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1.  Use of a radiopaque localizer grid to reduce radiation exposure 
Minimally invasive spine surgery requires placement of the skin incision at an ideal location in the patient's back by the surgeon. However, numerous fluoroscopic x-ray images are sometimes required to find the site of entry, thereby exposing patients and Operating Room personnel to additional radiation. To minimize this exposure, a radiopaque localizer grid was devised to increase planning efficiency and reduce radiation exposure.
The radiopaque localizer grid was utilized to plan the point of entry for minimally invasive spine surgery. Use of the grid allowed the surgeon to accurately pinpoint the ideal entry point for the procedure with just one or two fluoroscopic X-ray images.
The reusable localizer grid is a simple and practical device that may be utilized to more efficiently plan an entry site on the skin, thus reducing radiation exposure. This device or a modified version may be utilized for any procedure involving the spine.
PMCID: PMC3177900  PMID: 21827694
Radiation; Exposure; Minimally Invasive; Spine Surgery; Localization; Innovation; Grid
2.  The Efficacy of Carotid Tubercle as an Anatomical Landmark for Identification of Cervical Spinal Level in the Anterior Cervical Surgery: Comparison with Preoperative C-arm Fluoroscopy 
Clinics in Orthopedic Surgery  2013;5(2):129-133.
In cervical anterior approach, transverse skin incision is preferred due to cosmetic reasons. Precise skin incision is required to reach the surgery segment while minimizing soft tissue injury. Skin incision site is frequently identified using C-arm fluoroscopy or the carotid tubercle. Accordingly, this study was conducted to investigate the efficacy of skin incision using the carotid tubercle as a marker.
This study was retrospectively conducted on 114 patients who underwent anterior cervical surgery by the same surgeon from April 2004 to June 2012. The rate of the appropriate insertion of K-wire, which was inserted into the disc after anterior approach, into the surgery segment was compared between 62 patients where skin incision site was identified using C-arm fluoroscopy before skin incision and 52 patients where skin incision site was identified using carotid tubercle palpitation before surgery.
The needle was shown to have been inserted into the planned site in 106 patients out of the total 114 patients. The appropriate insertion of the needle was shown in 59 patients of group I (95.2%) and in 47 patients of group II (90.4%). Although the success rate was higher in group I than group II, it was statistically insignificant. The success rate of one-segment surgery was shown to be 89.7% in group I and 82.6% in group II. Although the success rate was higher in group I than group II, it was statistically insignificant. The success rate of two-segment surgery was shown to be 100% in group I, and 96.4% in group II due to one case of the failure at C3-4 and C5-6. The success rate of three- and four-segment surgeries was shown to be 100% in both groups.
The identification of skin incision site via carotid tubercle palpation was useful for surgeries involving two or more segments. Furthermore, it could be useful for one-segment surgery if surgical site is identified using vertebral body or soft tissues such as longus collis rather than insertion into the disc.
PMCID: PMC3664672  PMID: 23730477
Anterior cervical surgery; Carotid tubercle; Anatomical landmark; Skin incision
3.  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
4.  Sils without Frills 
The Indian Journal of Surgery  2012;74(3):270-273.
Historically, invasive, large incisions were necessary to perform “open” abdominal surgical procedures. While effective, this method increased the possibility of multiple complications, including post-operative pain, wound infection, incisional hernia and prolonged hospitalization. Concerns over the rate of complications and morbidities led surgeons to develop laparoscopic surgical techniques, in which operations in the abdomen are performed through small incisions as opposed to larger, open incisions across the surgical site. There was a continuous effort to minimize the number of ports, and finally single incision laparoscopic surgery (SILS) came into practice. Sils without frills is a concept where multiple ports are made in a curved 2.5 cm incision in a triangle. The chopstick method is used to minimize instrument and telescope clash during the procedure. Standard laparoscopic instruments are introduced along with a 30 ° telescope. Instrument clashes are avoided by chop stick technique of crossing them at a proximal point so that ends are away from each other. Dissection takes place in forward backward movement after making lateral retraction by the other instrument. With experience the operative time is expected to become comparable with conventional laparoscopic cholecystectomy. But benefits regarding post operative pain in SILS has not been confirmed. It is felt that expertise and reduction of operative time may reduce post operative pain. No special telescopes, ports or hand instruments are needed for this procedure but may have a role in advanced laparoscopic procedures.
PMCID: PMC3397183  PMID: 23730055
Sils; Spa; Single; Incision; Laparoscopy
5.  Small right vertical infra-axillary incision for minimally invasive port-access cardiac surgery: a moving window method 
Port-access cardiac surgery has been developed to minimize skin incision and improve cosmetic outcomes. Using this method, a skin incision is generally made just above where the thoracotomy will be placed, horizontally along the intercostal space at the anterolateral submammary position. However, this type of incision can affect the frontal view and shape of the breast. Here, we report our experience with minimally invasive cardiac surgery using a port-access approach via a small vertical right infra-axillary incision and a moving window method. Twenty patients underwent surgical procedures with this approach from December 2010 to January 2012. Thirteen patients underwent mitral valvuloplasty, four mitral valve replacement, one mitral and tricuspid valve replacement and atrial septal defect closure and two atrial septal defect closure. All surgical procedures were completed using this minimally invasive method. All patients had an uneventful recovery and indicated that they were satisfied with the cosmetic results during the follow-up. Our experience suggests that this technique can effectively minimize skin incision and improve cosmetic outcomes.
PMCID: PMC3598043  PMID: 23293265
Minimally invasive cardiac surgery; Vertical infra-axillary incision; Port-access cardiac surgery
6.  Minimally Invasive Total Hip Arthroplasty Using a Transpiriformis Approach: A Preliminary Report 
Continuing efforts have been made to develop minimally invasive surgery techniques for THA. One of the most commonly performed of these techniques is the mini-posterior approach. All reported series using this approach describe surgical detachment of the short external rotators of the hip. In 2008, Penenberg et al. described an innovative surgical technique that preserves the short external rotators. We present the results of a single-incision modification of this technique in 135 patients.
Description of Technique
This technique is based on preservation of all of the short external rotators of the hip with the exception of the piriformis or conjoined tendon. This single-incision technique required the development of specialized instrumentation for exposure and reaming of the acetabulum. The specialized retractors also successfully minimized trauma to the skin and subcutaneous tissue.
For the 135 patients undergoing THA with this technique, we analyzed demographic and operative data. We recorded complications, evaluated postoperative clinical function using the Harris hip score, and assessed cup abduction angle, cup anteversion, and stem alignment on radiographs. Minimum followup was 14 months (mean, 22 months; range, 14–33 months).
There were no dislocations, no sciatic nerve palsies, no wound complications, and low transfusion rates (8%). The postoperative Harris hip score averaged 96.5 (range, 87–100). Overall acetabular cup abduction angle averaged 41° (range, 21°–49°) and anteversion averaged 21° (range, 15°–27°). Four percent and 2% of femoral components were inserted into more than 2° varus and 2° valgus alignment, respectively.
This technique shows promise as an alternative tissue-sparing method for minimally invasive THA.
Level of Evidence
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Electronic supplementary material
The online version of this article (doi:10.1007/s11999-011-2225-z) contains supplementary material, which is available to authorized users.
PMCID: PMC3392401  PMID: 22215476
7.  The ALIF concept 
European Spine Journal  2000;9(Suppl 1):S035-S043.
The terms ‘minimally invasive’ or ‘less invasive surgery’ have been used recently to describe surgical approaches or operations that are performed with less trauma to anatomical structures on the way to or surrounding the surgical ‘target area’. These types of surgical procedures are usually performed with the help of ‘high-tech’ instruments such as surgical endoscopes or surgical microscopes, modern video techniques and automated instruments. Within the last 10 years, such techniques have been developed in the field of spinal surgery. The application of minimally or less invasive procedures has concentrated predominantly on anterior approaches to the thoracic and lumbar spine. This article describes two anterior approach techniques for performing anterior lumbar interbody fusion (ALIF) through a minimally invasive retroperitoneal or transperitoneal approach. The technical principles are microsurgical modifications of traditional anterior approaches to the lumbar spine. Through small (4-cm) skin incisions, the target area can be exposed. Preliminary results suggest decreased peri - and postoperative morbidity, less blood loss, earlier rehabilitation and acceptable complication rates. The technique is currently used by the author for all patients requiring anterior lumbar interbody fusion.
PMCID: PMC3611443
Key words Microsurgery; Lumbar spine; Mini ALIF; Anterior lumbar interbody fusion
8.  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.
PMCID: PMC3421002  PMID: 22930635
Minimally invasive surgery; thyroidectomy; parathyroidectomy
9.  Video-Assisted Parathyroidectomy by a Skin-Lifting Method for Primary Hyperparathyroidism 
The use of endoscopic surgical procedures has rapidly spread to abdominal and thoracic surgeries and subsequently to surgeries of the neck region. Several surgeons initiated endoscopic parathyroidectomy using CO2 insufflation to create the working space; however, they reported various complications. We describe here a skin-lifting method that may have few complications.
A 65-year-old man was diagnosed with primary hyperparathyroidism due to a solitary adenoma of the left inferior parathyroid gland. A 3-cm oblique incision was made below the left clavicle, and a 5-mm incision was made on the lateral neck. After the skin was lifted up, we performed video-assisted parathyroidectomy.
Parathyroid extirpation took 2 hours and blood loss was minimal. The patient had minimal pain and no complications postoperatively. Serum concentrations of calcium and intact parathyroid hormone were normalized on the next day.
Using the skin-lifting method, we obtained a sufficient operative view and encountered no complications. This procedure is cosmetically desirable, and we consider it a feasible alternative for the treatment of parathyroid adenoma.
PMCID: PMC3015429  PMID: 11394437
Endoscopic surgery; Parathyroidectomy; Skin-lifting device
10.  Gasless Single Incision Endoscopic Thyroidectomy 
A chest wall approach combined with a gasless technique appears to make single-incision endoscopic thyroidectomy feasible and practicable.
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.
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.
Advantages of the chest wall approach combined with the gasless technique have made single-incision endoscopic thyroidectomy more feasible and practicable.
PMCID: PMC3407459  PMID: 22906332
Endoscopic surgery; Thyroidectomy; Gasless; Single-incision surgery
11.  Preemptive analgesia with intra-articular pethidine reduces pain after arthroscopic knee surgery 
Postoperative pain relief is important in procedures of the lower extremity. Several previous studies have evaluated the efficacy of intra-articular (IA) pethidine as a compound, which has local anesthetic and opioid agonist properties, on postoperative pain relief in arthroscopic knee surgery (AKS). This study compared the postoperative analgesic effect of pre- and post-surgical IA pethidine administration in AKS.
Materials and Methods:
Seventy-five patients of American Society of Anesthesiologists (ASA) I and II undergoing AKS with general anesthesia were enrolled in this double-blind study. Patients were randomized in three equal groups to receive either 50 mg IA pethidine before surgical incision incision and saline after skin closure (PS), saline before surgical incision and pethedine after skin closure (SP), and only saline at two different times (SS). In each patient with operated knee joint, pain at rest and joint movement was evaluated at 1, 2, 6, 12, and 24 h after surgery completion using Visual Analog Scale (VAS). Data were analyzed using analysis of variance (ANOVA)-repeated measure, t-paired, and Chi-square tests.
Postoperative pain score at rest and joint movement in PS group was significantly lower than those in other groups. The time (Mean ± SD) between completion of operation and patient's request for morphine, total morphine consumption (Mean ± SD) in postoperative 24 h, and the numbers of patients requesting analgesic in PS, SP, SS, groups were: 5.2 ± 1.3, 3.3 ± 1.5, and 2 ± 1.3 h (P < 0.05); 4.4 ± 2.4, 8.7 ± 2, and 11.6 ± 4.4 mg (P < 0.05); 11, 18, and 21 persons (P < 0.05), respectively.
The present study shows that preemptive intra-articular pethidine 50 mg injection is more effective than preventive injection for postoperative pain relief at rest and joint movement in arthroscopic knee surgery.
PMCID: PMC3732886  PMID: 23930254
Arthroscopy; intra-articular; knee; pain after surgery; pethidine
12.  Comparison of operating field sterility in open versus minimally invasive microdiscectomies of the lumbar spine 
Surgical Neurology International  2013;4(Suppl 5):S295-S298.
Postoperative wound infection is a preventable risk that can lead to significant adverse outcomes and increased cost of care. Minimally invasive surgeries (MIS) have been found to have lower rates of postoperative infection compared with the traditional approach. To assess if the reported difference is related to intraoperative contamination or to other factors, we assessed the surgical field for sterility.
We compared 10 MIS versus 10 traditional microdiscectomies. Swabs of the operating field were obtained before and after the procedure from multiple sites in the operating room. Positive and negative controls were taken of the skin immediately before and after preparation of the incision site. All swabs were plated out on Columbia blood agar plates and grown for 48 hours. Colony counting was performed to determine growth.
There was no statistically significant difference in the colony counts of swab sites in traditional microdiscectomies compared with MIS microdiscectomies. There was no significant contamination of the operating field using either approach.
In this prospective study, we found that there was no significant difference in bacterial counts in swabs of operative sites in either traditional or MIS microdiscectomies, suggesting that the decreased rate of postoperative infection in the reported literature for MIS cases may be related to other factors, such as patient selection and/or postoperative care.
PMCID: PMC3716002  PMID: 23878763
Infection; lumbar surgery; microdiscectomy; sterility
13.  Ultrasonography Accurately Evaluates the Dimension and Shape of the Pilonidal Sinus 
Clinics (Sao Paulo, Brazil)  2009;64(3):189-192.
To study the benefits of ultrasonography for detecting the borders of pilonidal sinus tissue. The correlation between physical and ultrasonographic examination was used for surgical planning.
Between April and December 2004, 73 patients were recruited for this study. All patients were examined, and the borders of the sinus tissue were marked on the skin according to palpation before surgery. The surgeon also made a treatment plan considering the diseased tissue and marked a possible incision line. Patients were subsequently examined with ultrasonography. According to the ultrasonographic evaluation, the margins, extensions, and openings of pilonidal sinus tissue were determined and marked on the patient in a different color by a radiologist prior to surgery. The most suitable surgical treatment was decided according to the information obtained by ultrasonography.
The average age was 23.03 ± 3.05 (range 18–39) years. We found 81 lesions in 73 patients. Ultrasonographic borders of sinus tissue were similar to the borders marked by the surgeon in 56 patients (76.7%). In the remaining 17 patients (23.3%), ultrasonography detected branches or borders that distinctly exceeded the planned incision line. After ultrasonographic examination, the surgeon changed his incision line in 14 patients and the surgical intervention in 3 patients.
Palpation and methylene blue injection do not provide appropriate information in many patients. Our study revealed that pre-operative ultrasonography can improve the identification of the sinus tract and its branches when compared to palpation and methylene blue injection.
PMCID: PMC2666454  PMID: 19330243
Pilonidal sinus; Ultrasonography; Surgical plan; Complication
14.  Comparison of analgesic efficacy of transversus abdominis plane block with direct infiltration of local anesthetic into surgical incision in lower abdominal gynecological surgeries 
Transversus abdominis plane block is a safe, simple and effective technique of providing analgesia for lower abdominal surgeries with easily identifiable landmarks.
To compare the analgesic efficacy of transversus abdominis plane block with that of direct infiltration of local anesthetic into surgical incision in lower abdominal procedures.
Settings and Design:
Prospective randomized controlled trial in lower abdominal surgeries done under general anesthesia.
Materials and Methods:
52 ASA I-II patients undergoing lower abdominal gynecological procedures under general anesthesia were divided randomly into two groups each after written informed consent. A bilateral TAP block was performed on Group T with 0.25% bupivacaine 0.6 ml/kg with half the volume on either side intra-operatively after skin closure before extubation using a short bevelled needle, whereas Group I received local infiltration intra-operatively after skin closure with the same amount of drug. The time taken for the first rescue analgesic and visual analog score (VAS) was noted, following which, the patient was administered intravenous morphine 0.1 mg/kg and connected to an intravenous patient controlled analgesia system with morphine for 24 hrs from the time of block administration. 24 h morphine requirement was noted. VAS and sedation scores were noted at 2, 4, 6 and 24 h postoperatively.
Statistical Analysis Used:
The results were analyzed with SPSS 16. A P value < 0.05 was considered significant. Duration of analgesia and 24 h morphine requirement was analysed by Student's t-test. VAS scores, with paired comparisons at each time interval, were performed using the t-test or Mann-Whitney U-test, as appropriate. Categorical data were analyzed using Chi square or Fisher's exact test.
In Group T, the time to rescue analgesic was significantly more and the VAS scores were lower (P = 0.001 and 0.003 respectively). The 24 hr morphine requirement and VAS at 2, 4, 6 and 24 h were less in the Group T (P = 0.001). Incidence of PONV was significant in Group I (P = 0.043), whereas Group T were less sedated at 2 and 4 h (P = 0.001 and 0.014).
Transversus abdominis plane block proved to be an effective means of analgesia for lower abdominal surgeries with minimal side-effects.
PMCID: PMC3590547  PMID: 23493578
Transversus abdominis plane block; lower abdominal surgeries; local infiltration
15.  Making your mark again in surgery. 
Accurate, durable pre-operative skin marking that withstands the necessary vigorous surgical skin preparation on the theatre table minimises confusion and the risk of mistakes occurring perioperatively, as well as assisting the surgeon with the technicalities of required skin incisions. Felt-tipped marker pens vary widely in achieving these objectives. A selection of markers, including a number used by junior surgical staff on the wards, was investigated.
PMCID: PMC2503769  PMID: 11995755
16.  Left Transperitoneal Adrenalectomy with a Laparoendoscopic Single-Site Surgery Combined Technique: Initial Case Reports 
Case Reports in Medicine  2011;2011:651380.
Laparoendoscopic single-site surgery (LESS) is a step toward the development of minimally invasive surgery. It is initially difficult for surgeons with limited experience to perform the surgery. We describe two cases of left adrenalectomy with a LESS combined with the addition of an accessory port. After a 2.5-cm skin incision was made at the level of the paraumbilicus to insert the primary 12-mm trocar for the laparoscope, a 5-mm nonbladed trocar was placed through the skin incision side-by-side with the primary trocar. A second 3-mm nonbladed trocar was then placed along the anterior axillary line; a multichannel trocar was not used as a single port. Both adrenalectomies were completed successfully. In patients with a minor adrenal tumor, a combined technique using LESS and an additional port is easier than LESS alone and may, therefore, be a bridge between the conventional laparoscopic approach and LESS.
PMCID: PMC3085471  PMID: 21541182
17.  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.
PMCID: PMC2532092  PMID: 16552579
18.  First experience with a new negative pressure incision management system on surgical incisions after cardiac surgery in high risk patients 
Sternal wound infection remains a serious potential complication after cardiac surgery. A recent development for preventing wound complications after surgery is the adjunctive treatment of closed incisions with negative pressure wound therapy. Suggested mechanisms of preventive action are improving the local blood flow, removing fluids and components in these fluids, helping keep the incision edges together, protecting the wound from external contamination and promoting incision healing. This work reports on our initial evaluation and clinical experience with the Prevena™Incision Management System, a recently introduced new negative pressure wound therapy system specifically developed for treating closed surgical incisions and helping prevent potential complications. We evaluated the new treatment on sternal surgical incisions in patients with multiple co-morbidities and consequently a high risk for wound complications.
The Prevena™incision management system was used in 10 patients with a mean Fowler risk score of 15.1 [Range 8-30]. The negative pressure dressing was applied immediately after surgery and left in place for 5 days with a continuous application of -125 mmHg negative pressure. Wounds and surrounding skin were inspected immediately after removal of the Prevena™ incision management system and at day 30 after surgery.
Wounds and surrounding skin showed complete wound healing with the absence of skin lesions due to the negative pressure after removal of the Prevena™ dressing. No device-related complications were observed. No wound complications occurred in this high risk group of patients until at least 30 days after surgery.
The Prevena™system appears to be safe, easy to use and may help achieve uncomplicated wound healing in patients at risk of developing wound complications after cardiothoracic surgery.
PMCID: PMC3305521  PMID: 22145641
incision; wound healing; negative pressure wound therapy; cardiac surgery; median sternotomy
19.  Effectiveness of Antimicrobial Incise Drapes versus Cyanoacrylate Barrier Preparations for Surgical Sites 
Surgical wound infections are one of the leading causes of morbidity and mortality in surgical patients. We compared the effectiveness of antimicrobial incise drapes versus cyanoacrylate microbial sealant adhesive barrier in preventing skin flora contamination of surgical wounds in an animal model. Staphylococcus aureus in suspension was placed on fresh ovine skin across 60 circular marks of defined area: 20 circles were designated as controls, 20 were covered with antimicrobial incise drapes, and 20 were covered with cyanoacrylate. Incisions were made through the circles; swab cultures were taken, serially diluted after agitation, and cultured on blood agar plates. The number of colony forming units (CFUs) was then counted and compared between the samples from the two drapes. While there were no differences between antimicrobial incise-draped areas (108.3 ± 90 CFUs) and undraped controls (82.7 ± 93.3 CFUs), the cyanoacrylate-treated group demonstrated lower wound bed contamination (0.3 ± 0.6 CFUs) when compared to controls.
PMCID: PMC2690753  PMID: 19277806
20.  The transdural approach for thoracic disc herniations: a technical note 
European Spine Journal  2010;19(7):1206-1211.
Surgery for thoracic disc herniations is still challenging, and the disc excision via a posterior laminectomy is considered risky. A variety of dorsolateral and ventral approaches have been developed. However, the lateral extracavitary and transthoracic approach require extensive surgical exposure. Therefore, we adopted a posterior transdural approach for direct visualization without entry into the thoracic cavity. Three cases that illustrate this procedure are reported here with the preoperative findings, radiological findings and surgical techniques used. After the laminectomy, at the involved level, the dorsal dura was opened with a longitudinal paramedian incision. The cerebrospinal fluid was drained to gain more operating space. After sectioning of the dentate ligaments, gentle retraction was applied to the spinal cord. Between the rootlets above and below, the ventral dural bulging was clearly observed. A small paramedian dural incision was made over the disc space and the protruded disc fragment was removed. Neurological symptoms were improved, and no surgery-related complication was encountered. The posterior transdural approach may offer an alternative surgical option for selected patients with thoracic paracentral soft discs, while limiting the morbidity associated with the exposure.
PMCID: PMC2900008  PMID: 20143105
Disc herniation; Transdural approach; Thoracic
21.  The Relationship Between Skeletal Muscle Serum Markers and Primary THA: A Pilot Study 
Various reports confirm elevations in serum markers associated with skeletal muscle injury after orthopaedic surgery in the absence of overt clinical manifestations of myocardial injury. We therefore measured the influence surgical approach has on these serum markers after primary THA. We nonrandomly enrolled 30 nonconsecutive patients undergoing THA in three groups of 10 based on current surgical approaches used at our facility: (1) minimally invasive (MIS) modified Watson Jones approach; (2) miniposterior transmuscular approach (MIS-I); and (3) MIS-II incision. Blood samples for hemoglobin, hematocrit, cardiac troponin I, total creatine kinase, creatine phosphokinase, and serum myoglobin were obtained the morning before surgery as a baseline, immediately postoperatively, and 72 hours thereafter. We found reproducible trends in serum enzyme levels consistent with skeletal muscle damage resulting from primary THA. Troponin I remained normal in all but one patient indicating no myocardial contribution to measured serum enzyme levels. All three procedures resulted in similar trends in serum enzyme markers relevant to primary THA. Our preliminary data suggest no surgical approach appears to affect the degree of muscle trauma more or less than another.
PMCID: PMC2690757  PMID: 19326181
22.  Management of insertional Achilles tendinopathy through a Cincinnati incision 
About 10% of patients not responding to 3–6 months of conservative management for insertional Achilles tendinopathy undergo surgery. Traditionally, surgery of the Achilles tendon is performed through longitudinal extensile incisions. Such surgery is prone to the complications of wound healing, wound breakdown and iatrogenic nerve injury.
We describe our current method of exposure of the Achilles tendon insertion and debridement of the peritendinous and tendon tissue with osteotomy of the calcaneum through a transverse skin incision at the level of the Achilles insertion.
This method has been used since 2002 on over 40 patients for exposure of the Achilles tendon insertion and the distal Achilles tendon.
The Cincinnati incision allows adequate exposure, has minimal risk of symptomatic iatrogenic nerve injury, and has minimal problems related to the scar.
PMCID: PMC1976314  PMID: 17697370
23.  Changing knives a wasteful and unnecessary ritual. 
The use of two knives for making a surgical incision is a deeply ingrained practice of British surgery and a postal survey of the theatre superintendents in the South-West Thames Region revealed that out of 143 surgeons all but one use this technique. Therefore we undertook a bacteriological study of the knife blades used on a general surgical unit. This showed that under normal conditions pathogenic organisms do not contaminate the knife blade and are not carried into the wound by it. The use of only one knife to make an incision does not increase the incidence of wound infection. A survey of the world literature confirms these findings. The wasteful and unnecessary ritual of using two knives to make an incision through normal skin has no theoretical, scientific or clinical basis and can be discontinued.
PMCID: PMC2498033  PMID: 4004043
24.  Laparoendoscopic single-site surgery in gynaecology: A new frontier in minimally invasive surgery 
To review the recent developments and published literature on laparoendoscopic single-site (LESS) surgery in gynaecology.
Minimally invasive surgery has become a standard of care for the treatment of many benign and malignant gynaecological conditions. Recent advances in conventional laparoscopy and robotic-assisted surgery have favorably impacted the entire spectrum of gynaecological surgery. With the goal of improving morbidity and cosmesis, continued efforts towards refinement of laparoscopic techniques have lead to minimization of size and number of ports required for these procedures. LESS surgery is a recently proposed surgical term used to describe various techniques that aim at performing laparoscopic surgery through a single, small-skin incision concealed within the umbilicus. In the last 5 years, there has been a surge in the developments in surgical technology and techniques for LESS surgery, which have resulted in a significant increase in utilisation of LESS across many surgical subspecialties. Recently published outcomes data demonstrate feasibility, safety and reproducibility for LESS in gynaecology. The contemporary LESS literature, extent of gynaecological procedures utilising these techniques and limitations of current technology will be reviewed in this manuscript.
LESS surgery represents the newest frontier in minimally invasive surgery. Comparative data and prospective trials are necessary in order to determine the clinical impact of LESS in treatment of gynaecological conditions.
PMCID: PMC3002012  PMID: 21197247
Conventional laparoscopy; laparoendoscopic single-site surgery; single-incision laparoscopic surgery; single port
25.  Single-incision bilateral laparoscopic oophorectomy 
Although single-incision laparoscopic surgery made an appearance on the surgical scene only recently, it is being increasingly applied in the treatment of a variety of disorders. We report single-incision bilateral laparoscopic oophorectomy and salpingooophorectomy performed in two patients who had previously undergone breast conservation surgery for early breast cancer. Each procedure was undertaken using two 5-mm and one 3-mm ports inserted through a 2-cm transverse supraumbilical incision and standard laparoscopic instruments. The operative time was 50 and 65 min respectively and the blood loss negligible. The patients were discharged 36 and 24 h after surgery, required minimal postoperative analgesia and remain well at a follow up of 19 and 17 months, respectively. With the benefit of improved cosmesis, the single-incision approach holds the potential to replace the traditional bilateral laparoscopic oophorectomy.
PMCID: PMC3002015  PMID: 21197250
Laparoscopy; oophorectomy; single-incision; single port access

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