Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1127_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
transvaginal approach is the risk of subsequent infection
described in the past when culdoscopy was performed.
In this respect, fertiloscopy has given a clear answer: there
is no risk of infection or dyspareunia. In our last series of
3000 cases, we have observed only one case of infection, in
a patient who had salpingitis at the time of the procedure,
despite the fact that no antibiotics were given either pre - or
postoperatively [5].
Another concern is the risk of postoperative dyspareunia
related to the vaginal scar; in fact, in our series no dyspareunia was reported. Consequently, vaginal small entry (the
caliber of the fertiloscope being 6 mm) should not be considered a risk.
Complications of f ertiloscopy
There is only one risk, which is bowel injury, as the trocar
is inserted between the cervix and the rectum. Bowel perforation is a complication that inexperienced surgeons face,
with an incidence between 0.4% and 0.6% of cases. These
injuries are mostly due to a disrespect of contraindications,
and occur mostly in the fi rst 50 cases [6].
Contraindications must be noted either when the rectum
is stuck to the cervix as in endometriosis of the recto -vaginal
septum, or when there is obstruction of the pouch of Douglas
in the presence of a mass such as a big fi broid or in the case
of fi xed uterine retroversion. The incidence of such contraindications was 5.9% in a series of 2000 fertiloscopies
performed in infertile patients.
One outstanding feature of the bowel injury is its benign
nature: the perforation occurs in a retroperitoneal portion
of the rectum and is therefore never serious. The treatment
is always conservative: broad -spectrum antibiotics are given
for fi ve days and no further treatment is necessary.
we have also developed a technique of ultrasound -guided
insertion, which may be useful, especially for beginners
(see Video 17.3).
Following our experience in fertiloscopy, attempts were
then made to see if it was possible to develop a similar technique permitting not only for gynecologic NOTES operations
to be performed but also visceral NOTES procedures. We
have subsequently described the method discussed in the
following section.
Safe and simplifi ed method for NOTES
(see Video 17.4) [7]
Based on the same principle (i.e., a purely endoscopic
approach), we have developed a technique that allows the
introduction of a scope (up to 15 mm), which is the minimum
requirement for NOTES procedures such as transvaginal
gallbladder removal.
In this technique we use a Step ™ trocar (Covidien, USA).
The fi rst trocar is a 3 mm (Figure 17.4) dilating trocar with
a Veress needle inside. Once inserted into the pouch of
Douglas, it is fi lled with saline. Saline is more appropriate
that CO
, which will rise, thereby not creating a safety space
2
in the pouch of Douglas. At that point, it is possible to insert
a small rigid 2.9 mm scope to verify its adequate position and
the vacuity of the pouch of Douglas. If that is the case, a
bigger trocar is then inserted into the small one (Figure
17.5). The system allows for the insertion of either a 12 mm
or a 15 mm trocar. It is then possible to use a fl exible endoscope and from that point onward, CO
may be instilled. CO
2
2
will rise above the level of saline, allowing surgical procedures to be performed.
Lessons from f ertiloscopy
Fertiloscopy has demonstrated its innocuous nature in term
of infection; in addition, the absence of any dyspareunia
may also be related to the small size of the scar but also to
the fact that the vagina is not closed. These facts must be
borne in mind to develop further transvaginal approaches.
Learning c urve in f ertiloscopy
Fertiloscopy as such is a very easy technique; however, some
problems have been identifi ed, which have prevented its
wide acceptation and that should also be the case for
NOTES. First, when using a transvaginal route, the view is
inverted when compared to standard laparoscopy: anatomy
has to be revisited accordingly. Second, the transvaginal
approach involves the insertion of a needle or trocar
between the cervix and the rectum. Even if a rectal injury
is never serious and is always treated conservatively, it
appears that a proportion of surgeons are afraid to blindly
insert a Veress needle into the pouch of Douglas. That is why
184
Figure 17.4 Simplifi ed method for transvaginal NOTES/insertion of the
3 mm Step ™ trocar.
Figure 17.5 Exchange and insertion of a bigger trocar.
https://t.me/med1917
The use of a composite medium (saline and CO 2) seems
to be the safest way to perform transvaginal NOTES
procedures.
Today, our experience is limited and we have only performed a few cases of tubal ligation (three cases) and ovarian
cystectomy (two cases) but the technique requires only 10
minutes to be performed.
At the end of the procedure, the vagina is closed with one
stitch of 2/0 Dexon sutures. This part of the procedure takes
its inspiration from our personal experience with fertiloscopy. We believe that a mere approximation of the tissue is
suffi cient, as it decreases the risk of fi brous scar, and therefore the risk of postoperative dyspareunia. In the 15 days
following the procedure, however, the patient is requested
to avoid sexual intercourse.
Other routes for gynecologic NOTES
A common problem for endoscopic procedures is the distance between the scope and the organs. For instance, if a
laparoscopic hysterectomy is performed on a very big uterus,
it is necessary to insert the scope several centimeters above
the umbilicus to gain good access with suffi cient space to
move the instruments. The same problem occurs in a transvaginal approach: it is relatively easy to perform adnexal
surgery but a transgastric approach will be preferred in cases
where uterine surgery is involved.
It is therefore a paradox of NOTES that transvaginal access
may be more useful for non -gynecologic operations and the
transgastric route more useful for gynecologic operations. A
last option may be the use of hybrid techniques such as
transgastric combined with transvaginal. To date, few studies
have explored this possibility except in the porcine model,
where transgastric salpingectomy has been performed with
success [8].
CHAPTER 17 Gynecologic Applications of NOTES
Which gynecologic operations may benefi t
from NOTES?
Gynecologic NOTES already available
Ovarian drilling (see Video 17.5)
As previously mentioned, fertiloscopy as such is a true
NOTES procedure. Initially, this endoscopy was purely diagnostic. An operative channel was then used on the trocar,
allowing some “minor” operations to be performed. The
most popular one is ovarian drilling, which is performed in
patients presenting with polycystic ovarian syndrome
(PCOS), a benign and common disease (incidence being
estimated between 2% and 5% of the general population)
characterized by hormone changes and infertility.
Ovarian drilling is an old procedure. In the 1960s it was
performed by laparotomy (ovarian wedge resection) with
good results but with a very high incidence of postoperative
adhesions. The technique became less invasive in the 1990s,
carried out laparoscopically. The ultimate minimally invasive evolution was ovarian drilling per fertiloscopy, performed since the year 2000.
In the case of ovarian drilling per fertiloscopy, a bipolar
needle is used (Gynecare Versapoint ™, USA). Since endoscopy is performed using a saline solution, the only available
energy is bipolar. The size of every hole is similar to the
bipolar needle, which is 5 French (1.5 mm) in diameter [9],
and six to eight holes are made on each ovary. The technique is simple and quickly performed, provided that the
landmark, which is the utero -ovarian ligament, is correctly
identifi ed. Failure to do so means the surgeon is potentially
at risk of drilling the sigmoid colon, which may appear
similar to an enlarged white ovary.
Since then there are more publications that demonstrate
good results, with a cumulative pregnancy rate of 60%
obtained very rapidly (average 4 months). We have also
demonstrated that this technique is very safe, with no risk
of damaging the ovaries (because the energy used is bipolar
with very little injury outside of the hole drilled) and no risk
of adhesion formation. Finally, this technique is performed
in an outpatient setting and simultaneously allows for a
complete exploration of the genitalia and treatment of
PCOS.
It has been demonstrated that the disease may recur after
a pregnancy. In such cases, it is possible to perform a second
ovarian drilling with the same good results. The minimally
invasive nature of the procedure is well accepted by patients.
Adhesiolysis
Fertiloscopy through its operative channel also allows adhesiolysis to be performed. Not all adhesions may be removed
through this route. However, when adhesions affect the
tubo-ovarian area, they may be removed in a very accurate
185
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
way using either bipolar needle or cold scissors of the same
size (5 French). This procedure is useful in infertile patients
presenting with peri -adnexal adhesions, which represent a
mechanical factor for infertility.
Endometriosis
Minimal endometriosis may also be treated per fertiloscopy
providing that lesions are limited to the pouch of Douglas.
In this case, destruction is carried out with bipolar coagulation. Nevertheless, one has to be very careful when dealing
with endometriosis because all lesions must be treated and,
due to the vision of fertiloscopy, which is limited to the area
of the pouch of Douglas, one can never be sure that there
are no other lesions (e.g., in the anterior pouch).
This situation is rare (less than 5% of cases) but it demonstrates the actual limitation of fertiloscopy. Since a rigid
scope is used, it is not possible to have correct visualization
of the anterior space or of the upper abdominal cavity.
This is why we call this endoscopy “fertiloscopy, ” because
it is strictly indicated in infertile patients and not, for
example, in patients with pelvic pain.
Zygote intra-fallopian transfer
Another technique that could benefi t from the NOTES
approach is zygote intra -fallopian transfer (ZIFT). This technique was popular in the 1980s as an alternative to in vitro
fertilization (IVF). It involves introducing the freshly fertilized embryo (zygote) directly into the fallopian tube, which
is the natural site for conception [10]. This technique,
though successful, was quickly abandoned when egg collection for IVF could be performed by ultrasound: laparoscopy
required for intra -fallopian transfer was considered as much
too heavy.
Today, due to the minimally invasive nature of fertiloscopy, this option may be revisited, especially in older patients
(over the age of 38) where the results of ZIFT are good. We
have already conducted a feasibility study, which was positive. Results now need to be confi rmed.
Outcome of gynecologic NOTES
Theoretically, all gynecologic operations could be performed
by NOTES providing that proper tools were available and an
adequate approach was appropriately selected. As for the
tools, as in every surgical procedure, it will be necessary to
have the following:
• proper means of coagulation, keeping in mind that gynecologic procedures require proper coagulatation of vessels as
big as 7 mm in diameter (uterine artery);
• ability to suture;
• ability to perform suction -irrigation.
Concerning the approach as mentioned above, the main
consideration is the distance between scopes, instrumentation, and organs, and the possibility of triangulation. Subsequently, the approach has to be selected accordingly. Until
today, there have been no publications about gynecologic
NOTES save from fertiloscopy and single -port laparoscopy.
Single-port laparoscopy can be considered NOTES if the
umbilicus is considered a natural orifi ce. The procedures are
similar to conventional laparoscopy with some technical
prerequisites and limitations due to the limited space available for instrumentation.
We consider that adnexal surgery could be carried out
rather easily by the transvaginal route, keeping in mind that
it would require special training since the view is inverted.
Retroperitoneal procedures may also be proposed even if
the fi rst trials on cadavers demonstrate some anatomical
diffi culties: this may be a transitory problem, which may be
solved with experience, in which case lymphadenectomies
could be performed.
For uterine surgery (such as surgery of fi broids, hysterectomy), a hybrid technique could be imagined: transgastric
for dissection and transvaginal for mass extraction.
The transvaginal approach is useful for adnexal surgery,
and is also used as a hybrid technique in combination with
the transgastric approach to remove the anatomical specimens such as fi broids after removal.
Which patients are good candidate for
gynecologic NOTES?
Since NOTES is a new surgical fi eld one should be very cautious when using this technique, even if our experience with
fertiloscopy seems to demonstrate that the transvaginal
approach is very safe.
In fertiloscopy the technique is really minimally invasive,
but if the decision is made to insert a bigger endoscope, its
long-term impact in young patients should be considered.
Today, few studies have evaluated the acceptance of a new
surgical approach such as the transvaginal route. The results
are somewhat ambivalent, some describing negative perceptions by the potential candidates for transvaginal NOTES
[11], and others that are very positive [12]. Nevertheless, it
seems that we should be very cautious when proposing
transvaginal procedures in young patients who have shown
some concern about their fertility or the quality of their
sexual life after such procedures. It is therefore probably
safer to propose the vaginal route only in patients who have
already conceived. Information and consent in such cases
should be examined very carefully. Should more studies
demonstrate the safety of the procedure, it will then be possible to extend this alternative to every woman.
Conclusion
NOTES is a new way of performing surgery with a novel
approach: the transvaginal route is probably a very good one
186
CHAPTER 17 Gynecologic Applications of NOTES
https://t.me/med1917
to perform visceral surgery but may be of limited value in
gynecology. However, the transgastric route may be very
useful for gynecologic surgery when all technical problems
such as safety and ease of closure of the gastric incision have
been resolved. In addition, today, hybrid or combined techniques are seen as the most promising development of gynecologic NOTES.
Cooperation between different specialties is very stimulating, even if no one can predict the exact future of NOTES
at this point. The same could be said about laparoscopy
thirty years ago, at a time when no one could predict what
the future would hold for this approach and the new possibilities it would offer. Consequently, one should be open
minded regarding this new technological approach. The
combination of new instruments, robotic surgery, and
experiments in pilot centers may yield results in the near
future that one could hardly imagine today. Should this
be the case, we cannot see any reason why gynecologic
NOTES should not benefi t from technological advances,
since the fi rst human application of NOTES was carried out
transvaginally.
Chapter video clips
Video 17.1 Fertiloscopy: animation.
Video 17.2 Fertiloscopy: technique.
Video 17.3 Ultrasound-guided fertiloscopy.
Video 17.4 Endoscopic simplifi ed technique for transvaginal
NOTES.
Video 17.5 Fertiloscopic ovarian drilling.
References
2 Gordts S, Campo R, Rombauts L, Brosens I. Transvaginal hydro-
laparoscopy as an outpatient procedure for infertility investigation. Hum Reprod 1998;13,99–103.
3 Watrelot A, Dreyfus JM. Fertiloscopie (hydrolaparoscopy trans-
vaginale). In Encyclopedi Medico - Chirurgicale, Techniques chirurgi-
cales - Gyn é cologie. Elsevier Masson SAS , Paris, 2008, pp. 41–517.
4 Watrelot A, Nisolle M, Chelli H, et al. Is laparoscopy still the gold
standard in infertility assessment? A comparison of fertiloscopy
versus laparoscopy in infertility. Results of an international multicentre prospective trial: the FLY study 2003 . Hum Reprod
2003;18:834–9.
5 Watrelot A. Place of transvaginal fertiloscopy in the manage-
ment of tubal factor disease . Reprod Biomed Online 2007;15:
389–95.
6 Gordts S, Watrelot A, Campo R, Brosens I. Risk and outcome of
bowel injury during transvaginal pelvic endoscopy . Fertil Steril
2001;76:1238–41.
7 Watrelot A, Nassif J, Law WS, Maresaux J, Wattiez A. Safe and
simplifi ed endoscopic technique in transvaginal NOTES . Surg
Laparosc Endosc Percutan Tech 2010;20:92–4.
8 Nassif J, Zacharopoulou C, Marescaux J, Wattiez A. Transvaginal
extraperitoneal lymphadenectomy by natural orifi ces transluminal endoscopic surgery (NOTES) technique in porcine model:
feasibility and survival study . Gynecol Oncol 2009;112:405–8.
9 Fernandez H, Watrelot A, Alby JD, et al. Fertility after ovarian
drilling by transvaginal fertiloscopy for treatment of polycystic
syndrome. J Am Assoc Gynecol Laparosc 2004;11:374–8.
10 Pilikian SQ, Watrelot A, Drezyfus JM, Ecochard R, Gennaro JD.
Gamete intra fallopian transfer (GIFT) with cryopreserved donor
semen following AID failure . Hum Reprod 1990;5:944–6.
11 Rao A, Kynaston J, MacDonald ER, Ahmed I. Patient prefer-
ences for surgical techniques: should we invest in new
approaches? Surg Endosc 2010;24:3016–25.
12 Peterson CY , Ramaoorthy S, Arden B, et al. Women ’s positive
perception of transvaginal NOTES surgery . Surg Endosc
2009;23:1770–74.
1 Marescaux J, Dallemagne B, Perretta S, et al. Surgery without
scars: report of transluminal cholecystectomy in a human being .
Arch Surg 2007;142(9):823–6; discussion 826 –7.
187
18
https://t.me/med1917
NOTES Thyroidectomy
Tahar Benhidjeb
1
Department of General Surgery Burjeel Hospital, Abu Dhabi, UAE
2
The New European Surgical Academy (NESA), Berlin, Germany
1,2
& Michael Stark
Background
It is the goal of every surgeon to minimize patient morbidity
while maximizing the benefi cial outcomes of the planned
procedure. This applies also to neck surgery, which is one of
the newest fi elds in minimally invasive surgery. Traditional
open thyroid surgery involves a low transverse cervical incision, at least 4 cm long, that results in a visible scar. Given
that the preponderance of thyroid surgery is performed on
young female patients, often with benign histology, there
has been an effort to minimize the invasiveness of surgery
and improve cosmesis [1]. The technology development of
the past two decades in the fi eld of video -assisted surgery
has opened up new opportunities, including in thyroid
surgery. Initial efforts to apply minimally invasive neck
surgery focused on the parathyroid adenoma [2,3] and later
on the thyroid as well [4]. The technique of minimally invasive video -assisted thyroidectomy (MIVAT) developed by
Miccoli [5] is the method that has become most widespread
to date. Limiting factors of this method include the bothersome 20 mm cervical incision and consequently the specimen size to remove. Furthermore, most of the discomfort
and complications associated with this approach are caused
by the cervical incision itself: the longer the incision, the
stronger the pain intensity and the higher the risk for wound
infection (Figures 18.1 and 18.2). Rather than the length of
the neck incision, the quality of the scar also is a determinant for the cosmetic result (Figures 18.3 and 18.4). Since
mediastinoscopy, retroperitoneoscopy, and total extraperitoneal endoscopic hernioplasty have familiarized us with
ways of creating the operative space needed for surgical
techniques, several authors have described extracervical
approaches aiming to avoid scars in the neck region: such
2
accesses are the chest, the axillary, and the combined axillary bilateral breast approach [6]. The development of cervical scarless thyroid surgery is indeed a great step toward
better cosmetic outcomes. However, these techniques simply
moved the scars from the front neck region to the axilla or
the chest where they are partly visible. Furthermore, the
extracervical approaches do not comply with the use of the
term “minimally invasive, ” since they are associated with an
extensive dissection of the skin and subcutaneous layers of
the chest and neck region, thus being rather maximally
invasive for the patients (Figures 18.5–18.7). In order to
avoid this, it is necessary to perform surgical procedures
without cutting the surface of the body and to use natural
openings as entry points [7]. The concept of NOTES has
changed the surgeon ’s perspective; natural openings of the
body are used by interdisciplinary teams to reach the target
region directly, thereby causing minimal tissue trauma,
reducing collateral damage and skin incision -related complications, and improving recovery of the patient [8]. Following this logic, an ideal thyroidectomy approach should meet
the following criteria:
• The access itself should be close to the thyroid gland.
• Surgical planes in thyroidectomy should be respected.
• An optimal cosmetic result may only be achieved by performing a scarless operation.
• This optimal cosmetic result with scarless surgery should
be achieved with minimal trauma.
• The minimally invasive character of this approach and the
optimal cosmetic result may not be reached at the expense
of patient ’s safety.
The technique that fulfi ls all these criteria is the transoral
access because the distance between the sublingual place
and the thyroid gland is short, thus avoiding extensive dissection maneuvers. Furthermore, the mouth mucosa can be
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
188
Figure 18.1 Wound with thermic lesion following minimally invasive
https://t.me/med1917
video-assisted thyroidectomy (MIVAT).
CHAPTER 18 NOTES Thyroidectomy
Figure 18.3 Keloid formation following traditional thyroidectomy.
Figure 18.2 Abscess formation following traditional thyroidectomy.
sutured without diffi culties and repairs itself without leaving
any visible scars.
The feasibility of the transoral access to the thyroid has
been recently demonstrated by a member of our group in a
porcine model by using a modifi ed axilloscope [9]. However,
the described technique is a hybrid one since an additional
3.5 mm cervical skin incision was necessary for the insertion
of a fi xation forceps through a trocar. Inspired by this idea
of Witzel et al., we developed a purely endoscopic transoral
and minimally invasive approach for thyroidectomy using a
three-point access sublingually and bilaterally in the vestibule of the mouth [10].
Figure 18.4 Large unsightly scar following traditional thyroidectomy.
Rationale and history of transoral surgery
All extracervical and minimally invasive accesses as well as
the traditional approaches to the thyroid gland do not
respect the anatomically given surgical planes, since they
are all based on a transection of skin, platysma, and in
some cases also the strap muscles (Figure 18.8). This may
result in the mentioned local complications such as scar
development and swallowing disorders. In fact, it remains
unclear whether dysphagia after surgery is caused by scarring, specifi cally in the platysmal layer. Most of these late
189
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
Figure 18.5 Hematomas following axillo bilateral breast approach
(ABBA).
Figure 18.6 Maximally invasive character of extracervical approach
(ABBA).
Figure 18.7: Thermic lesion following axillo bilateral breast approach
(ABBA).
Figure 18.8 Principle of cervical and extracervical approach to the
thyroid.
complications are not well documented due to the absence
of suffi cient follow -up. By using the transoral approach of
direct access to anatomically defi ned fascial layers and planes
of the neck, a bloodless and gentle surgery under endoscopic
view and magnifi cation is possible (Figure 18.9).
Only a few reports describe transoral surgery on humans.
One of its fi rst applications was the resection of the submandibular gland, which is performed classically through a
cervical incision. The cervical approach, however, results in
a visible and prominent scar, which is particularly troublesome in young patients [11]. Transoral resections of the
submandibular gland date back to the early 1960s, as
190
Downton and Qvist described the transoral approach by
open surgery via the fl oor of the oral cavity [12]. Review
of the English -language literature shows that no reports
were found until the article of Smith et al., published in May
2000 [13], although in the Spanish -language literature
the intraoral glandular excision was described by Yoel in
1961 [14]. The recent advent of endoscopic procedures has
also compelled both plastic and neck and head surgeons to
reconsider the conventional methods by which the excision
of the submandibular gland has been classically achieved.
An endoscopic intra -oral approach is described for the submandibular gland resection, avoiding a transcervical scar.
Figure 18.9 Principle of transoral approach to the thyroid.
https://t.me/med1917
The endoscopic technique permits both good visualization
and illumination of the anatomical landmark, which allows
a wider surgical fi eld than the conventional intra -oral
approach [11]. Hong and Yang evaluated the surgical results
associated with the intra -oral approach in a series of 77
operations for chronic sialadenitis and benign mixed tumors
in the submandibular gland [15]. The infection rate for this
group was 2.6% (2 patients) compared with 7.3% for 251
patients treated with a transcervical approach. Proper pre operative preparation and continuous suction drainage with
the hemovac through the oral cavity after dissection may
prevent infections [15]. Another application area was
reported by Shellenberger et al. [16], who described transoral excision guided by pre -operative ultrasonography for
a series of three consecutive patients with differentiated
thyroid cancer metastatic to the retropharyngeal space. In
all cases, the metastatic lateral retropharyngeal lymph node
was removed successfully by transoral retropharyngotomy
without complications. All patients resumed an oral diet
within 24 h after surgery, with only mild discomfort similar
to that of a tonsillectomy. One patient who underwent retropharyngotomy alone was discharged on the fi rst postoperative day. Two patients who underwent the procedure
with concurrent neck dissection were discharged on the fi rst
and fourth postoperative days [16]. Other endoscopic surgical procedures were also performed to treat fractures of the
mandible, but they were still limited to the narrow spaces
surrounding the oral cavity.
All these reports showed that transoral procedures are
feasible and safe for the patient. This approach provides safe
dissection and is associated with very low infection risk.
Because endoscopic surgery provides good illumination and
CHAPTER 18 NOTES Thyroidectomy
magnifi cation on the monitor, the operation proceeds clearly
and sharply in a bloodless fi eld. Another advantage is that
a transcervical scar is avoided [11].
Despite these positive scientifi c fi ndings, when a new suggested surgical method departs substantially from the current
standard of care, scientifi c evaluation is a conditio sine qua non
[17,18]. Feasibility and safety must be secured before starting with clinical application. In this sense, we performed a
series of investigations according to the Good Clinical Practice guidelines.
Technique of totally transoral videoassisted thyroidectomy ( TOVAT )
The aim of our study was to defi ne anatomical spaces, surgical planes, and related neural and vascular structures to
create a safe and reproducible transoral access and pathway
to the cervical spaces, especially to the more distant thyroid
gland.
This access should guide an easy and safe way to preformed anatomical spaces between different fascial layers of
the neck. In these ‘‘sliding’’ layers, a preparation without any
bleeding should be possible and neural structures can be
spared. The space to be reached is the subplatysmal layer
above the pretracheal strap muscles. Here, the linea alba coli
can easily be identifi ed and transected, and the thyroid gland
visualized, mobilized, and resected. Since the border of the
per -oral region to gain access to the cervical spaces and
thyroid by a transoral, natural orifi ce approach has never
been described before, it was necessary to perform in the
fi rst step extensive anatomical studies of the cervical region.
Anatomical studies
This anatomical study was carried out in eight human specimens (fi ve males, three females) with a mean age of 81 years
[19]. Three embalmed human specimens were dissected for
complete anatomical information of the cervical region. In
an additional fi ve fresh frozen human specimens after an
experimental transoral thyroidectomy, the anatomical structures and pathways were evaluated. Anatomical dissections
were performed, based on surgical planes: fi rst the skin,
subcutaneous tissue, and platysma muscle were removed.
Beyond the superfi cial fascia, the vessel architecture and the
nerves of the anterior triangle of the neck were separated
from the connective tissues and lymph nodes. Then, the
different surgical spaces in the submandibular grove were
demonstrated and the way through the fl oor of the oral
cavity to the sublingual space was shown. In the three
embalmed human specimens, the vascular system and
neural structures of the frontal and lateral neck region were
dissected to defi ne landmarks for a pathway through the
fl oor of the oral cavity. After this, we developed the transoral
access to the pretracheal space in fi ve fresh frozen human
191
SECTION 2 Current Clinical Applications and Techniques
https://t.me/med1917
cadavers. To qualitatively determine damage to anatomically
relevant structures, all fi ve specimens were dissected after
performing the surgical procedure [19].
Our hypothesis was that a working space under the
platysma muscle in the anterior neck region (level VI) can
be created with respect to the surgical planes and fascial
layers of the neck and without signifi cant damage to anatomical structures, such as vessels and nerves. Within this
area, it should be possible to reach the vessels and lymph
nodes under the sternocleidomastoid muscle as well as the
pretracheal region. In this compartment, the thyroid can be
visualized and resected. To access the working space by a
transoral manner in a fi rst attempt, a trocar for optical information with a 3 mm Hopkins endoscope (Karl Storz GmbH,
Tuttlingen, Germany) was placed in the midline between
and before the papillae of Wharton ’s duct. The endoscope
passed the muscles of the fl oor of the oral cavity easily
without damage to relevant anatomical structures. The
muscles of the fl oor of the oral cavity are separated bilaterally in the midline. No vessels or nerves are present in this
area, and hence, there are no structures at risk (Figure
18.10).
To get access for our 3 mm working trocars, we passed the
fl oor of the oral cavity sublingually on both sides through
the submandibular triangle. The latter can be divided into
two compartments: the sublingual and the submandibular
space. In the sublingual spatium, it was possible to localize
the duct of the submandibular gland, the sublingual glands,
and the lingual nerve as well as the sublingual artery and
vein (Figure 18.11). The submandibular space includes the
gland, the hypoglossal nerve, the facial artery, and parts of
the lingual nerve. The two spaces are partially divided by
the mylohyoid muscle. The complete submandibular triangle is covered with a shield of the superfi cial cervical fascia,
originating from the premandibular subplatysmal plane,
enveloping the gland totally and running to its attachment
at the posterior belly of the digastric muscle. Superfi cial to
the submandibular gland, the facial vein crosses the superfi cial fascia to reach the anterior border of the mandible. The
facial artery enters the triangle under the posterior belly of
the digastric and stylohyoid muscle; it ascends to emerge
above or through the upper border of the gland (Figure
18.11). The marginal mandibular branch of the facial nerve
courses through the triangle under the platysma muscle and
under the superfi cial fascia but outside the submandibular
‘‘bag’.’ It courses over the facial vessels as it travels upward
to supply the peri -oral muscles. The hypoglossal nerve
enters the triangle deep to the posterior belly of the digastric
muscle. It lies on the surface of the hypoglossus muscle and
courses deep to the mylohyoid muscle to supply motor function to the tongue. The lingual nerve, a branch of the mandibular nerve, is found under the border of the mandible on
the hypoglossus muscle superfi cial to the hypoglossal nerve.
It is attached to the submandibular gland by the submandibular ganglion and courses deep to the mylohyoid muscle to
provide sensation to the anterior tongue and fl oor of the oral
Digastric &
mylohyoid
muscles
Hypoglossal
nerve
Geniohyoideal
muscle
ECA
Figure 18.10 Muscles of the fl oor of the oral cavity and relevant neural
and vascular structures. The blue circle indicates the entry point for the
median sublingual trocar. ECA, external carotid artery. (With kind
permission from Springer Science + Business Media: Eur Arch
Otorhinolaryngol, Wilhelm T, Harlaar J, Kerver A, Kleinrensink GJ,
Benhidjeb T. 2010; 267:1285–90.)
192
Mylohyoid
muscles
(in place)
Facial
artery
ECA
Sublingual artery & vein
SHM
MHM
SMG
DM-AB
Sublingual nerve
GHM
Figure 18.11 Muscles of the fl oor of the oral cavity. The blue circle
indicates pass through of the optical trocar, optical trocar in the midline,
and working trocar on the left side in place. MHM, mylohyoid muscle;
SHM, sternohyoid muscle; DM -AB, anterior belly of the digastrics muscle;
GHM, geniohyoid muscle; ICA, internal carotid artery; ECA, external
carotid artery; RMV, retromandibular vein; HGN, hypoglossal nerve; SMG,
submandibular gland – lifted up. (With kind permission from Springer
Science + Business Media: Eur Arch Otorhinolaryngol, Wilhelm T, Harlaar
J, Kerver A, Kleinrensink GJ, Benhidjeb T. 2010; 267:1285–90.)
WHARTON’s duct
RMV
ECA
HGN
ICA
CHAPTER 18 NOTES Thyroidectomy
https://t.me/med1917
5.8°
(a)
Figure 18.12 Triangulation of instruments in two investigated
approaches. (a) Exclusively sublingual approach; (b) sublingual bi vestibular approach. (With kind permission from Springer
Science + Business Media: Eur Arch Otorhinolaryngol, Wilhelm T, Harlaar
J, Kerver A, Kleinrensink GJ, Benhidjeb T. 2010; 267:1285–90.)
(b)
25.8°
cavity (Figure 18.11). Finally, when passing the sublingual
gland and the Wharton ’s duct medially and proceeding
forward to the submandibular gland, it is possible to reach
the submandibular triangle safely. In this region, we have to
carefully avoid damage to the lingual and hypoglossal nerve
and leave the submandibular ‘‘bag’’ to reach the working
space through the mylohyoid muscle. Relevant vascular and
nervous structures are passed rectangular to get maximum
safety.
A major disadvantage of this access was the minimal tri-
angulation of the working instruments, which only reaches
5.8° (Figure 18.12). Therefore, either special instruments
with fl exible tips have to be developed or a modifi ed
approach has to be established. Consequently, we changed
our transoral exclusively sublingual approach to a combined
bi-vestibular and sublingual access. The optical access port
is also placed in the midline sublingually, but the working
trocars are moved to the vestibule of the oral cavity bilaterally beneath the incisive teeth of the mandible (Figure
18.13). Through a 5 mm incision in the mucosa of the vestibule we can reach the periost of the mandible directly and
pass under the platysma muscle and the superfi cial fascia to
get access to the infrahyoidal working space. By entering the
plane under the superfi cial fascia it was possible to avoid
damage to the marginal branch of the facial nerve as well
as damage to the facial vein. The only structure at risk is the
mental nerve. Blunt submucosal dissection helps in securing
intact function of the nerve after surgery. In all, anatomical
dissections after the transoral combined bi -vestibular and
sublingual access procedure, all relevant structures, e.g.,
Figure 18.13 Sublingual bi -vestibular approach: the two working and
the midline optic trocars are in place under the platysma muscle without
insuffl ation. (With kind permission from Springer Science + Business
CO
2
Media: Eur Arch Otorhinolaryngol, Wilhelm T, Harlaar J, Kerver A,
Kleinrensink GJ, Benhidjeb T. 2010; 267:1285–90.)
muscles of the fl oor of the oral cavity as well as all vessels
and nerves, were intact. The triangulation of the instruments reached an acceptable 20 –30° (Figure 18.12) [19].
With this method, we performed the fi rst successful endoscopic thyroidectomy utilizing a tree -point exclusively transoral access on May 14, 2008 [10].
Application in cadavers (Video 18.1)
The TOVAT itself was performed on two further human
cadavers with the help of one 5 mm and two 3 mm trocars
that were introduced through the mouth fl oor and the vestibulum oris subplatysmal. A working space was created by
insuffl ating CO
tion”). Surgical dissection of the further working space was
realized with 3 mm bipolar scissors [10].
The procedure consists of the following steps (Video 18.1):
• 5 mm small incision between the carunculae sublinguales
and insertion of a 5 mm trocar.
• Blunt dissection subplatysmal by CO
dissection”).
•CO
insuffl ation (4 –6mmHg) and creation of a working
2
space.
• Insertion of two 3 mm trocars in the vestibulum oris on
the right and left sides.
• Division of the linea alba coli and exposure of the strap
muscles.
• Separation of the sternothyroid muscle from the thyroid
gland.
• Isthmus transection and blunt dissection of the dorsal part
of the thyroid gland from the trachea.
at a pressure of 4 –6 mmHg ( “air dissec-
2
insuffl ation ( “air
2
193
Соседние файлы в папке Библиотека им академика М.И. Перельмана