopic vision using conventional endoscopic instruments. The video aided group included 11 patients. All patients were women with a average age of 54.
Results
We performed thyroidectomy in 8 cases and hemithyroidectomy in 3 cases. The operative average time has been 170 minutes.
Conclusion
Nowadays this minimally invasive surgery, in selected patients, clearly demonstrates excellent results regarding patient cure rate and comfort, with shorter hospital stay, reduced postoperative pain and most attractive cosmetic results.
doi:10.1186/1471-2482-5-9
PMCID: PMC1131909  PMID: 15857503
minimally invasive thyroidectomy; MIVA; video-assisted surgery
3.  Minimal access surgery — thyroid and parathyroid 
The concept of surgical invasiveness cannot be limited to the length or to the site of the skin incision. It must be extended to all structures dissected during the procedure. Therefore, MIT or MIP should properly be defined as operations through a short and discrete incision that permits direct access to the thyroid or parathyroid gland, resulting in a focused dissection.
Parathyroid glands are particularly suitable for minimally invasive surgery as most parathyroid tumors are small and benign. MIP are performed through a limited or discrete incision when compared to classic open transverse cervical incision and are targeted on one specific parathyroid gland. The concept of these limited explorations is based on the fact that 85% of patients will have single-gland disease. MIP must be proposed only for patients with sporadic hyperparathyroidism in whom a single adenoma has been clearly localized by preoperative imaging studies.
The minimal access approaches to the thyroid gland may be broadly classified into three groups: the mini-open lateral approach via a small incision, minimally invasive video-assisted thyroidectomy via the midline and various endoscopic techniques. Endoscopic extracervical approaches have the main advantage of leaving no scar in the neck but cannot reasonably be described as minimally invasive as they require more dissection than conventional open surgery.
Initially the indications for MIT were a solitary thyroid nodule of less than 3 cm in diameter in an otherwise normal gland. Today, MIT are also proposed in patients with small nodular goiters, Graves’s diseases and low risk papillary thyroid cancers. Some concern remains about the radicality of MIT in this latter group but preliminary results are comparable to those of conventional surgery both in terms of I-131 uptake and serum thyroglobuline levels.
Demonstrating the advantages of MIT and MIP over conventional surgery is not easy. Main complications, such as nerve injury, hypoparathyroidism, or hemorrhage, are the same as in conventional surgery. Several studies comparing conventional surgery with minimally invasive techniques using a cervical access have shown a diminution of postoperative pain, and better cosmetic results with minimally invasive techniques. MIP and MIT seem overall to be an advance but only randomized studies will demonstrate the real benefit.
doi:10.1007/s13193-010-0033-7
PMCID: PMC3421002  PMID: 22930635
Minimally invasive surgery; thyroidectomy; parathyroidectomy
4.  Gasless Single Incision Endoscopic Thyroidectomy 
A chest wall approach combined with a gasless technique appears to make single-incision endoscopic thyroidectomy feasible and practicable.
Background:
Endoscopic thyroidectomy making the scar outside the neck area has a cosmetic appeal for patients. Based on an anterior chest wall approach combined with the gasless technique, we developed a novel method for gasless endoscopic thyroidectomy with a single incision.
Materials and Methods:
From March 2009 to November 2010, 48 patients with benign thyroid nodules underwent thyroidectomy with the gasless single-incision endoscopic surgery technique via the anterior chest wall approach. A 3-cm long skin incision parallel to the clavicle was made on the anterior chest wall on the side of the lesion. The platysma flap was lifted up to maintain working space from the incision to the thyroid cartilage. Dissection of the thyroid was begun from the inferior pole of the thyroid. The line of resection was selected to preserve recurrent laryngeal nerve and parathyroids. A 5-mm drainage tube was inserted into the lower portion of the operative space through the incision after the thyroid gland and the lesion were resected using the Harmonic scalpel.
Results:
The overall operating time was 126 minutes (range, 90 to 210), 138 minutes (range, 80 to 160) in first 24 cases; and 112 minutes in the second 24 patients (P<.05). Three cases were converted to the conventional procedure: 2 because of a malignancy diagnosed on frozen section, and one due to uncontrolled bleeding from the middle thyroid vein. Another malignancy diagnosed on final pathological examination was treated with additional surgery to complete the thyroidectomy by using the conventional open method. There were 2 cases of postoperative complications: transient hoarseness and hematoma. No wound infection occurred in our series. The scar was well hidden beneath the clothes, and the patients were satisfied with the cosmetic result of the surgery.
Conclusions:
Advantages of the chest wall approach combined with the gasless technique have made single-incision endoscopic thyroidectomy more feasible and practicable.
doi:10.4293/108680812X13291597715989
PMCID: PMC3407459  PMID: 22906332
Endoscopic surgery; Thyroidectomy; Gasless; Single-incision surgery
5.  Experience of 1166 Thyroidectomy without Use of Prophylactic Antibiotic 
BioMed Research International  2014;2014:758432.
Background. Although the procedure requires a small surgical incision and a short duration, incision infection rate is very low in thyroidectomy; however, doctors still have misgivings about infection events. Aim. We retrospectively analyzed the prevention of incision infection without perioperative use of antibacterial medications following thyroidectomy. Materials and Methods. 1166 patients of thyroidectomy were not administered perioperative antibiotics. Unilateral total lobectomy or partial thyroidectomy was performed in 68.0% patients with single-side nodular goiter or thyroid adenoma. Bilateral partial thyroidectomy was performed in 25.5% patients with nodular goiter or Graves' disease. The mean time of operation was 80.6 ± 4.87 (range: 25–390) min. Results. Resuturing was performed in two patients of secondary hemorrhage from residual thyroid following bilateral partial thyroidectomy. Temporally recurrent nerve paralysis was reported following right-side total lobectomy and left-side subtotal lobectomy in a nodular goiter patient. One case had suppurative infection in neck incision 5 days after bilateral partial thyroidectomy. Conclusions. Thyroidectomy, which is a clean incision, involves a small incision, short duration, and minor hemorrhage. If the operation is performed under strict conditions of sterility and hemostasis, antibacterial medications may not be required to prevent incision infection, which reduces cost and discourages the excessive use of antibiotics.
doi:10.1155/2014/758432
PMCID: PMC4037569  PMID: 24900986
6.  A rare instance of retrosternal goitre presenting with obstructive sleep apnoea in a middle-aged person 
INTRODUCTION
In endemic goitre areas, 20% of the population over 70 will have retrosternal goitre.12 Obstructive sleep apnoea (OSA) occurs when there are repeated episodes of complete or partial blockage of the upper airway during sleep.
PRESENTATION OF CASE
A 55-year-old man was being treated for obstructive sleep apnoea, came with stridor worsening over the 2 and was advised CPAP ventilation. In our institution, he was diagnosed to have goitre with retrosternal extension with no hypo/hyperthyroidism. He was an obese (BMI – 30 Kg/m2) male with a short, broad neck and clinically no obvious swelling in the neck. He had stridor, with positive Kocher's test as well as Pemberton's sign. His TFT's were normal and CT scan revealed widening of superior mediastinum. Patient was pre-medicated with low dose (0.1 μg) fentanyl, and induced with inhalational anaesthesia (sevoflourane). Endotracheal intubation was done using 6 no. ET tube, without muscle relaxation, and the thyroid was removed through a conventional Kocher's incision. Thyroid was enlarged 25 cm by 10 cm in retrosternal position. Postoperatively, pt was reversed and shifted to ICU, was monitored for the next 24 hours. He was extubated uneventfully the next morning. Patient had a good post-op recovery and was discharged on the 7th post-op day.
DISCUSSION
Terms such as retrosternal, substernal, intrathoracic, or mediastinal have been used to describe a goitre that extends beyond the thoracic inlet. However, there is a lack of consensus regarding the exact definition of a retrosternal goitre (RSG).1 The majority of patients present with shortness of breath or asthma like symptoms (68.8%), as was the case in the studied patient. Other modes of presentation include neck mass (75%), hoarseness of voice (37.5%), dysphagia (31.3%), stridor/wheezing (19%), or SVC obstruction. Upper airway obstruction due to thyroid gland has been reported up to 31%2 and difficulty in intubation has been reported in 11%.3 Central airway obstruction produces symptoms of dyspnoea, stridor, or obstructive pneumonia and is often misdiagnosed as asthma.4 The CT scan was the most useful tool showing the nature and extent of the lesion in the reported case. In a recent publication, the CT scan was considered the gold-standard preoperative radiological investigation.5 Surgery is the only effective treatment for retrosternal goitres. In most cases, suppressive therapy with thyroxine is ineffective in reducing the size of multinodular goitres;7,8 radio-iodine therapy is both generally ineffective in large goitres8 and may induce acute inflammation and swelling of the gland with the potential for airway obstruction. The operation of choice is usually a total thyroidectomy. Only around 2% of patients undergoing thyroidectomy for retrosternal goitre will require surgical access other than a standard collar incision (either manubriotomy, sternotomy or thoracotomy).9
CONCLUSION
Despite all the advances in investigative modalities, retrosternal goitre still exists in 20% of patients over 70 years in endemic regions. It has to be recognised that it can be a cause of obstructive sleep apnoea. Early detection and prompt management goes a long way in decreasing the morbidity and mortality in patients with RSG.
doi:10.1016/j.ijscr.2013.07.040
PMCID: PMC3860032  PMID: 24212758
Retrosternal goitre; Obstructive sleep apnoea
7.  Prospective randomized comparison of the safety, efficacy, and cosmetic outcome associated with mini-transverse and mini-longitudinal radical prostatectomy incisions 
Aims:
Open radical retropubic prostatectomy (ORP) has traditionally been performed through a lower midline incision. Prior efforts to reduce pain and expedite recovery include a variety of alterations in length and the orientation of the incision. The aim of our study is to compare the safety, efficacy, and cosmetic outcomes associated with transverse and longitudinal mini-radical prostatectomy incisions.
Materials and Methods:
Consecutive patients undergoing ORP at a single institution were studied. Patients were randomized to receive either a modified transverse or longitudinal incision. In all patients, the length of the incision was 7cm. The following parameters were compared between the two groups: Perioperative blood loss, duration of surgery, technical factors, pain and analgesic requirements, length of hospital stay (LOS), and pathological stage. The Patient and Observer Scar Assessment Scale (POSAS) was used to compare the cosmetic aspects associated with the incisions.
Results:
Fifty-six patients underwent a transverse (n=27) and longitudinal (n=29) mini- incision ORP. No significant differences were noted in the perioperative parameters that were compared (P>0.116). None of the patients required blood transfusion, there were no wound complications. Perioperative pain and analgesic requirements were not significantly different among the two study arms (P>0.433). The POSAS indicated no significant difference in cosmesis scores with both incisions (P>0.09).
Conclusions:
Seven-centimeter transverse and longitudinal mini-incisions offer alternatives to the standard ORP incision, and to minimally invasive approaches. Both incisions are safe, associated with little postoperative pain, and a short postoperative LOS. Both incisions provide highly satisfactory cosmesis for the patient.
doi:10.4103/0970-1591.70563
PMCID: PMC2978431  PMID: 21116351
Cosmesis; localized prostate cancer; prostate cancer treatment; radical prostatectomy
8.  Minimally invasive video-assisted thyroidectomy versus conventional thyroidectomy: A single-blinded, randomized controlled clinical trial 
We aimed to test the hypothesis that Minimally Invasive Video-assisted Thyroidectomy (MIVAT) affords comparable safety and efficacy as to the open conventional surgery, when dealing with patients with unilateral thyroid nodules or follicular lesions, in terms of cosmetic results, intraoperative and postoperative complications, postoperative pain and hospital stay.
MATERIALS AND METHODS:
This was a single-blinded randomised controlled trial comparing the MIVAT with conventional thyroidectomy. The primary endpoints of the study were measurement of postoperative pain after 24 and 48 hours from operation and self-rated patient satisfaction with cosmetic outcome three months postoperatively. The secondary outcome measures were operative time, incidence of temporary and permanent recurrent laryngeal nerve injury, postoperative haematoma formation, length of incision, and duration of hospital stay.
RESULTS:
Operative time was significantly less with open thyroidectomy than with MIVAT, while MIVAT was associated with less pain 24 hours postoperatively. Blood loss did not reach significance between procedures. Comparisons between the two procedures with regard to pain scores after 24 and 48 hours, respectively, depicted statistically significant differences in favour of the MIVAT after 24 hours. MIVAT was associated with less scarring and more satisfactory cosmetic results. There were statistically no significant differences between both procedures for the presence of transient recurrent laryngeal nerve palsy and hypoparathyroidism.
CONCLUSIONS:
MIVAT is a safe procedure that produces outcomes, in view of short-term adverse events, similar to those of open thyroidectomy, and is superior in terms of immediate postoperative pain and cosmetic results.
doi:10.4103/0972-9941.59307
PMCID: PMC2843132  PMID: 20407568
Thyroid surgery; minimally invasive
9.  Minimally invasive surgery using mini anterior incision for thyroid diseases: a prospective cohort study 
Aim: Minimally invasive surgical techniques have attracted interest in all surgical specialties since 1980. The thyroidectomy technique requires meticulous surgical dissection, absolute hemostasis, en bloc tumor resection and adequate visualization of the operative field, all of which can be accomplished with minimally invasive techniques. Methods: The study group comprised all patients undergoing MITS from its introduction in 2010 until July 2012. All data were prospectively recorded in the Elbistan Hospital and Suleyman Demirel University in Turkey. This study was designed to demonstrate our experience with mini-incision-technique in thyroidectomy. Results: Over the 2-year period, 37 patients underwent bilateral MITS procedures. The procedure made with a small (2.5 cm) anterior incision made above the isthmus. The final diagnoses were benign multinodular goitre (37%), follicular adenoma (28%) incidental carcinoma (11%), Hashimoto’s thyroiditis (15%), Hurtle cell adenoma (5%), subacute thyroiditis (3%), residual thyroid-non carcinoma (2%), simple cyst (1%), diffuse hyperplasia (1%) and other (1%). Of the carcinomas, 80% were papillary thyroid cancer, 13% were follicular, and the remaining 7% were Hurtle cell carcinomas. We dont need to extend our incision in any cases. Two patients had temporary recurrent laryngeal nevre paresis and one patient had temporary hypocalcemia. Conclusions: It is not easy to demonstrate the advantages of MIT over conventional and video-assisted surgery. The main complications, such as nerve injury, hypoparathyroidism, or hemorrhage, are the same as in other surgical approaches. MIT has demonstrated advantages over conventional open approaches for both hemi- and total thyroidectomy and the benefits do not depend on the open or video-assisted approach. The anterior mini-incision approach can be performed with an operative time and postoperative complication profile equivalent to conventional thyroidectomy while providing excellent cosmesis with a 2 cm scar in both total thyroidectomy and lobectomies.
PMCID: PMC4238546  PMID: 25419375
Minimal invasive thyroid surgery; anterior mini insicion; thyriodectomy; thyroid disease
10.  Single-Incision Transaxillary Robotic Thyroidectomy: Challenges and Limitations in a North American Population 
Objective
We reviewed our initial experience with robotic thyroidectomy to identify challenges and limitations of this new surgical approach when applied to a North American population.
Study Design
Case series.
Setting
Academic institution.
Subjects/Methods
Retrospective review of 18 consecutive robotic thyroid lobectomies performed from February 2010 to April 2012 involving 16 female patients. Two patients underwent robot-assisted completion thyroidectomy a few months following the initial thyroid surgery, one for cancer and the other for goiter.
Results
Median age was 47.5 years (range, 18–62 years), and median body mass index was 28.7 (range, 19.4–44.5). Median thyroid nodule size was 2.9 cm (range, 1.1–4.7 cm). All but 1 case (6%) was performed successfully via single axillary incision. There was no conversion to an open approach. Median operative time was 170 minutes (range, 95–220 minutes), and median blood loss was 12.5 mL (range, 5–75 mL). Complications occurred in 4 cases (22%) to include temporary vocal cord pareses (n = 3) and a postoperative hematoma that required exploration. Median hospital stay was 2 days (range, 1–3 days).
Conclusion
Single-incision transaxillary robotic thyroidectomy can be technically challenging in North American patients with a larger body frame due to difficulty in optimal placement of all 4 robotic instruments via a single axillary incision. All 3 cases of temporary vocal cord paresis occurred early in our experience and may have been due to our relative inexperience with this new approach and associated instrumentation. Other limitations include less than optimal visualization of the recurrent laryngeal nerve in the contralateral lobe as well as poor access to the substernal region.
Level of Evidence
4
doi:10.1177/0194599812461610
PMCID: PMC3902132  PMID: 23008331
thyroid surgery; robotic thyroidectomy; transaxillary; thyroid
11.  Robotic-Assisted Minimally Invasive Surgery for Gynecologic and Urologic Oncology 
Executive Summary
Objective
An application was received to review the evidence on the ‘The Da Vinci Surgical System’ for the treatment of gynecologic malignancies (e.g. endometrial and cervical cancers). Limitations to the current standard of care include the lack of trained physicians on minimally invasive surgery and limited access to minimally invasive surgery for patients. The potential benefits of ‘The Da Vinci Surgical System’ include improved technical manipulation and physician uptake leading to increased surgeries, and treatment and management of these cancers.
The demand for robotic surgery for the treatment and management of prostate cancer has been increasing due to its alleged benefits of recovery of erectile function and urinary continence, two important factors of men’s health. The potential technical benefits of robotic surgery leading to improved patient functional outcomes are surgical precision and vision.
Clinical Need
Uterine and cervical cancers represent 5.4% (4,400 of 81,700) and 1.6% (1,300 of 81,700), respectively, of incident cases of cancer among female cancers in Canada. Uterine cancer, otherwise referred to as endometrial cancer is cancer of the lining of the uterus. The most common treatment option for endometrial cancer is removing the cancer through surgery. A surgical option is the removal of the uterus and cervix through a small incision in the abdomen using a laparoscope which is referred to as total laparoscopic hysterectomy. Risk factors that increase the risk of endometrial cancer include taking estrogen replacement therapy after menopause, being obese, early age at menarche, late age at menopause, being nulliparous, having had high-dose radiation to the pelvis, and use of tamoxifen.
Cervical cancer occurs at the lower narrow end of the uterus. There are more treatment options for cervical cancer compared to endometrial cancer, however total laparoscopic hysterectomy is also a treatment option. Risk factors that increase the risk for cervical cancer are multiple sexual partners, early sexual activity, infection with the human papillomavirus, and cigarette smoking, whereas barrier-type of contraception as a risk factor decreases the risk of cervical cancer.
Prostate cancer is ranked first in men in Canada in terms of the number of new cases among all male cancers (25,500 of 89,300 or 28.6%). The impact on men who develop prostate cancer is substantial given the potential for erectile dysfunction and urinary incontinence. Prostate cancer arises within the prostate gland, which resides in the male reproductive system and near the bladder. Radical retropubic prostatectomy is the gold standard treatment for localized prostate cancer. Prostate cancer affects men above 60 years of age. Other risk factors include a family history of prostate cancer, being of African descent, being obese, consuming a diet high in fat, physical inactivity, and working with cadium.
The Da Vinci Surgical System
The Da Vinci Surgical System is a robotic device. There are four main components to the system: 1) the surgeon’s console, where the surgeon sits and views a magnified three-dimensional image of the surgical field; 2) patient side-cart, which sits beside the patient and consists of three instrument arms and one endoscope arm; 3) detachable instruments (endowrist instruments and intuitive masters), which simulate fine motor human movements. The hand movements of the surgeon’s hands at the surgeon’s console are translated into smaller ones by the robotic device and are acted out by the attached instruments; 4) three-dimensional vision system: the camera unit or endoscope arm. The main advantages of use of the robotic device are: 1) the precision of the instrument and improved dexterity due to the use of “wristed” instruments; 2) three-dimensional imaging, with improved ability to locate blood vessels, nerves and tissues; 3) the surgeon’s console, which reduces fatigue accompanied with conventional laparoscopy surgery and allows for tremor-free manipulation. The main disadvantages of use of the robotic device are the costs including instrument costs ($2.6 million in US dollars), cost per use ($200 per use), the costs associated with training surgeons and operating room personnel, and the lack of tactile feedback, with the trade-off being increased visual feedback.
Research Questions
For endometrial and cervical cancers,
1. What is the effectiveness of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
2. What are the incremental costs of the Da Vinci Surgical System vs. laparoscopy and laparotomy for women undergoing any hysterectomy for the surgical treatment and management of their endometrial and cervical cancers?
For prostate cancer,
3. What is the effectiveness of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
4. What are the incremental costs of robotically-assisted radical prostatectomy using the Da Vinci Surgical System vs. laparoscopic radical prostatectomy and retropubic radical prostatectomy for the surgical treatment and management of prostate cancer?
Research Methods
Literature Search
Search Strategy
A literature search was performed on May 12, 2010 using OVID MEDLINE, MEDLINE In-Process and Other Non-Indexed Citations, OVID EMBASE, Wiley Cochrane, CINAHL, Centre for Reviews and Dissemination/International Agency for Health Technology Assessment for studies published from January 1, 2000 until May 12, 2010. Abstracts were reviewed by a single reviewer and, for those studies meeting the eligibility criteria, full-text articles were obtained. Reference lists were also examined for any additional relevant studies not identified through the search. Articles with unknown eligibility were reviewed with a second clinical epidemiologist, then a group of epidemiologists until consensus was established. The quality of evidence was assessed as high, moderate, low or very low according to GRADE methodology.
Inclusion Criteria
English language articles (January 1, 2000-May 12, 2010)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a primary data source (e.g. obtained in a clinical setting)
Journal articles that report on the effectiveness or cost-effectiveness for the comparisons of interest using a secondary data source (e.g. hospital- or population-based registries)
Study design and methods must be clearly described
Health technology assessments, systematic reviews, randomized controlled trials, non-randomized controlled trials and/or cohort studies, case-case studies, regardless of sample size, cost-effectiveness studies
Exclusion Criteria
Duplicate publications (with the more recent publication on the same study population included)
Non-English papers
Animal or in-vitro studies
Case reports or case series without a referent or comparison group
Studies on long-term survival which may be affected by treatment
Studies that do not examine the cancers (e.g. advanced disease) or outcomes of interest
Outcomes of Interest
For endometrial and cervical cancers,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Number of complications*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of conversions to laparotomy*
Number of lymph nodes recovered
For prostate cancer,
Primary outcomes:
Morbidity factors
- Length of hospitalization
- Amount of morphine use/pain*
Peri-operative factors
- Operation time
- Amount of blood loss*
- Number of transfusions*
- Duration of catheterization
- Number of complications*
- Number of anastomotic strictures*
Number of lymph nodes recovered
Oncologic factors
- Proportion of positive surgical margins
Long-term outcomes
- Urinary continence
- Erectile function
Summary of Findings
Robotic use for gynecologic oncology compared to:
Laparotomy: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations.
The beneficial effect of robotic surgery was shown in pooled analysis for complications, owing to increased sample size.
More work is needed to clarify the role of complications in terms of safety, including improved study designs, analysis and measurement.
Laparoscopy: benefits of robotic surgery in terms of shorter length of hospitalization, less blood loss and fewer conversions to laparotomy likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for length of hospitalizations and blood loss is low.
Fewer conversions to laparotomy indicate clinical effectiveness in terms of reduced morbidity.
Robotic use for urologic oncology, specifically prostate cancer, compared to:
Retropubic surgery: benefits of robotic surgery in terms of shorter length of hospitalization and less blood loss/fewer individuals requiring transfusions. These results indicate clinical effectiveness in terms of reduced morbidity and safety, respectively, in the context of study design limitations. There was a beneficial effect in terms of decreased positive surgical margins and erectile dysfunction. These results indicate clinical effectiveness in terms of improved cancer control and functional outcomes, respectively, in the context of study design limitations.
Surgeon skill had an impact on cancer control and functional outcomes.
The results for complications were inconsistent when measured as either total number of complications, pain management or anastomosis. There is some suggestion that robotic surgery is safe with respect to less post-operative pain management required compared to retropubic surgery, however improved study design and measurement of complications need to be further addressed.
Clinical significance of significant findings for length of hospitalizations is low.
Laparoscopy: benefits of robotic surgery in terms of less blood loss and fewer individuals requiring transfusions likely owing to the technical difficulty of conventional laparoscopy, in the context of study design limitations.
Clinical significance of significant findings for blood loss is low.
The potential link between less blood loss, improved visualization and improved functional outcomes is an important consideration for use of robotics.
All studies included were observational in nature and therefore the results must be interpreted cautiously.
Economic Analysis
The objective of this project was to assess the economic impact of robotic-assisted laparoscopy (RAL) for endometrial, cervical, and prostate cancers in the province of Ontario.
A budget impact analysis was undertaken to report direct costs associated with open surgery (OS), endoscopic laparoscopy (EL) and robotic-assisted laparoscopy (RAL) based on clinical literature review outcomes, to report a budget impact in the province based on volumes and costs from administrative data sets, and to project a future impact of RAL in Ontario. A cost-effectiveness analysis was not conducted because of the low quality evidence from the clinical literature review.
Hospital costs were obtained from the Ontario Case Costing Initiative (OCCI) for the appropriate Canadian Classification of Health Intervention (CCI) codes restricted to selective ICD-10 diagnostic codes after consultation with experts in the field. Physician fees were obtained from the Ontario Schedule of Benefits (OSB) after consultation with experts in the field. Fees were costed based on operation times reported in the clinical literature for the procedures being investigated. Volumes of procedures were obtained from the Ministry of Health and Long-Term Care (MOHLTC) administrative databases.
Direct costs associated with RAL, EL and OS included professional fees, hospital costs (including disposable instruments), radiotherapy costs associated with positive surgical margins in prostate cancer and conversion to OS in gynecological cancer. The total cost per case was higher for RAL than EL and OS for both gynecological and prostate cancers. There is also an acquisition cost associated with RAL. After conversation with the only supplier in Canada, hospitals are looking to spend an initial 3.6M to acquire the robotic surgical system
Previous volumes of OS and EL procedures were used to project volumes into Years 1-3 using a linear mathematical expression. Burden of OS and EL hysterectomies and prostatectomies was calculated by multiplying the number of cases for that year by the cost/case of the procedure.
The number of procedures is expected to increase in the next three years based on historical data. RAL is expected to capture this market by 65% after consultation with experts. If it’s assumed that RAL will capture the current market in Ontario by 65%, the net impact is expected to be by Year 3, 3.1M for hysterectomy and 6.7M for prostatectomy procedures respectively in the province.
RAL has diffused in the province with four surgical systems in place in Ontario, two in Toronto and two in London. RAL is a more expensive technology on a per case basis due to more expensive robot specific instrumentation and physician labour reflected by increased OR time reported in the clinical literature. There is also an upfront cost to acquire the machine and maintenance contract. RAL is expected to capture the market at 65% with project net impacts by Year 3 of 3.1M and 6.7M for hysterectomy and prostatectomy respectively.
PMCID: PMC3382308  PMID: 23074405
12.  Minimally invasive video-assisted thyroidectomy for the early-stage differential thyroid carcinoma 
Journal of Translational Medicine  2012;10(Suppl 1):S13.
Background
Minimally invasive video-assisted thyroidectomy (MIVAT), the modified Miccoli’s thyroid surgery, is the most widespread minimally invasive technique and has been widely used for treatment of thyroid disease. This study aimed to verify the potential benefits of the modified Miccoli’s thyroid surgery, determine the feasibility of the MIVAT for early-stage differential thyroid carcinoma and evaluate the likelihood of the surgical method as a standard operation for early malignant thyroid carcinoma.
Methods
A total of 135 patients were retrospectively compared which included two groups of patients: the first group underwent the conventional thyroidectomy; the other group underwent MIVAT. Patients with thyroid nodule smaller than 20 mm and without previous neck surgery were included while those with wide-ranging and distant metastases of cervical tissues, or any suspected thyroid nodal metastases were excluded for analysis. MIVAT and the central compartment (level VI) lymph nodes dissection (LND) were considered as a new treatment method for this retrospective study. In addition to the comparison of surgical outcomes between the new treatment and the conventional thyroid surgery, other surgical parameters including operative time, operative volume of hemorrhage, incisional length, postoperative volume of drainage, length of hospitalization, accidence of hoarse voice, accidence of bucking, accidence of hypocalcemia and peak angle of cervical axial rotation were also compared.
Results
Out of 135 patients, 111 patients underwent conventional thyroid surgery and 24 patients underwent MIVAT plus level VI LND for treatment of early-stage differential malignant carcinoma. Patients who received the new surgical treatment had significantly shorter incisional length (3.1 cm vs. 6.9 cm, p < 0.0001), shorter operative time (109 min vs. 139 min, p = 0.014) and fewer operative hemorrhage (29.5 ml vs. 69.7 ml, p < 0.0001) when compared to the conventional treatment. Postoperative peak angle of cervical axial rotation of patients treated with MIVAT was less than those treated with conventional surgery (L: 31.5° vs. 39.0°, p < 0.0001; R: 31.5° vs. 38.0°, p < 0.0001). Incisional wound infection, postoperative hoarse voice, bucking and hypocalcemia were not observed in all patients. Postoperative analgetica was not required as well.
Conclusions
Compared with conventional thyroid surgery for early-stage differential thyroid carcinoma, the new surgical treatment could be considered as an alternative surgical method for treatment of early-stage thyroid carcinoma since it was feasible, safe and clinically effective with better surgical and cosmetic outcomes.
doi:10.1186/1479-5876-10-S1-S13
PMCID: PMC3445859  PMID: 23046557
13.  Single-incision laparoscopic cholecystectomy versus traditional four-port cholecystectomy 
Laparoscopic cholecystectomy has traditionally been performed using multiple small sites. Single-incision laparoscopic surgery has emerged as an alternative technique to improve cosmesis and minimize complications associated with multiple incisions. A retrospective study was performed of all patients who underwent laparoscopic cholecystectomy by a single surgeon (DTA) from April 2008 to August 2011. Charts were reviewed for surgical indication, operative technique (multiple vs. single transumbilical incision), operative time, length of stay, and surgical complications. Sixty-three patients underwent laparoscopic cholecystectomy using a traditional approach of four skin incisions, while 62 patients underwent a single-incision transumbilical approach. Average age and sex were comparable between the two groups. Indications for surgery included cholelithiasis, cholecystitis, biliary dyskinesia, biliary pancreatitis, and porcelain gallbladder. Of those undergoing single-incision cholecystectomy, 85% (53/62) went home the same day, compared with 70% (44/63) of those undergoing four-incision cholecystectomy (P = 0.03). Among those not discharged on the same day of surgery, the average length of stay trended shorter in the single-incision group (2.8 days, range 1–6) compared with the four-incision group (3.3 days, range 1–12; P = NS). Operative time was slightly longer for those undergoing single-incision surgery (65 minutes, range 35–141) versus traditional four-incision surgery (51 minutes, range 41–109) (P < 0.001). With this single surgeon's single-incision transumbilical technique, costs were comparable between the two groups. One patient who underwent traditional four-incision cholecystectomy was readmitted for biliary pancreatitis and bacteremia on postoperative day 3. In the single-incision group, one patient was readmitted 1 month later with pancreatitis. In conclusion, single-incision transumbilical laparoscopic cholecystectomy can be an effective alternative to traditional four-incision cholecystectomy, with the added benefit of minimized scarring and a shorter length of stay. A longer operative time may be needed initially to adjust for a learning curve. This technique can be performed safely for patients with a multitude of gallbladder diseases without resulting in additional complications.
PMCID: PMC3448568  PMID: 23077377
14.  Total Hip Arthroplasty Using Two-Incision Technique 
Clinics in Orthopedic Surgery  2011;3(4):268-273.
Background
To evaluate the effectiveness of minimally invasive surgery total hip arthroplasty (THA) using the two-incision technique as described by Mears.
Methods
From January 2003 to December 2006, sixty-four patients underwent total hip arthroplasty using the one-incision (group I) and two-incision (group II) technique by one surgeon. There were 34 hips in group I and 30 hips in group II. There was no difference in age, gender, and causes of THA between the two groups. We evaluated the operation time, bleeding amount, incision length, ambulation, hospital stay, and complications between the two groups.
Results
There was no difference in the bleeding amount between the two groups. Operation time was longer in the two-incision group than in the one-incision group. Operation time of the two-incision technique could be reduced after 15 cases. Patients started ambulation after surgery earlier in group II than group I, and the hospital stay was shorter in group II than in group I. There was no difference in clinical results between the two groups. There was no difference in component position of the acetabular cup and femoral stem between the two groups. Intraoperative periprosthetic fracture occurred in four cases (13.3%) in group II.
Conclusions
Two-incision THA has the advantage of rapid recovery and shorter hospital stay. However, longer operation time and a high complication rate compared to one-incision are problems that need to be solved in the two-incision technique.
doi:10.4055/cios.2011.3.4.268
PMCID: PMC3232353  PMID: 22162788
Total hip arthroplasty; Minimal invasive surgery; Two-incision technique
15.  Transverse Skin Crease versus Vertical Midline Incision versus Laparoscopy for Right Hemicolectomy: A Systematic Review—Current Status of Right Hemicolectomy 
BioMed Research International  2014;2014:643685.
Purpose. The right hemicolectomy may be conducted through laparoscopic or laparotomic surgery, transverse or midline incisions. The transverse laparotomy offers some advantages compared to the midline laparotomy and laparoscopy. A literature review was performed to evaluate the possible advantages of the transverse incision versus midline incision or laparoscopic right hemicolectomy. Methods. A systematic research was performed in Medline, Embase, Cochrane Central Register of Controlled Trials, CINAHL, BioMed Central, and the Science Citation Index. Results. Laparotomic right hemicolectomy with transverse incision is preferable to laparotomic hemicolectomy with midline incision. A transverse incision offers a lessened postoperative pain following physical activity, a lessened need to administer analgesic therapy during the post-operative time, better aesthetic results, and a better post-operative pulmonary function. Open surgery with transverse or midline incision ensured a shorter operative time, lower costs and a greater length of the incision compared to the laparoscopic. However, there are no differences in the oncological outcomes. Conclusions. It was not possible to identify significant differences between the open right hemicolectomy with transverse incision versus the open right hemicolectomy with midline incision or laparoscopic hemicolectomy.
doi:10.1155/2014/643685
PMCID: PMC3925523  PMID: 24605333
16.  Long-term results of retroperitoneoscopic nephroureterectomy for upper urinary tract transitional cell carcinoma in China 
Objective:
We compared long-term clinical outcomes of upper urinary tract transitional cell carcinoma (TCC) patients treated by retroperitoneoscopic nephroureterectomy (RNU) or open radical nephroureterectomy (ONU).
Methods:
Upper urinary tract TCC patients were treated with RNU (n = 86) or ONU (n = 72) and followed-up for more than three years. Demographic and clinical data, including preoperative indexes, intraoperative indexes and long-term clinical outcomes, were retrospectively compared to determine long-term efficacy of the two procedures.
Results:
The RNU and ONU groups were statistically similar in age, gender, previous bladder cancer history, tumour location, pathologic tumour stage, pathologic node metastasis or tumour pathologic grade. The original surgery time required for both RNU and ONU was statistically similar, but RNU was associated with a significantly smaller volume of intraoperative estimated blood loss and shorter length of postoperative hospital stay. Follow-up (average: 42.4 months, range: 3–57) revealed that the RNU 3-year recurrence-free survival rate was 62.8% and the 3-year cancer specific survival rate was 80.7%. In the ONU group, the 3-year recurrence-free survival and the three-year cancer-specific survival rates were 59.2% and 80.3%, respectively. Neither of the survival rates were statistically different between the two groups. T stage, grade, lymph node metastasis and bladder tumour history were risk factors for tumour recurrence; the operation mode and the bladder cuff incision mode had no correlation with the recurrence-free survival.
Conclusion:
The open surgery strategy and the retroperitoneoscopic nephroureterectomy strategy are equally effective for treating upper urinary tract TCC. However, the RNU procedure is less invasive, and requires a shorter duration of postoperative hospitalized care; thus, RNU is recommended as the preferred strategy.
doi:10.5489/cuaj.11128
PMCID: PMC3668393  PMID: 22630340
17.  Robotic Surgery for Thyroid Disease 
European Thyroid Journal  2013;2(2):93-101.
Robotic surgery is an innovation in thyroid surgery that may compensate for the drawbacks of conventional endoscopic surgery. A surgical robot provides strong advantages, including three-dimensional imaging, motion scaling, tremor elimination, and additional degrees of freedom. We review here recent adaptations, experience and applications of robotics in thyroid surgery. Robotic thyroid surgeries include thyroid lobectomy, total thyroidectomy, central compartment neck dissection, and radical neck dissection for benign and malignant thyroid diseases. Most of the current literature consists of case series of robotic thyroidectomies. Recent retrospective and prospective analyses have evaluated the safety and oncologic efficacy of robotic surgery for thyroid cancer. Although robotic thyroid surgery is often associated with longer operation times than conventional open surgery, robotic techniques have shown similar or superior levels of surgical completeness and safety compared with conventional open or endoscopic surgery. Compared to open thyroidectomy, robotic thyroidectomy has been associated with several quality-of-life benefits, including excellent cosmetic results, reduced neck pain and sensory changes, and decreased voice and swallowing discomfort after surgery. For surgeons, robotic surgery has improved ergonomics and has a shorter learning curve than open or endoscopic surgery. The advantages of robotic thyroid surgery over conventional surgery suggest that robotic thyroidectomy with or without neck dissection may become the preferred surgical option for thyroid diseases. Robotic thyroid surgery will likely continue to develop as more endocrine and head-and-neck surgeons are trained and more patients seek this newly developed surgical option.
doi:10.1159/000350209
PMCID: PMC3821507  PMID: 24783046
Robot; Thyroid; Thyroidectomy; Robotic thyroidectomy; Neck dissection; Robotic neck dissection

18.  The impact of minimally invasive total hip arthroplasty on the standard procedure 
International Orthopaedics  2006;30(3):167-171.
Minimally invasive total hip arthroplasty using a short skin incision is a subject of much debate in the literature. The present study estimates the possible minimal length of the exposure in an unselected patient cohort and compares the lateral mini-incision technique and traditional total hip arthroplasty (THA). One hundred and two patients were divided into three groups according to the type of surgery and length of incision: mini-incision (less than 10 cm) was performed in 38 patients; midi-incision (10–14 cm) in 43; and standard-incision (longer than 14 cm) in 21 patients. No statistical difference was found with regard to intraoperative and total blood loss, the rate of complications, and postoperative recovery. Significantly decreased body mass index (BMI), shorter operative time, and higher number of hips with malpositioning of the acetabular cup were found in the mini-incision group. These patients, however, experienced less pain in the early postoperative period and were highly satisfied with the cosmetic results. The length of incision was shortened and optimized (less than 14 cm) in 82% of patients, and mini-incision was performed in 38 patients of this unselected cohort. Because of the understandable demand of the patients for less invasive intervention, the surgeon should use a smaller but not necessarily mini-incision with minimal soft tissue trauma that still allows him to perform the procedure well, without compromising the type of implants and the otherwise excellent long-term results. Randomized prospective studies are needed to explore the real value of the minimally invasive total hip arthroplasty.
doi:10.1007/s00264-005-0049-8
PMCID: PMC2532092  PMID: 16552579
19.  Minimally Invasive Video-Assisted Thyroidectomy 2.0: Expanded Indications in a Tertiary Care Cancer Center 
Head & neck  2010;33(11):1557-1560.
Background
Minimally invasive video-assisted thyroidectomy (MIVAT) advantages include a smaller incision, less extensive surgical dissection, improved visualization secondary to rigid fiberoptics, and decreased postoperative pain. The aims of our study were to report our experience using expanded indications of MIVAT.
Methods
A retrospective chart review of a single surgeon's initial experience was carried out at a tertiary academic cancer center.
Results
In all, 53 patients were identified, of whom 40 underwent total thyroidectomy and 13 underwent hemithyroidectomy. Thyroid volume, nodule size, incision length, and surgical time were all examined. Most common pathology was well-differentiated papillary thyroid cancer (69.8%): 42% of patients had evidence of thyroiditis found on pathology; 17% of patients had temporary vocal cord paralysis, with only 1 case of vocal cord paralysis persisting >6 months (1.9%). Six patients (11%) experienced temporary hypocalcemia, requiring postoperative calcium supplementation; no patients experienced permanent hypocalcemia.
Conclusions
The use of MIVAT with expanded indications shows complication rates comparable to those of traditional open thyroidectomy.
doi:10.1002/hed.21633
PMCID: PMC3772771  PMID: 21990219
thyroid; minimally invasive; thyroidectomy; thyroid neoplasm; video-assisted surgery
20.  Gas-less Video-assisted Thyroidectomy for a Solitary Thyroid Nodule: Technical Report of the First Case Performed at a Rural Teaching Hospital in India and Review of Literature 
Minimally invasive thyroidectomy is still in its phase of evolution with various techniques being practiced only in certain centers internationally. The conventional thyroidectomy performed by the Kocher's cervicotomy often leaves an undesirable scar over the neck, the size of which is usually around 8–10 cm long. The main aim of minimally invasive thyroid surgery is to minimize or avoid the scar over the neck. Endoscopic thyroid surgery in India, especially in the state of Kerala, is still in its infancy. Here, we describe the first case report of a modified technique of video-assisted thyroid surgery using a laparoscope and conventional open surgical instruments. Video-assisted thyroidectomy enables adequate visualization of the operative field and provides a magnified view of the vital structures like the parathyroid gland, the recurrent laryngeal nerve, and the thyroid vasculature. The procedure described here can be considered as a more cost-effective alternative to the conventional minimally invasive video-assisted thyroidectomy (MIVAT), and therefore is feasible in a rural setup.
doi:10.4103/2006-8808.100350
PMCID: PMC3461774  PMID: 23066460
Endoscopic thyroidectomy; minimally invasive thyroidectomy; thyroid surgery; video-assisted thyroidectomy
21.  Clinical and biomechanical outcome of minimal invasive and open repair of the Achilles tendon 
Introduction
With evolutions in surgical techniques, minimally invasive surgical (MIS) repair with Achillon applicator has been introduced. However, there is still a lack of literature to investigate into the clinical merits of MIS over open surgery. This study aims to investigate the correlation between clinical outcome, gait analysis and biomechanical properties comparing both surgical methods.
Materials and methods
A single centre retrospective review on all the consecutive operated patients between January 2004 and December 2008 was performed. Twenty-six patients (19 male and 7 female; age 40.4 ± 9.2 years) had experienced a complete Achilles tendon rupture with operative repair. Nineteen of the patients, 10 MIS versus 9 open repairs (13 men with a mean age of 40.54 ± 10.43 (range 23-62 yrs) and 6 women with a mean age of 45.33 ± 7.71 (range 35-57 yrs) were further invited to attend a thorough clinical assessment using Holz's scale and biomechanical evaluation at a mean of 25.3 months after operation. This study utilized the Cybex II isokinetic dynamometer to assess the isokinetic peak force of plantar-flexion and dorsiflexion of both ankles. The patients were also invited to return to our Gait Laboratory for analysis. The eight-infrared camera motion capture system (VICON, UK) was utilized for the acquisition of kinematic variables. Their anthropometric data was measured according to the Davis and coworkers' standard.
Results
The mean operative time and length of hospital stay were shorter in the MIS group. The operative time was 54.55 ± 15.15 minutes versus 68.80 ± 18.23 minutes of the MIS group and Open group respectively (p = 0.045), whereas length of stay was 3.36 ± 1.21 days versus 6.40 ± 3.70 days respectively (p = 0.039). There is statistically significant decrease (p = 0.005) in incision length in MIS group than the open surgery group, 3.23 ± 1.10 cm versus 9.64 ± 2.55 cm respectively. Both groups attained similar Holz's scores, 11.70 ± 0.95 versus 12.0 ± 1.50 respectively (p = 0.262). The mean percentage stance time of the injured leg for MIS patient was 58.44% while the mean percentage stance time of the injured leg for patients with open repair was 56.57%. T-test has shown there were no significance differences between the results of the two groups of patients. The loss of peak torque and total work done with respect to the injured side were similar between the MIS and open group.
Discussion and conclusion
MIS using Achillon method can achieve smaller incisions, shorter operative time and hospital stay. There is no statistical significance difference in clinical outcome, the stance time to strike time ratio and biomechanical properties on the leg receiving Achilles tendon repair using MIS method and open surgery.
doi:10.1186/1758-2555-3-32
PMCID: PMC3259046  PMID: 22185429
22.  Surgical techniques for sciatica due to herniated disc, a systematic review 
European Spine Journal  2012;21(11):2232-2251.
Introduction
Disc herniation with sciatica accounts for five percent of low-back disorders but is one of the most common reasons for spine surgery. The goal of this study was to update the Cochrane review on the effect of surgical techniques for sciatica due to disc herniation, which was last updated in 2007.
Materials and methods
In April 2011, we conducted a comprehensive search in CENTRAL, MEDLINE, EMBASE, CINAHL, PEDRO, ICL, and trial registries. We also checked the reference lists and citation tracking results of each retrieved article. Only randomized controlled trials (RCT) of the surgical management of sciatica due to disc herniation were included. Comparisons including chemonucleolysis and prevention of scar tissue or comparisons against conservative treatment were excluded. Two review authors independently selected studies, assessed risk of bias of the studies and extracted data. Quality of evidence was graded according to the GRADE approach.
Results
Seven studies from the original Cochrane review were included and nine additional studies were found. In total, 16 studies were included, of which four had a low risk of bias. Studies showed that microscopic discectomy results in a significantly, but not clinically relevant longer operation time of 12 min (95 % CI 2–22) and shorter incision of 24 mm (95 % CI 7–40) compared with open discectomy, but did not find any clinically relevant superiority of either technique on clinical results. There were conflicting results regarding the comparison of tubular discectomy versus microscopic discectomy for back pain and surgical duration.
Conclusions
Due to the limited amount and quality of evidence, no firm conclusions on effectiveness of the current surgical techniques being open discectomy, microscopic discectomy, and tubular discectomy compared with each other can be drawn. Those differences in leg or back pain scores, operation time, and incision length that were found are clinically insignificant. Large, high-quality studies are needed, which examine not only effectiveness but cost-effectiveness as well.
doi:10.1007/s00586-012-2422-9
PMCID: PMC3481105  PMID: 22814567
Herniated disc; Sciatica; Surgery; Discectomy; Systematic review
23.  A modified two-incision technique for primary total hip arthroplasty 
Indian Journal of Orthopaedics  2008;42(3):267-274.
Background:
Minimally invasive surgery can be technically demanding but minimizes surgical trauma, pain and recovery. Two-incision minimally invasive surgery allows only intermittent visualization and may require fluoroscopy for implant positioning. We describe a modified technique for primary total hip arthroplasty, using two small incisions with a stepwise approach and adequate visualization to reliably and reproducibly perform the surgery without fluoroscopy.
Materials and Methods:
One hundred and two patients with an average age of 60 years underwent modified two-incision minimally invasive technique for primary THA without fluoroscopy. The M/L taper femoral stem (Zimmer, Warsaw, IN) and Trilogy (Zimmer) hemispherical titanium shell, with a highly cross-linked polyethylene liner, was used. Operative time, blood loss, postoperative hospital stay, radiographic outcomes and complications were recorded.
Results:
The mean operating time was 77 min. The mean blood loss was 335 cc. The mean hospital stay was 2.4 days. Mean cup abduction angle was 43.8°. Mean leg length discrepancy was 1.7 mm. Thirteen patients had lateral thigh numbness and two patients had wound complications that resolved without any treatment.
Conclusion:
A modified two-incision technique without fluoroscopy for primary total hip arthroplasty has the advantage of preserving muscles and tendons, shorter recovery and return to function with minimal complications. Provided that the surgeon has received appropriate training, primary total hip arthroplasty can be performed safely with the modified two-incision technique.
doi:10.4103/0019-5413.41850
PMCID: PMC2739461  PMID: 19753151
Minimally invasive surgery; total hip arthroplasty; two-incision surgery for THA
24.  Minimally Invasive Video-Assisted versus Minimally Invasive Nonendoscopic Thyroidectomy 
BioMed Research International  2014;2014:450170.
Minimally invasive video-assisted thyroidectomy (MIVAT) and minimally invasive nonendoscopic thyroidectomy (MINET) represent well accepted and reproducible techniques developed with the main goal to improve cosmetic outcome, accelerate healing, and increase patient's comfort following thyroid surgery. Between 2007 and 2011, a prospective nonrandomized study of patients undergoing minimally invasive thyroid surgery was performed to compare advantages and disadvantages of the two different techniques. There were no significant differences in the length of incision to perform surgical procedures. Mean duration of hemithyroidectomy was comparable in both groups, but it was more time consuming to perform total thyroidectomy by MIVAT. There were more patients undergoing MIVAT procedures without active drainage in the postoperative course and we also could see a trend for less pain in the same group. This was paralleled by statistically significant decreased administration of both opiates and nonopiate analgesics. We encountered two cases of recurrent laryngeal nerve palsies in the MIVAT group only. MIVAT and MINET represent safe and feasible alternative to conventional thyroid surgery in selected cases and this prospective study has shown minimal differences between these two techniques.
doi:10.1155/2014/450170
PMCID: PMC3996987  PMID: 24800227
25.  Total thyroidectomy with ultrasonic dissector for cancer: multicentric experience 
Background
We conducted an observational multicentric clinical study on a cohort of patients undergoing thyroidectomy for thyroid carcinoma. The aim of this study was to evaluate the benefits of the use of ultrasonic dissector (UAS) vs. the use of a conventional technique (vessel clamp and tie) in patients undergoing thyroid surgery for cancer.
Methods
From June 2009 to May 2010 we evaluated 321 consecutive patients electively admitted to undergo total thyroidectomy for thyroid carcinoma. The first 201 patients (89 males, 112 females) presenting to our Department underwent thyroidectomy with the use of UAS while the following 120 patients (54 males, 66 females) underwent thyroidectomy performed with a conventional technique (CT): vessel clamp and tie.
Results
The operative time (mean: 75 min in UAS vs. 113 min in CT, range: 54 to 120 min in UAS vs. 68 to 173 min in CT) was much shorter in the group of thyroidectomies performed with UAS. The incidence of transient laryngeal nerve palsy (UAS 3/201 patients (1.49%); CT 1/120 patients (0.83%)) was higher in the group of UAS; the incidence of permanent laryngeal nerve palsy was similar in the two groups (UAS 2/201 patients (0.99%) vs. CT 2/120 patients (1.66%)). The incidence of transient hypocalcaemia (UAS 17/201 patients (8.4%) vs. CT 9/120 patients (7.5%)) was higher in the UAS group; no relevant differences were reported in the incidence of permanent hypocalcaemia in the two groups (UAS 5/201 patients (2.48%) vs. 2/120 patients (1.66%)). Also the average postoperative length of stay was similar in two groups (2 days).
Conclusion
The only significant advantage proved by this study is represented by the cost-effectiveness (reduction of the usage of operating room) for patients treated with UAS, secondary to the significant reduction of the operative time. The analysis failed to show any advantages in terms of postoperative transient complications in the group of patients treated with ultrasonic dissector: transient laryngeal nerve palsy (1.49% in UAS vs. 0.83% in CT) and transient hypocalcaemia (8.4% in UAS vs. 7.5%in CT). No significant differences in the incidence of permanent laryngeal nerve palsy (0.8% in UAS vs. 1.04% in CT) and permanent hypocalcaemia (2.6% in UAS vs. 2.04% in CT) were demonstrated. The level of surgeons’ expertise is a central factor, which can influence the complications rate; the use of UAS can only help surgical action but cannot replace the experience of the operator.
doi:10.1186/1477-7819-10-70
PMCID: PMC3412706  PMID: 22540914
Thyroidectomy; Ultrasonic dissector; Harmonic scalpel; Hypocalcaemia; Laryngeal nerve palsy; Thyroid cancer

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