Exploring Essential Surgery: Head and Neck

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The selection of minipigs as an animal model was based on animal availability and the approval track of the Animal Ethics Committee of the University of Geneva. The key elements for selecting an animal model for END were a neck size and anatomy similar to those of humans. It was essential that the neck was neither too small to preclude the intended surgery nor too big, which might facilitate the procedure but render the results irrelevant to humans. Another consideration for the use of minipigs as an animal model was cost; larger animals are more expensive.

The minipigs used in the study were routinely monitored with equipment similar to that used during the administration of human general anesthesia. While we do not have data detailing the sequential and continuous recording of blood pressure, electrocardiogram, and expiratory gas levels for review, an intermittent examination of equipment displays during the procedure did not reveal any significant change in these variables.

In particular, balloon insufflation did not result in any significant hemodynamic changes. So far, only 3 reports, an experimental study of parathyroidectomy in 8 dogs, 16 an experimental attempt of endoscopic neck surgery in 10 pigs, 17 and a case report of a human parathyroidectomy, 18 have dealt with endoscopic surgery within the neck. Both of the animal studies were plagued with a large number of complications that were often fatal.

The occurrence of pneumothorax, especially with the use of insufflation gases to maintain the endosurgical working cavity, is more worrisome. In our study, we did not encounter such complications, although our evaluation may not have been as thorough. Nevertheless, we assessed pneumothorax by bilateral auscultation at the end of the procedure in all animals and used chest x-ray in the last 3 animals without any evidence of abnormalities.

A possible explanation for the occurrence of pneumothorax is that these experimental studies, including the report by Carreno et al, 17 examined dissection of the lower extent of the neck thyroid or parathyroid surgery.

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We often addressed level IV nodes at the end of the procedure, when there may have been significant air leakage around the trocars. Because the trocars allowed for upward traction, we only relied heavily on gas insufflation during the beginning of each procedure. We are convinced that pneumothorax should not result from dissection of the lower extent of level V because the porcine lungs are protected with a large zone of fatty tissue beneath the subclavius muscle.

Further studies are needed to address these issues prior to human application. The possibility of END as a viable surgical technique has not previously been reported. Our data support its feasibility without untoward complications. While this study is oriented toward lymph node counts to provide a quantitative outcome, the aim of the surgical procedure is to perform a complete neck dissection, including the removal of all fibrofatty tissue. The yield in terms of retrieved lymph nodes was compared with the total number of lymph nodes removed, using open surgery to explore for remaining tissue.

Oftentimes, the remaining lymph nodes were not deeply located, but were against the superficial flaps. The efficiency of END may therefore be increased by a more careful endoscopic inspection of this area. While human application of END is still premature, it is possible that these surgical techniques could be applied to the majority of current neck surgical procedures. Contrary to previous reports, 16 - 18 we tend to propose endoscopic neck surgery for intermediate lesions, such as submandibular gland removal.

The procedure is best performed after a large working cavity is created, a complex dissection compared with the surgical removal of small lesions, such as the excision of lymph nodes for diagnostic purposes. If END were used for the mapping of sentinel nodes, 19 - 21 it could allow for the evaluation of neck status with minimal morbidity before the final treatment decision is made. Precise knowledge of neck status can dramatically alter treatment protocols and decrease morbidity associated with these treatments. However, prior to using endoscopic surgical techniques for the neck in humans, extensive training with endoscopic surgical techniques in closed cavities is mandatory.

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Familiarity with endoscopic knot tying is required for handling potential bleeding sources. Like all new and involved surgical techniques, END is initially time-consuming, and there is certainly a learning curve. Whether this technique is worthwhile in terms of operating room time, complications, and morbidity remains to be determined. Ann Otol Rhinol Laryngol. Otolaryngol Head Neck Surg. Comprehensive Management of Head and Neck Tumors. Endoscopic exploration and lymph node sampling of the axilla: Br J Plast Surg.

Dr. Aru Panwar, Head and Neck Surgery

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Exploring Essential Surgery: Procedures

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Books by Maurice Brygel

Sign in to make a comment Sign in to your personal account. Create a free personal account to make a comment, download free article PDFs, sign up for alerts and more. Our website uses cookies to enhance your experience. To download from the iTunes Store, get iTunes now. A diverse collection of clinical material pertaining to common surgical conditions is not really available at any one time - we have collected such material and use it to illustrate the diagnostic process and subsequent management.

This is an interactive program using text, graphics, images and drawings to assist medical students, hospital doctors, surgeons in training, general practitioners and allied health professionals in their understanding of common and important surgical conditions. Patients and interested lay people would also benefit from this program. Gerard Ahern is a clinical anatomist, general practitioner and final year medical school coordinator. Maurice Brygel is a general surgeon specialising in hernia, haemorrhoid and perianal surgery.

Numerous expert anatomists and surgeons contributed to the program. They contain additional material including over videos of experts commenting on surgical conditions. Overview Music Video Charts. Opening the iTunes Store.