Endonasal Endoscopic Approach to Sphenoid Sinus Lesion

Background: Anatomical position of sphenoid sinus, sellar and parasellar regions are located in the skull base having difficulty to approach due to presence of vital structures in its proximity. The presence of carotid artery and optic nerve in its lateral wall make the situation difficult due to lack of illumination and visual limitation. In the past traditional techniques to approach this region like external ethmoidectomy, transseptal transsphenoidal routes were used causing significant trauma, bleeding and risk of possible complication in skull base region. Aim: to access the efficacy and safety of the endonasal endoscopic approach to the sphenoid sinus Method: This study was done in the department of ENT Shaikh Zayed hospital Lahore, 33 patients who were diagnosed to have lesions involving sphenoid sinus. Detailed history, thorough ENT examination, relative investigations were done and all were managed naso-endoscopically. Results: The review of these cases showed that the endoscopic technique was found to have the advantages of being minimally invasive with no external incisions. There is less trauma to the patient, no need for operating microscope or intraoperative image intensifier. Conclusion: The conclusion of our study showed that naso-endoscopes are excellent tools for better visualization due to availability of different angled scopes and good illumination. The disease is better assessed and cleared identifying landmarks with quicker postoperative recovery and lesser overall morbidity. Over the last few years, endoscopic approach to these regions has gained much popularity because of advances in optics, endoscopes and illumination. Keywords: Endoscopic sinus surgery, sphenoid sinus

Facial trauma aggravating paediatric orbital cellulitis

We describe a case of paediatric orbital cellulitis with subperiosteal abscess following blunt facial trauma. Clinical features of orbital cellulitis developed on day 1 post-trauma. A subperiosteal collection subsequently formed lateral to the globe, causing significant ocular compromise. Surgical drainage and sinus washout were performed via external incisions, with satisfactory outcome. This case highlights how trauma may represent a non-sinogenic aggravating factor in orbital cellulitis. We describe how a subperiosteal abscess may vary depending on its aetiology, and how the surgical approach can be modified to locate and drain a laterally sited subperiosteal abscess.

Preliminary outcomes of endoscopic middle-ear surgery in 103 cases: a UK experience

BackgroundTotally endoscopic ear surgery and endoscope-assisted microsurgery are still new concepts, with relatively few centres in the UK performing them. Advantages include better visualisation of difficult to reach areas, such as the sinus tympani, and limited external incisions. This paper reports our short-term outcomes for endoscopic middle-ear surgery.MethodsA prospective review was conducted of the first 103 consecutive patients undergoing totally endoscopic ear surgery or endoscope-assisted microsurgery in 1 centre performed by 1 operator. The outcomes assessed were: tympanic membrane healing, audiological data and complications.ResultsTwenty-five patients underwent endoscope-assisted microsurgery, while 78 had totally endoscopic ear surgery. There were no reported cases of dead ear or permanent facial nerve palsy. The average air–bone gap following stapedectomy was 7.38 dB. The tympanic membrane healing rate was 89 per cent.ConclusionOur results confirm that endoscopic middle-ear surgery is safe, and the short-term outcomes are comparable with conventional surgery.

Design of an Adjustable Table Mount for Multifunctional NOTES Robot

Natural orifice transluminal endoscopic surgery (NOTES) is a method in which tools are passed through a natural orifice to the surgical site. This removes the need for external incisions, which can allow patients to recover more quickly without any visible abdominal scarring. This surgical method also has several limitations including limited space, complex lumen geography, and difficult visualization [1]. To address these problems, researchers have developed various tools, including endoscope-based robots [2], and insertable bimanual robots [3]. However, some of the aforementioned constraints/limitations remain, and consideration of accessories for use with these tools remains relevant. Our lab designed a multifunctional NOTES robot, which consists of a snakelike linkage driven by cables that are attached to motors in an external housing to navigate through the lumen geometry; it also includes a bimanual end effector with interchangeable tool tips [4]. This paper introduces the design of an adjustable table mount to address the limitations related to transluminal insertion. It provides four passive degrees of freedom (DOFs) to grossly place the robot, and enables the robot to be fixed on surgical tables with different sizes. Benchtop testing on a surgical table with a patient mannequin demonstrates its functionality.

Simplified Transoral Load-Bearing Osteosynthesis with Preformed Mandible Reconstruction Plates

Transcutaneous submandibular approaches are the preferred technique for the application of load-bearing mandibular osteosynthesis plates. However, an extraoral approach is associated with several shortcomings, like the risk of harming the facial nerve and scarring. This technical note presents a specialized mandibular reconstruction plate (MatrixMANDIBLE Preformed Reconstruction Plate [Synthes Maxillofacial, Paoli, PA]), simplifying the transoral application by its design with a preformed curvature along the lateral surface of the mandible. The application of wide-spanning plates reaching from the posterior margin of the ramus even into the contralateral body region is facilitated. Transoral application of preformed mandibular reconstruction plates seems to be a promising option to bypass external incisions and to reduce operating room time.

Articulated Mechanism Design and Kinematics for Natural Orifice Translumenal Endoscopic Surgery Robot

Natural orifice translumenal endoscopic surgery (NOTES) has reduced the invasiveness of surgery by eliminating external incisions on the patient. With this type of procedure, recovery time is drastically shortened, cosmetics are improved, and infections and pain are greatly reduced. For NOTES procedures to be successfully performed, a flexible endoscope or similar instrument is important for passing orifice flexures. However, technological deficiencies like poor angulations of surgical instruments introduced through working channels in flexible endoscopes, the lack of scope fixation, and lack of scope stiffening are technological barriers which prevent NOTES from being widely accepted in human surgeries. A novel multifunctional robot with an articulated drive mechanism for NOTES has been developed. The steerable articulating drive mechanism is connected to the robotic end effector to guide the robot and navigate through a natural orifice. The design process for the articulating drive mechanism and engineering analysis are discussed in this paper. Workspace of the drive mechanism with and without a translational insertion degree of freedom is presented in detail. The kinematics of the drive mechanism is also discussed. Additionally, friction in the spherical joints of the drive mechanism is explored to characterize its influence on the overall shape achieved by the articulation, including the effects of varying the total length in the steering mechanism. The surgeon control console for the drive mechanism is briefly discussed as well. Bench-top testing results are presented as proof of feasibility of the design.

Recent advances in the CoBRASurge robotic manipulator and dexterous miniature in vivo robotics for minimally invasive surgery

Minimally invasive surgery (MIS) reduces trauma and improves patient recovery. Traditional laparoscopic procedures are performed using multiple long, thin tools that are inserted through small incisions in the abdominal wall. The advantages of these procedures are often restricted to less complicated procedures owing to imaging and tissue manipulation limitations. These limitations can be overcome using advanced surgical systems, such as da Vinci®, that provide the surgeon with enhanced visualization and improved tool dexterity. However, the da Vinci system is expensive and occupies significant space in the operating room. The compact bevel-geared robot for advanced surgery, CoBRASurge, is a compact robotic system that addresses the space and expense limitations of large external robotic systems. This system provides a stable platform for laparoscopic tool manoeuvring, while also allowing the surgical team improved access to the patient. New methods for performing MIS, including single incision and natural orifice access, are also being developed to further minimize invasiveness through reducing or eliminating external incisions. However, the instruments for these procedures are further limited by accessing the peritoneal cavity through a single insertion point. Dexterous miniature robots that are completely inserted into the peritoneal cavity are being developed that mitigate these limitations to provide improved triangulation.

Microscopic Endonasal Surgery for Repair of CSF Leaks

This manuscript will detail our experience using a microscopic endonasal surgery (MES) approach in the repair of spontaneous, traumatic, and/or iatrogenic cerebrospinal fluid (CSF) fistula into the ethmoid and sphenoid sinuses. The location of the fistula in 22 patients was determined by a direct endoscopic or microscopic visualization, intrathecal fluorescein, or computed tomography (CT) with metrizamide. Several of these patients had been treated unsuccessfully with previous neurosurgical, intracranial, and extracranial approaches to stop the leak. The CSF fistulas in all these patients were repaired with a MES approach, packing the leak with either a septal mucosal graft, or abdominal fat and fascia, and no external incisions were utilized. Furthermore, this approach allowed for an overall closure rate of 95% and offered a direct means to locate the fistula at the time of surgery. It also allowed for precise placement of grafts to cover the defect, an opportunity to perform bimanual dissection, and in general afforded an excellent field of vision.