Robotic enucleation & uncinectomy of complex lesions of the proximal pancreas

BACKGROUND

Malignant tumours within the proximal pancreas traditionally require pancreaticoduodenectomy (PD) for cure. For smaller lesions with borderline malignant potential the risk/benefit of PD becomes difficult to justify. Robotic approaches to these lesions allow for parenchymal preserving resection with reduced complication profile without oncological compromise.

METHODS

A review of a single surgeons prospectively collated database across two institutions of consecutive robotic enucleations or parenchyma preserving resections of the proximal pancreas was performed between July 2018 and October 2021. Standard demographic data, preoperative variables, intraoperative parameters, post-operative outcomes, morbidity and mortality were recorded.

RESULTS

Thirteen patients (8 female and 5 male) underwent robotic enucleation (EN) (8) and/or uncinectomy (UN) (5) in the proximal pancreas. Mean BMI was 32(kg/m2 ). Three patients (21%) underwent preoperative prophylactic pancreatic duct stenting. One patient required conversion to open. The median operative time in the EN group was 170 min (108-224 min) and the UN group was 160 min (110-204 min). The majority (8) of lesions were pNETs. Three lesions were IPMNs, with 1 solitary fibrous tumour and a serous cystic neoplasm (SCN) respectively. Median tumour size was 23 mm (11-58 mm) in the EN group, and 27 mm (17-38 mm) in the UN group. Ten of 13 patients had an R0 resection. There was no mortality in our series. Four (31%) patients across both groups developed clinically relevant POPF while none developed new endocrine or exocrine insufficiency. Average outpatient follow-up has been 6 months (1-18 months).

CONCLUSION

A robotic approach in proximal parenchymal preserving pancreatectomy is expanding, safe and feasible.

Anatomical Step-by-Step Dissection of Complex Skull Base Approaches for Trainees: Endoscopic Endonasal Approach to the Orbit

Introduction  Although endonasal endoscopic approaches (EEA) to the orbit have been previously reported, a didactic resource for educating neurosurgery and otolaryngology trainees regarding the pertinent anatomy, techniques, and decision-making pearls is lacking. Methods  Six sides of three formalin-fixed, color latex-injected cadaveric specimens were dissected using 4-mm 0- and 30-degree rigid endoscopes, as well as standard endoscopic equipment, and a high-speed surgical drill. The anatomical dissection was documented in stepwise three-dimensional (3D) endoscopic images. Following dissection, representative case applications were reviewed. Results  EEA to the orbit provides excellent access to the medial and inferior orbital regions. Key steps include positioning and preoperative considerations, middle turbinate medialization, uncinate process and ethmoid bulla removal, complete ethmoidectomy, sphenoidotomy, maxillary antrostomy, lamina papyracea resection, orbital apex and optic canal decompression, orbital floor resection, periorbita opening, dissection of the extraconal fat, and final exposure of the orbit contents via the medial-inferior recti corridor. Conclusion  EEA to the orbit is challenging, in particular for trainees unfamiliar with nasal and paranasal sinus anatomy. Operatively oriented neuroanatomy dissections are crucial didactic resources in preparation for practical endonasal applications in the operating room (OR). This approach provides optimal exposure to the inferior and medial orbit to treat a wide variety of pathologies. We describe a comprehensive step-by-step curriculum directed to any audience willing to master this endoscopic skull base approach.

Efficiency of minimal oblique resection of the uncinate process during an anterior cervical discectomy and fusion

Hypertrophy of the uncinate process (UP) can cause radiculopathy. Minimal UP resection is considered to remove the lesion while minimizing the risk of complications. This study aimed to elucidate the surgical results of minimal oblique resection of the UP. This study is a retrospective review of about sixty segments in 34 patients who underwent anterior cervical discectomy and fusion (ACDF) with minimal oblique uncinectomy between 2016 and 2018. The cross-sectional area of the UP was measured pre- and postoperatively. The interspinous distance, segmental Cobb angle, subsidence, fusion rate, surgical time, estimated blood loss, and postoperative complications were evaluated. The mean resected areas of the UP were 17.4 ± 8.7 mm2 (25.9%) on the right and 17.3 ± 11.2 mm2 (26.2%) on the left. The difference in interspinous distance in flexion-extension was 7.1 ± 3.2 and 1.6 ± 0.6 mm pre- and postoperatively, respectively (P = .000). The fusion rate after ACDF was 91.7% when measured according to segment (55/60) and 91.2% when measured according to patients (31/34). The difference in the segmental Cobb angle in flexion-extension was 8.3 ± 6.2° and 1.9 ± 0.3° pre and postoperatively, respectively (P = .000). Subsidence occurred in 4 (11.8%) patients and 5 (8.3%) segments. The average surgical time per segment was 68.8 ± 9.3 minute, and the estimated blood loss was 48.5 ± 25.0 mL. Postoperative complications comprised 1 case each of neck swelling, wound infection, pneumonia, and gastrointestinal bleeding. Our findings therefore revealed that minimal oblique uncinectomy during an ACDF can maintain the stability of the uncovertebral joint while sufficiently decompressing the neural foramen.

Seeker Uncinectomy: A Randomized Controlled Cadaveric Trial

Background

Endoscopic sinus surgery is a common surgery, in which the uncinate process of the ethmoid is removed as the first surgical step. There are multiple techniques for uncinectomy. Herein we describe a new and simple uncinectomy technique.

Methods

We performed a randomised controlled trial with blinded assessors. Eight cadaveric heads were used to compare the new technique to the commonly used technique; retrograde uncinectomy. The procedures were performed by 2 rhinologists, and the findings were evaluated by 2 senior rhinologists blinded to the technique and the surgeon who did. They assessed the final view of the procedure and the complications. Thereafter, they assessed the procedure for the duration and ease of each technique for teaching purposes.

Results

Fifteen uncinectomies were performed, 7 using the retrograde technique, and 8 using the new technique. The mean durations were 5.64 min using the seeker uncinectomy and 7.57 min using the retrograde uncinectomy, p-value = 0.017. The completion was better in seeker uncinectomy; however, not significant statistically, p > 0.05. The complications with the new technique were inferior turbinate injury in 12.5% and natural ostium non-identification in 12.5%, p > 0.05. With retrograde uncinectomy, lacrimal injury occurred in 14.3%, p > 0.05. The ease of teaching scores was higher for the seeker uncinectomy.

Conclusion

Based on this cadaveric trial, seeker uncinectomy seems to be a safe and easy to perform technique. However, injury to the inferior turbinate and missing the natural ostium must be taken into consideration. These warrant further studies on the clinical application of this procedure.

Total Anterior Uncinatectomy During Anterior Discectomy and Fusion for Recurrent Cervical Radiculopathy: A Two-dimensional Operative Video and Technical Report

A common cause of cervical radiculopathy from degenerative foraminal stenosis is severe uncovertebral hypertrophy. It is difficult to accomplish complete foraminal decompression in these cases with posterior techniques without the removal of a large portion of the facet joint. Total removal of the uncovertebral joint from an anterior approach allows for complete decompression of the exiting cervical nerve root and has been shown to be a safe technique. In this surgical video and technical report, we demonstrate the surgical anatomy and operative technique of a two-level anterior uncinatectomy during anterior discectomy and fusion (ACDF) for recurrent cervical radiculopathy after a previous multi-level posterior foraminotomy. The patient is a 67-year-old male with a progressive left arm and neck pain with radiographic, clinical, and electrophysiologic diagnostic evidence of active C6 and C7 radiculopathies from degenerative foraminal stenosis at the C5-6 and C6-7 levels. Posterior foraminotomies had been performed without significant improvement in his radicular pain. A repeat MRI demonstrated lateral foraminal stenosis from severe uncovertebral joint hypertrophy at the C5-6 and C6-7 levels. After acquiring informed consent from the patient, an anterior approach was performed with complete removal of the uncovertebral joints at both levels with discectomy and fusion. Postoperatively, the patient had complete resolution of his radicular pain and remained pain-free at the latest follow-up. Complete uncinatectomy and ACDF is an effective technique for complete foraminal decompression in cases of refractory radiculopathy and neck pain after unsuccessful posterior decompression.

Safety and efficacy of direct nerve root decompression via anterior cervical discectomy and fusion with uncinectomy for cervical radiculopathy

Cervical radiculopathy is a common spinal condition associated with pain, sensory disturbances, and motor weakness. Symptoms often can be attributable to either disc herniation and/or bony foraminal stenosis due to uncinate hypertrophy. Posterior cervical foraminotomy and conventional anterior cervical discectomy and fusion (ACDF) represent the mainstay of treatment. In patients with severe bony foraminal stenosis, posterior foraminotomy and standard ACDF without complete resection of uncinate process may result in incomplete decompression. ACDF with uncinectomy allows for complete and direct decompression of the exiting nerve root, and may lead to improved clinical outcome in appropriately selected patients. We describe the technique for ACDF with uncinectomy and report the clinical outcome in a consecutive series of patients.

Swing door technique for uncinectomy versus standard technique: a comparative study

INTRODUCTION

Uncinectomy can be performed using various methods. The aim of the present study was to compare the results and complications of uncinectomy and middle meatus antrostomy using the standard and swing door techniques during functional endoscopic sinus surgery.

METHODS

In a prospective controlled study, 60 patients (aged 18-50 years) suffering from chronic maxillary sinusitis underwent functional endoscopic sinus surgery from January 2007 to December 2008 at a tertiary care centre. The patients were randomly divided into two groups of 30: Group A underwent uncinectomy using the standard technique, while Group B underwent uncinectomy using the swing door technique.

RESULTS

Group B showed more improvement in symptoms, with a mean visual analogue scale score of 80.58 ± 14.34 compared to 78.50 ± 16.63 in Group A. Both groups had no major complications. At the end of Week 2, minor complications were observed in 8 (26.7%) of the patients from Group A and 2 (6.7%) from Group B. By the sixth week, the minor complication rate was 1 (3.3%) and 0 (0%) in Group A and Group B, respectively. When compared statistically during the second week using chi-square test, the difference in the minor complication rate was found to be statistically significant (p < 0.05, χ² = 4.81), with lower incidence of complications in Group B.

CONCLUSION

The swing door technique for uncinectomy produces good postoperative results, with fewer complications, as compared to the standard technique.

Total uncinectomy of the cervical spine with an osteotome: technical note and intraoperative video

Total uncinate process resection or uncinectomy is often required in the setting of severe foraminal stenosis or cervical kyphosis correction. The proximity of the uncus to the vertebral artery, nerve root, and spinal cord makes this a challenging undertaking. Use of a high-speed burr or ultrasonic bone dissector can be associated with direct injury to the vertebral artery and thermal injury to the surrounding structures. The use of an osteotome is a safe and efficient method of uncinectomy. Here the authors describe their technique, which is illustrated with an intraoperative video.

Extent of maxillary sinus surgery and its effect on instrument access, irrigation penetration, and disease clearance

BACKGROUND

Middle meatal antrostomy (MMA) provides limited access to the anteromedial and inferior aspect of the maxillary sinus (MS) often resulting in residual disease and inflammatory burden. Newer extended procedures, such as mega-antrostomy (Mega-A) and extended modified mega-antrostomy (EMMA), have been developed to address this limitation. This study assesses the effect of varying extent of MS surgery on irrigation penetration and access of instrumentation.

METHODS

The MS of 5 fresh-frozen cadavers were sequentially dissected. Irrigation was evaluated with a squeeze bottle (SB) in different head positions and using different volumes of fluid. Surgical reach and visualization were examined using common sinus instruments and different angled endoscopes. A disease simulation was also performed to check for residual debris after instrumentation and irrigations.

RESULTS

Irrigation penetration improved as antrostomy size increased (p < 0.0001), with a significant difference observed between the extended procedures and MMA. The effect of the volume was significant for SB (p < 0.0001) but head positions appeared irrelevant (p = 0.613). Overall visualization improved for Mega-A and EMMA. A similar trend was seen for the reach of the instruments to all sinus wall subsites. EMMA facilitated the most removal of "sinus disease" in the disease simulation model when compared with both MMA and Mega-A, due to its reach of the anteroinferior aspects of the maxillary sinus.

CONCLUSIONS

High-volume irrigation using SB achieved good sinus penetration, irrespective of head position. Extended MS procedures appear to further increase irrigation penetration as well as surgical access.