DR.M.M.PRABHAKARDIRECTOR GOVERNMENT SPINE INSTITUTEMEDICAL SUPERINTENDENTHEAD OF ORTHOPEDIC DEPT.B.J.MEDICAL COLLEGECIVIL HOSPITAL AHMEDABAD

MISS THORASIC INFECTIONMISS THORASIC INFECTION

Anterior Spinal endoscopy Anterior Spinal endoscopy and Minimal access and Minimal access

surgery.surgery.

Conventional Surgical Approach to spineConventional Surgical Approach to spine

• Conventional thoracotomy require large approach. • More morbidity• Rib resection cause post operative costal pain.• More blood loss• Post operative pleural adhesion and loss of lung

compliance. • Postoperative shoulder stiffness.• Late recovery, late rehabilitation, longer hospital

stay and higher cost of treatment.

ThoracotomyThoracotomy

Conventional Surgical Approach to spineConventional Surgical Approach to spine

• Conventional retroperitoneal and laparotomy again need large exploration.

• More morbid cause of large dissection trough abdominal musculature.

• Requires mobilization of big vessels.• Complication like incisional hernia is

possible.• Peritoneal adhesion causes post

operative pain.• Infection and instrumentation failure is

common• Late recovery, longer rehabilitation and

training is required.

Retroperitoneal ApproachRetroperitoneal Approach

Trans peritoneal Lumber Trans peritoneal Lumber surgery surgery

Video assisted Minimal access Video assisted Minimal access surgerysurgery

• Video assisted minimal access surgeries is done through small incision with special retractor system.

• Enhanced visualization with help of telescope placed from same portal or different portal.

• Promising result with faster recovery.• Less morbid approach.• All possible spinal procedure can be

done.

Minimal access thoracotomyMinimal access thoracotomy

Minimal access Laparotomy.Minimal access Laparotomy.

SPINAL ENDOSCOPYSPINAL ENDOSCOPY

• Minimum-access techniques have been introduced throughout surgery, including Orthopaedics and traumatology, where, since the early 80s, arthroscopy has revolutionized the treatment of joint disorders.

SPINAL ENDOSCOPYSPINAL ENDOSCOPY

• The first Thoraco-scopy was performed by H.C. Jacbaeus in Stockholm in 1910 using cystoscope for the division of tuberculous adhesions.

• Till early 1980’s laparoscopy was used extensively to perform general surgical work.

• In early 1990’s VATS was used to treat various pulmonary conditions like recurrent pleural effusion, recurrent pneumothoraces, for lung biopsy and evaluation of mediastinal adenopathy.

SPINAL ENDOSCOPYSPINAL ENDOSCOPY• Obenchain performed a laparoscopic L5-S1

discectomy, followed, in 1992, by Thomas Zdeblick’s L5-S1 fusion by laparoscopic placement of an interbody cage.

• In 1994, Rosenthal et al reported the first excision of a herniated thoracic disc by thoracoscopic surgery.

• In 1994, Le Huec and Husson performed the first endoscopic retroperitoneal approach to the lumbar spine.

Together, these three techniques provide access to the thoracic and lumbar spine in its entirety.

Advantages over conventional Advantages over conventional approachapproach

• Minimal access to thorasic, retroperitoneal, and abdominal cavity.

• Faster recovery• Less post operative pain• Less morbidity• Less blood loss• Less hospital stay• Quick return to work

Requires higher skills and long learning curve.

• VATS on the spine should be performed in a standard operating room. Some modifications from routine spinal procedures are needed.

• Double-lumen Endotracheal tube placement for one lung anesthesia.

• Position: in the lateral decubitus position and secured. The lower extremities are gently flexed away.

• The operating table should be capable of Trendelenburg or reverse Trendelenburg positions in order to allow the deflated lung to fall away from the spine to increase visualization and decrease inadvertent injury during the procedure.

• Both the Spine surgeon and Thoracic surgeons stand on the same side of the patient, the abdominal side, across from the video monitor.

• The third assistant, if necessary, stands on the back side of the patient and faces an opposing second monitor.

• The thoracic surgeon usually obtains and holds the exposure, the orthopaedic surgeon controls the orthopaedic instruments with both hands, and the third assistant may hold the camera and/or retract the lung.

• Equipment includes telescopes, cameras, illumination sources, monitors, insufflators, trocars, vascular clipping devices, graspers, retractors, bipolar electric cauteries.

Thoracoscopy-TelescopeThoracoscopy-Telescope• Usually 30 degree, 10mm DM scope

is used for all spinal procedure. • Rigid scope had flexible claw camera

attachment at rear end and light source on side.

Trocar systemTrocar system

• Trocar system are the portals to enter the Thorasic, Retroperitoneal or Abdominal cavity.

• They come in size from 5 mm to 12 mm sleeve size.

• The Trocar it self is of different variety like blunt tip, blade tip and dilating tip according to the tissue to be approached.

• The cannula size also comes from 60 mm to 110 mm length.

Simple trocar systemSimple trocar system

Different tips of TrocarDifferent tips of Trocar

• The first trocar inserted for thoracoscopy is at the usual site in 5th or 6th intercostal space. According to marker over spine.

• Usually blunt tip trocar to avoid damage to lung.

• Other ports are taken in direct vision to allow optimum placement for the intended procedure.

Blunt tip TrocarsBlunt tip Trocars

Outer sleeves or cannulasOuter sleeves or cannulas• They are simple cylindrical or conical,

smooth with flanges or ribbed one for better hold in soft tissue.

After placement of ports outer lookAfter placement of ports outer look

• Multiple portals are required. • Anterior portals are kept in anterior

axillary line and posterior portals are kept in posterior axillary line.

• The instruments required are to be of longer size, and strong as conventional instruments.

Some Modification to routine instruments

Calibration over the instruments helps to judge about depth.

Lung and soft tissue retractor.

IndicationIndication

• Release of anterior scoliosis and other deformities.

• Herniated disc disease• Vertebral fractures, decompression and

reconstruction of spinal column with or with out anterior Instrumentation

• Abscess drainage and debridement in tuberculous spine with reconstruction.

• Tumor biopsy and resection.

Thorasic InfectionThorasic Infection

• Use of large approach for drainage of spinal abscesses seems to be unrealistic in modern era

• Small portal surgery or conventional endoscopy can perform same work with less morbidity

• Thoraco-scopy is reliable method used for removal of adhesion of lungs in pleurisy and fibrolysis so can be used with adherent lung.

Common Spinal infective Common Spinal infective indicationsindications

• Tuberculosis of thoracic spine

• Pyogenic spondilitis

• Thoracic Discitis

• Thoracic spinal hydatid

• Diagnostic biopsy

Case 2Case 2

• MAFA BHAI JIVA BHAI RABARIMAFA BHAI JIVA BHAI RABARI

• MALE 50MALE 50

• TB DORSAL 6-7 WITH NORMAL TB DORSAL 6-7 WITH NORMAL NEUROLOGYNEUROLOGY

Pre operative AP Pre operative Lat.

MRI

MRI

Post operative AP Post operative Lat.

FOLLOW UP

Clinical on Follow-upClinical on Follow-up

Thank You