Minimally invasive surgery. Neurosurgery.

The introduction of minimally invasive techniques has greatly improved results for intracranial neurosurgery. Stereotaxy and improved imaging techniques have reduced surgical trauma by allowing surgeons to plan the least damaging route to operative sites and by increasing surgical precision. Stereotaxy has also allowed brain biopsies to be taken from sites such as the brain stem, which were rarely sampled before because free hand biopsy was so dangerous. Brain tumours can now be treated by interstitial radiotherapy--stereotactic insertion of catheters into the lesion for loading of radioactive iodine--or radiosurgery--focusing of intense beams of radiation on lesions without needing surgical incisions. Endoscopic neurosurgery can be used to reach cavities such as the ventricular system or cystic tumours. With interventional neuroradiology fine catheters can be introduced into most vessels in the cranium for embolisation or dilatation. The development of augmentative functional neurosurgery means that movement disorders, epilepsy, and intractable pain can be treated with implanted neurostimulating electrodes. Future developments will probably include frameless stereotaxy, when the rigid attachment of stereotactic apparatus to the patient''s head can be dispensed with, and at least partial automation of procedures such brain biopsy.     

Minimally invasive surgery in the field of gynecologic oncology

The aim of this paper was to present the results in minimal invasive surgery in the field of gynecologic oncology at General hospital Zabok, Croatia. 381 laparoscopic procedures were performed between 1994 and 1998. There were 263 operations of the benign adnexal masses, and 107 operations due to benign tumors of corpus uteri (there were 18 LAVH, 12 LH and 77 TLH). There were 11 laparoscopic operations due to carcinoma (1 ovary, 6 corpus and 4 cervix). Operations were: 3 LAVH (laparoscopically assisted vaginal hysterectomy), 5 TLH (total laparoscopic hysterectomy) with pelvic lymphadenectomy, 1 LAVH with pelvic lymphadenectomy, 1 coelio Shauta operation with laparoscopic pelvic lymphadenectomy and paraaortal lymphadenectomy, and 1 laparoscopic adnexectomy. Among laparoscopic procedures in 370 patients operations were successfully performed as planed, while in 11 patients it was necessary to switch to laprotomy. Among serious complications of laparscopic operations it is necessary to note 2 lesions of the ureter and 1 lesion of the bladder. Laparoscopic lymphadenectomies were performed successfully; there were no serious early or late postoperative complications. There was no operative mortality. Even though many authors claim that laparoscopic operations in the field of gynecologic oncology are safe and have the same results as in open surgery, patients benefit from shorter recovery and better quality of life during laparoscopic procedures.     

Minimally invasive surgery. Implications for hospitals,health workers,and patients.

Minimally invasive surgery is one of the great innovations of health care in the 20th century. It promises to revolutionise surgery by allowing many more operations to be performed with minimal hospitalisation. Pressure from patients has caused many techniques to spread rapidly before they have been adequately assessed. This must be resisted, and policy makers must pay more attention to minimally invasive surgery to ensure that good assessments are made. The widespread use of minimally invasive techniques has important implications for hospitals and health workers. As more patients are treated on an outpatient basis, fewer hospital beds will be needed, and traditional operating rooms will have to adapt to a greater turnover of patients. Surgeons will have to acquire new operating skills, possibly requiring formal training and accreditation, and, as different specialties fight for control of new technologies, surgery may eventually be merged with internal medicine so that specialists will deal with organ systems. Postoperative care will have to be carried out in the community rather than in hospitals, and policy makers will need to reorganise their health systems to cope with these developments.     

Minimally invasive harvest of the gracilis muscle.

Acceptance of minimally invasive plastic surgery has been predicated on decreasing morbidity while maintaining the quality and costs of outcomes. The major patient complaint about the gracilis muscle donor site has almost solely been related to the length of the thigh scar, and thus would appear to be an ideal indication for outcome improvement using minimally invasive techniques. A method of endoscopically assisted gracilis muscle harvest, therefore, was developed, starting with a transverse incision just proximal to the knee to identify the gracilis tendon. This endoscopic port allows retrograde subfascial dissection of the muscle and precise identification of its anatomic course, whereupon a small proximal medial thigh incision can be made secondarily for direct access to the vascular pedicle. This variation has now been used successfully in 10 patients. The mean proximal thigh scar length was 8.30 +/- 0.74 (SD) cm, and total surgical scars measured 11.84 +/- 0.95 cm, compared with 27.73 +/- 9.55 cm for 16 patients for whom an open method had been used. This diminished scar length was a statistically significant improvement (p < 0.05), verifying the value of the surgical endoscope as an adjunct for harvest of the gracilis muscle as a free flap.     

Future developments in phenylketonuria

Treatment of classical phenylketonuria (PKU) is very good, but problems still exist in regard to the duration of treatment and a means of ensuring that all women with PKU recommence dietary treatment before becoming pregnant. A 'one-shot' cure of the disease remains desirable and may become available in the more distant future by somatic cell gene therapy. Insertion of a normal gene or correction of the defective gene at the normal site in the chromosome and in liver cells is likely to be necessary both technically and ethically. Prevention by prenatal diagnosis is not widely accepted in Australia and is likely to have little effect on the frequency of the disease.     

New developments in invasive fungal disease

Invasive fungal infections continue to be a major cause of morbidity and mortality in immunocompromised or severely ill patients. This report highlights new research data presented at the 51st Interscience Conference on Antimicrobial Agents and Chemotherapy on invasive fungal disease and its treatment. A number of important clinical trials were reported, and there were also interesting presentations on the use of new diagnostic tools, further studies on therapeutic drug monitoring for azoles and updates on several of the emerging fungal pathogens.