THE ART OF SURGERY 4 General advantages of endoscopically assisted approach: Specific advantages of surgery in prone position: The anterior thoracic spine can be exposed from either side, addressing the problem at the site and side of the lesion. One skin incision of 13 mm takes the portal of the 10 mm thoracoscope, the second, 2-4 cm long, provides for a working channel, through which several instruments, retractors e.c. can be inserted. Since the size and mobility of the scapula are the limiters of the access in prone position cranially, any pathology between Th4 and Th1 should be approached in lateral decubitus of the patient. For all other locations of the thoracic spine and caudally till L2 for the technique presented here, both, the lateral decubitus and the prone position are an option. Since many procedures require additional posterior surgery, and since anatomical orientation in prone position seems easier, our endoscopically assisted approach of choice is the one in prone position. The 2-portal strictly intercostal technique allows exposure and manipulations for monosegmental epiphyseodesis, discectomies, interbody fusions to corpectomies and vertebral body replacement. Since anterior and posterior elements of the spine are exposed at the same time, titrated releases/osteotomies e.g. for fixed kyphosis are possible. For rigid double curves in scoliosis in one position the anterior releases of each curve can be combined with posterior release, instrumentation and fusion. Fractures: Posttraumatic kyphosis, instability: Interbody fusions, partial and complete corpectomies Degenerative stenosis/instability up to the thoraco-lumbar junction, if necessary in combination with lumbar PLIF surgery Tumours palliative: Corpectomy and vertebral body replacement Tumours curative: En bloc resection combined with simultaneous posterior dissection and reconstruction Pyogenic spondylitis: Debridement and anterior reconstruction Thoracic disc herniations Scoliosis idiopathic congenital: Anterior release and anterior fusion combined with posterior instrumentation Kyphosis, jatrogenic, congenital, ankylosing spondylitis, Scheuermann’s disease: Release/osteotomy and anterior reconstruction Just two small skin incisions, no division of muscles of the chest wall No rib osteotomy necessary! Strictly intercostal approach of 2-4 cm is sufficient Excellent intraoperative illumination and visualization for the whole team incl. scrub nurse and anaesthesist Better access to junctional zones cervico-thoracic or thoraco-lumbar than with open technique Lower morbidity due to reduced blood loss, reduced postoperative pain, early extubation Lower costs for instruments Lower costs due to reduced demand on intensive care, pain management and shorter rehabilitation Only one intercostal space is utilized for the two portals (reduced risk of damage of intercostal nerves) Spatial orientation better, since prone position is familiar from posterior surgery No single lung intubation necessary Better vision since following gravity, blood does not collect around the spinal canal (less demand for suction) Additional therapeutic options: - Amount of release/osteotomy of anterior or posterior column can be titrated according to the ongoing correction - The posterior iliac crests, the posterior spine from occiput to sacrum and the anterior spine from Th4 to L4 (thoracoscopic and retroperitoneal approach) are accessible in whatever sequence and repetition desired - Easy input of corrective force: For correction of kyphosis the assistant just puts pressure at the apex - Filling of the anterior gap after correction and fixation from posterior Cost reduction: Since the anterior surgery can be performed in prone position the patient needs to be positioned once No repositioning, redraping, changes of one-lung intubation Less operating-room time, hygiene-hazards of repositioning and redraping the patient Since staged procedures can be avoided: Shorter stay in intensive and regular care Even for major back-front-back surgery only one assistant is required Indications: Einführung Introduction Introducción Introduction Introduzione
RkJQdWJsaXNoZXIy MjI3MzI4