W. T. Ng

Endoscopic thyroid and parathyroid surgery

Having succeeded in doing hemithyroidectomies and also parathyroidectomies through an endoscopic approach, we are fully convinced that endoscopic neck surgery is set to open up new horizons in the ever-expanding field of minimally invasive surgery. Not only was the postoperative discomfort greatly reduced, but the cosmetic results, a primary concern in neck surgery, have been very satisfactory. Two technical points are conducive to smooth execution of endoscopic neck surgery. First, the operation is performed with the neck slightly flexed and the table tilted to the reverse Trendelenburg position (Fig. 1). An 11-mm incision is made just above the suprasternal notch. With the skin edges elevated, a plane is developed underneath the platysma muscle between the anterior border of the sternomastoid muscles. An 11-mm Endo-path trocar sleeve (Ethicon Endosurgery, Cincinnati) is fitted into the incision. This transparent cannula affords a wider field of vision. A pursestring suture picking up the platysma is tied around the cannula to achieve an air-tight seal. An end-viewing telescope is passed down the sleeve after the space is inflated with CO2 at 8 mmHg. A 5-mm trocar is introduced near the lower end of the anterior border of the sternamastoid muscle on the side opposite to the lesion. To ensure unimpeded movement of adjacent trocars, less bulky trocars—for instance, Hunt/Reich Secondary Trocars (Apple Medical Corporation Massachusetts), are preferred. The trocar sheath can be maintained in position by screwing the cannula in a clockwise direction or by anchoring the stopcock with a skin stitch. These plastic cannulas have the added advantage of not interfering with cautery should they come into contact with the metallic part of the instruments during activation of the diathermy. A pair of endoscopic scissors inserted through this cannula is used to develop a plane between the sternomastoid and the strap muscles. Dissection should be kept in the right plane, care being taken not to wander onto the anterior surface of the sternomastoid, which would invite unnecessary bleeding and the belly of the sternomastoid would sag down. Another 5-mm trocar is then inserted 2–3 cm lateral to the midline incision, piercing through the lower sternomastoid belly on its way. Exposure of the carotid artery readily leads to the posterolateral border of the thyroid gland. Further dissection will mimic that in the open surgery. A third trocar of smaller size might be required higher up on the same side. Second, a clear field in the depths of the working space is essential. Oozing from small blood vessels can be troublesome and obscures the view. The usual laparoscopic technique of suction and irrigation is not too desirable for the following reasons: (1) Suction readily collapses the small space; (2) irrigation dilutes the blood and delays clotting; (3) suction is frequently accompanied by fogging of the lens; (4) it is not possible to suck clear all the fluid staining the local tissues. By contrast, the proper use of gauze swabs can provide a dry and clear field. When blood is blocking the view, the telescope is withdrawn. A piece of Nu-gauze (Johnson & Johnson Medical Incorporation, Arlington, Texas) 2 cm × 2 cm in size is grasped by an endo-forceps and is passed all the way down the central cannula. With the camera in position again, the gauze swab is used to mop up the operative field. The gauze partially soaked with blood is tucked away from the operative site, ready to be used again. If required, compression by several pieces of Nu-gauze effects hemostasis. The fully soaked gauze swab can be easily removed by a grasping forceps while the flapper valve is kept open by depressing the desufflation lever. Despite encouraging early experience, the establishment of endoscopic thyroidectomy and parathyroidectomy as acceptable, if not better, alternatives to standard surgical treatment mandates a large prospective study comparing this technique with the classical open operation in a scientific manner.

One-trocar appendectomy

In a recent article entitled ‘‘One-Trocar Appendectomy: Sense and Nonsense,’’ Rispoli et al. [4] elegantly demonstrated that it is technically feasible, even in adult patients, to perform laparoscopically assisted appendectomy using a single umbilical port through which an operative telescope is passed to exteriorize the mobilized appendix, followed by appendectomy in a conventional manner. Nevertheless, it appears that the second half of the title is more intriguing. In our setting, wherein this most common abdominal emergency operation is largely relegated to surgery residents, we hasten to emphasize that the most sensible (and optimal) treatment strategy is an individualized approach, taking into consideration the patient, the disease condition, the surgeon, and of course, current technical developments. First, an important message emerges from reading Rispoli’s article alongside a similar one published 4 years earlier by one of his coauthors [1]. Notably, in the prior series, which included only patients 4 to 16 years of age, the success rate was 100% and the umbilical complication rate was 0%. In contrast, the success rate of the current, supposedly adult series is only 84.6%, and the complications resulting from manipulation of the umbilical region occurred at a rate of 11% despite several years’ more experience. The disparity between the results in the two series lends support to the premise that umbilical one-trocar appendectomy is more suited for pediatric patients in whom the cecum is closer to the umbilicus and the abdominal wall is more supple [6]. Notably also, the patient age in the ‘‘adult series’’ ranged from 13 to 40 years, (mean, 18 years). Not only did this series include many adolescents, but it also encompassed a proportion of nonacute cases with ‘‘recurrence pain syndrome.’’ The differences in clinical outcomes between the two series would be even more striking had adolescent and nonacute cases been excluded. Second, of the 65 patients in the current small series, 3 patients had serous discharge from the umbilical port wound, whereas an umbilical hematoma developed in 3 others. Plausibly, this is a consequence of forceful retraction or extension of the umbilical wound either for the extraction of the cecal cone or for placement of purse-string sutures. Almost concurrently, we have independently developed a one-trocar appendectomy, which is accomplished altogether intracorporeally, and has a demonstrated success rate of 100% in selected patients without untoward umbilical complications [2, 5]. We also use a 10-mm operative telescope and 450mm instruments. But in addition, endoloops are used to anchor the appendix while the mesoappendix is gradually divided using electrocautery. The appendix then is doubly ligatured at the base, again with endoloops, and retrieved through the single umbilical cannula without manipulation of the port wound. The endoloops can be made easily by passing a catgut suture through an intravenous catheter inserted percutaneously into the peritoneal cavity, fishing the distal end out with an endograsper, tying a slipknot, and pushing the latter down the cannula to reposition it intraperitoneally. Our one-trocar technique may appear rather complex, but in contrast to Rispoli’s technique, it does not involve mobilization of the cecum, which may be difficult or unsafe because only one instrument is used for dissection and electrocautery of adhesions and peritoneal attachments. Moreover, our technique is more advantageous in cases wherein the appendix is friable. Third, the described one-trocar technique offers merely modest clinical advantages over our current routine three-trocar technique using a 10-mm umbilical port and two 5-mm suprapubic ports placed below the line of pubic hair. Almost all our patients are satisfied with the superior cosmetic results. Further improvement in cosmesis would be rather marginal from the elimination of the two concealed scars. Also, given that the postlaparoscopic pain after appendectomy usually is felt predominantly over the right lower quadrant and the stretched umbilical wound, the reduction in overall pain by eliminating two 5-mm ports is very limited. More importantly, after diagnosing appendicitis on laparoscopy, we change the camera position to the left suprapubic port, while the ports on either side of the optical axis are used for working instruments. This ergonomically favorable setup [3] renders the approach userfriendly and safe for our trainees. As a corollary, an age-related treatment protocol has evolved in our department. In short, for pediatric and adolescent patients, the transumbilical one-trocar approach, as described by Rispoli et al. [4] is attempted first if the appendix, on laparoscopy, is found to be Letters to the editor

Treatment of childhood phimosis with a moderately potent topical steroid

Background: Recently, topical steroid application has been shown by a small number of studies to be an effective alternative to circumcision for the treatment of phimosis. However, only potent or very potent corticosteroids have been more thoroughly studied in this treatment option. A prospective study was conducted to determine whether comparable results could be achieved using a weaker steroid cream.

An optimal, cost-effective laparoscopic appendectomy technique for our surgical residents.

Since early 1999, we have implemented a standardized technique for laparoscopic appendectomy, which is simple, safe and easily learned and mastered by our residents. Besides superior ergonomics, it offers cosmetic advantages. It is inexpensive as only reusable instruments are used. It incorporates useful modifications, such as the use of suprapubic ports, inferior approach with repositioning of the videoscope from the umbilical port to the left suprapubic port, laparoscopic gauze swabs and instrument-assisted knotting, as well as skeletonization of the appendix. We analyze the outcome of this technique between January 2000 and December 2002. The overall conversion rate of 713 laparoscopic appendectomies was 8.7%, which is comparable with the “best” rates in international literature. Operative times (mean, 59.0 minutes) and the complication rate (6.7%) compared favorably with previous reports on resident training. In summary, our residents feel comfortable with our standardized approach, while producing acceptable results with low cost.

Port placement for laparoscopic appendectomy with the best cosmesis and ergonomics.

Dr. Kollmar and colleagues are to be commended for their elegant study comparing three different modes of port placement for laparoscopic appendectomy with respect to cosmesis and ergonomics [2]. In all these three two-handed techniques, the video laparoscope was inserted through the periumbilical port, whereas the two working ports were placed in the left and right lower quadrants in technique 1 (standard technique), in the left lower quadrant and the midline below the pubic hairline in technique 2, and bilaterally below the hairline in technique 3 (Fig. 1). The study found that 100% of patients were satisfied with the cosmetic results of procedure 3 with both working port scars concealed by pubic hair, compared to 54% with procedures 2 and 25% with procedure 1. On the other hand, among the three, technique 2 with a manipulation angle of 60 was deemed ergonomically most favorable. As a corollary, they have started to use technique 2 as the ‘‘standard’’ mode of access for laparoscopic appendectomy, while reserving technique 3 for cases where a perfect cosmetic result is desired. We would hasten to point out that siting the three access ports as in technique 3, and moving the laparoscope from the periumbilical to the left suprapubic port once laparoscopic appendectomy is decided, would achieve not only the best cosmetic results, but also better ergonomics compared to the above three procedures (Fig. 1). Ergonomically, our technique with the optical axis lying between the two working axes is superior to Kollmar’s techniques 2 and 3, in which the optical axis is outside the working angle [1]. Also, our manipulation angle of about 80 approaches that of the optimal layout for laparoscopic work [1]. In contrast, in the authors’ technique 3, the manipulation angle is too narrow — especially in those young females in whom the two suprapubic operating ports may have to be placed closely together within the narrow hair-bearing area (Fig. 1). Furthermore, with our technique, the main operating instrument through the periumbilical port is used conveniently in a plane at about 60 to the visual axis. The elevation angle of the working instrument traversing the umbilical region (which is at a higher level than the suprapubic region in an inflated abdomen) is likewise more optimal. In short, our surgeons, standing on the patient’s left, work comfortably without having one arm crossed over the patient’s body as in Kollmar’s technique 1. In practice, our technique offers several added advantages. First, the videoscope, pointing upward and to the right, affords much better visualization of the appendiceal stump and the inferior aspect of the cecum, especially during dissection of a retrocecal appendix [6]. In comparison, the visibility of a periumbilical videoscope is less desirable as it might be impaired by a distended ileitic cecum. Second, with the tip of appendix retracted upward by the left hand grasper, the flap of mesoappendix would assume a favorable position for skeletonization (serial disconnection of the mesoappendix close to the appendiceal wall, as practiced by Kollmar and us) by a dissecting forceps inserted through the periumbilical port. Third, a forceps in this position carries less risk of diathermy injury to the dilated sigmoid loop compared to when it is inserted through the suprapubic port. The described technique is user-friendly and can be mastered within a short time by surgical residents, who are, after all, the ones doing appendectomies in the middle of the night. Indeed, no sooner had it been introduced into our department than the proportion of appendectomies that our residents chose to do laparoscopically increased dramatically from 34% to 95% [5]. Since early 1999, more than 750 such procedures have been done with outcomes comparable with those reported in the best series, even though 92% of our cases were performed by junior residents under supervision [3, 5]. Because virtually all surgeons in our regional hospitals now prefer to use this technique to the exclusion of other alternatives [4], comparative studies with choice of trocar position dictated by the attending surgeon’s preference as in Kollmar’s study could not possibly get off the ground in our situation. As alluded to throughout the original text, the prevailing standard access technique for laparoscopic appendectomy a couple of years ago was to use a videoscope through a periumbilical incision and two working trocars in the left and right lower quadrants (procedure 1). Like all the other laparoscopic procedures, the technique of laparoscopic appendectomy is continuously evolving. We believe the aforementioned Correspondence to: W. T. Ng Letters to the editor

Endoscopic thyroidectomy in China

Endoscopic thyroidectomy (ET) techniques via various approaches have been touted for their cosmetic superiority. This is particularly true for those without any neck scars, such as the anterior chest approach, the breast approach, and the axillary approach. Recently, the Safe Introduction of New Procedures Committee of the Hospital Authority governing all of the 41 public hospitals in the Hong Kong Special Administrative Region of China has received submissions applying for permission to try the breast approach. Having been invited to chair the designated panel, I set out to search the English literature for clinical evidence; however, I could find only one comparative study without randomization (level 2 evidence) and four overlapping case series (level 3 evidence) [1–5]. The comparative study contained only 10–12 cases in each arm [5]. Also, three of these five publications came from the same university [3–5]. Given the paucity of published data, the jury seemed undecided about whether to allow its widespread adoption—until recently when I became acutely aware that ET is now commonplace in Mainland China. However, all relevant clinical reports have been written in Chinese. I feel compelled to unveil the current status of ET in China to the wider surgical fraternity based on my on-site observations and the data in the Manual of the 10th National Advanced Course in Endoscopic Thyroidectomy 2008—most aptly in Surgical Endoscopy, a specialty journal of international repute. An added impetus is that it was in the Journal that my first article on total video ET through three trocars in the neck appeared [6]. The year was 1997, during which the sovereignty of Hong Kong was reverted back to China. Unfortunately, the described technique rapidly fell into disfavor through lack of a high-sounding selling point. Zu and Wang were credited with being the first surgeons in Mainland China, successively performing an endoscopic thyroidectomy by the breast approach in 2001 and 2002, respectively, eliminating altogether the need for neck incisions [7]. Since then, an estimated 10,000 thyroidectomies have been performed under endoscopic vision in approximately 200 hospitals nationwide [7]. In 2006, a multicenter survey involving 26 hospitals from 13 provinces found a total of 1,327 cases of ET via breast approach, anterior chest approach, or axillary approach. Amongst the three approaches, the breast approach emerged as the clear favorite as evidenced by its exponential growth in number toward the mid 2000s (Fig. 1) [8]. This was simply because the disposition of trocars in the bilateral breast approach helps reap the dual benefits of excellent cosmesis and favorable ergonomics (visual axis between the working axes, 60 working angle and access to both lobes). The great majority of these 1,327 cases were benign solitary nodules, mainly adenomas, multinodular goiters, and sundry cystic lesions. Rarer pathologies were thyrotoxicosis (85 cases), thyroiditis (2 cases), and malignancy, mostly papillary microcarcinoma (31 cases). The overall incidence of early complications appeared to be acceptable (Table 1). The most common complication was related to the long subcutaneous path: collection or overlying skin bruising (1.28%). The second commonest complication was hoarseness of voice (0.6%). Notably, no major complications, including the most dreaded—tumor seeding in the access path—were experienced by these centers. It is tempting to extrapolate the present situation into the future: we can see a long-term trajectory of increased use of videoscopes for thyroidectomies because W. T. Ng (&) Department of Surgery, Yan Chai Hospital, 7-11 Yan Chai Street, Tsuen Wan, Hong Kong e-mail: houston_n@yahoo.com

A full review of port-closure techniques

I would like to congratulate Dr. Shaher on his timely review of one of the commonest procedure during laparoscopic surgery [28]. Indeed, closure of port wounds can be technically challenging and has taxed the brains of many ingenious surgeons, as evidenced by the publication of a plethora of technical innovations and modifications since the dawn of the laparoscopic era. It is therefore a daunting task firstly to design a system that can discretely categorize the dazzling array of described techniques of differing sophistication, and secondly, obtain an all-inclusive collection, serving ultimately as an archive for easy reference by future researchers in the field. Having closely followed the fascinating evolution of port-closure techniques over the last two decades, I feel compelled to strive to perfect the aforementioned review along these two directions. First, Dr. Shaher should be credited with first proposing an almost ideal classification. He categorized the retrieved techniques into three main groups: ‘‘[1] techniques that use assistance from inside abdomen (i.e., requiring two additional ports: one for the laparoscope and one for the grasper), [2] techniques that use extracorporeal assistance (i.e., needing only one additional port for the laparoscope), and [3] closure techniques that can be performed with or without (laparoscopic) visualization.’’ To avoid confusion caused by the overlap between the second and the third group, I would suggest that the last group be confined to those performed under direct vision without laparoscopic visualization (i.e., needing no port at all). Under this clear-cut classification, closure techniques using the sharp Reverdin needle and Deschamps needle under vision through the endoscope (for safety reasons and/ or to assist external manipulation to catch the suture in the eyelet) should be reclassified under the second group, instead of the third, as stated in the Results section of the manuscript. Also, there is a misquotation in the Results section: in describing the first group the author makes reference to an article by Conlon and Curtin while citing examples on the use of an angiocath needle to perform port closure. In fact, Conlon and Curtin described in that paper only the use of a J-shaped taper-cut needle (Ethicon Inc., Somerville, NJ) to suture the fascial defect under laparoscopic vision without the need for an endograsper [6]. Obviously, their technique should more properly be classified under the second group. Second, Dr. Shaher attempts to conduct an exhaustive search for port-closure techniques on Medline using the keywords ‘‘trocar’’ and ‘‘hernia’’. In fact, my extended search returned 26 additional relevant articles (including one in a recent laparoscopic textbook) that have not been included in the review article’s references [1–5, 7, 9–20, 22, 23, 25–27, 30–32]. Therefore, I would hasten to supplement his collective review by listing below the missing techniques or devices following the classification as amended.

Perfecting the dual-hemostat port-closure technique

Dr. Spalding and colleagues deserve congratulations for their original description of a very simple technique for port closure [2]. Basically, two hemostats are used. The first hemostat is inserted into the trocar wound to lift up one side of the wound while the second hemostat retracts the overlying subcutaneous tissue. The suture needle is driven through the abdominal fascia from outside to emerge between the splayed tips of the first hemostat. In practice, this technique is easy only if the skin incision approaches 3 cm in length and the subcutaneous fat layer is not thick. For smaller wounds, the splaying of the tips of the first hemostat would have stretched the overlying wound edge tightly. The curved needle would impinge on unyielding tissues during angling, such that it often fails to get a broad enough bite of the more deeply seated fascia and peritoneum to effect a secure closure (Fig. 1). Under such circumstances a useful trick is to drive the needle ‘‘inside-out’’ instead of ‘‘outside-in’’ as follows: Upon lifting up the trocar wound with a strong curved hemostat passed through it, a suture needle is inserted between the slightly opened jaws of the hemostat (Fig. 1). The tip of the needle pierces the undersurface of the abdominal wall almost 1 cm from the facial edge. While the buried needle tip is maintained in position, the hemostat is gently withdrawn to make room for the needle holder, which has to drive the needle through the thick aponeurotic layer in a rotating manner. Meanwhile, the overlying skin edge is retracted laterally for the emergence of the needle, which is facilitated by a fine hemostat grasping its tip prior to release by the needle holder. The same steps are repeated on the other side of the defect with another suture. The free ends of the two sutures are tied together and cut short. The knot is then pulled through the fascia, leaving a single monofilament suture to close the fascia. This ‘‘inside-out’’ technique has several advantages. First, it is more elegant and easier to execute. Second, it

A simple and useful method for retracting the left liver lobe.

The left lobe of the liver needs to be constantly retracted upward while laparoscopic dissection of the esophageal hiatus is being performed in a variety of operations, such as vagotomy, fundoplication, and esophageal myotomy. Many surgeons advocate using the suction and irrigation tube passed through the subxiphoid or the right subcostal trocar for retraction [2, 3, 5]. Different types of liver retractors, either expandable or malleable [1, 2, 4], have been designed. However, these various techniques carry disadvantages of one form or another, including the serious risk of inadvertent liver laceration, the need for an extra pair of hands (or a mechanical arm to maintain it in position), or the requirement of expensive instruments which have to be passed through 10-mm ports. A simple technique using the readily available grasping forceps is described. A self-locking atraumatic grasping forceps is inserted through an epigastric 5-mm trocar about 5 cm from the xiphisternum. With the left lobe of the liver elevated by another forceps inserted through a lateral working port, the grasping forceps is advanced into the hiatal area to grasp the uppermost muscle fibers of the crus of the diaphragm (or above). Liver retraction and exposure of the hiatus could be further enhanced by depressing the handle of the grasper. The locked grasper, once positioned optimally, may be held in place automatically by securing it to the surgical drapes using a towel clip (Fig. 1). This technique has added advantages, such as small port wound, elimination of the risk of instrumental injury to the liver, and unimpeded movement of the working instruments both inside and outside the abdominal cavity. It has been suggested in one surgical text that in the absence of a specially designed liver retractor, it might be necessary to divide the triangular ligament of the left liver lobe [1]. The described technique affords excellent exposure and obviates the need for detaching the diaphragmatic connections of the left lobe of the liver.

Routine contralateral exploration is advisable during extraperitoneal hernioplasty for left inguinal hernia

Controversy still exists as to whether the contralateral groin should be routinely explored during totally extraperitoneal hernioplasty for a clinically unilateral hernia. Bochkarev and colleagues are to be commended for their diligent study, which showed an overall 22% occurrence of occult contralateral hernia among 100 consecutive patients with a diagnosis of pure unilateral inguinal hernia before surgery [1]. They conclude, rather categorically, as in all previous studies of the same disorder, that routine bilateral groin exploration ‘‘appears’’ to be valuable. Interestingly, when we look at their raw data from a slightly differently perspective, two important messages emerge. First, in contradistinction to most previous studies, the current study is particularly revealing in that it specifically mentioned the side of hernia presentation in relation to the exploratory findings. Table 1 of the original paper correlates the number of occult defects with the respective side of the primary hernia at clinical examination. Unfortunately, there is an unintentional mix-up in the numbers of occult defects for the respective left and right hernia groups. The table is herein amended and further simplified/ modified to make the points we raise more easily recognizable (Table 1). It shows that as many as 19 (37%) of 52 patients with clinically unilateral left inguinal hernia have an occult right hernia at exploration, whereas only 3 (6% or 1/16) of 48 patients with right hernia have an occult left hernia at exploration. Notably, these markedly contrasting results are in agreement with those found in two studies published earlier [3, 5]. Indeed, the more recent study, albeit of smaller scale, found that patients with a preoperative diagnosis of left unilateral hernia were 10.5 times more likely to have bilateral inguinal hernia than those with a preoperative diagnosis of right hernia, when adjustment is made for age and sex [5]. Therefore, these few reports make a strong case for exploring the contralateral groin in all patients with a diagnosis of left inguinal hernia at clinical examination. However, it remains doubtful whether right inguinal hernia presentation warrants the additional procedure as a routine, especially in light of the current finding that 15 patients would need to be subjected to unnecessary exploration just to get one incipient unsuspected hernia. Second, the original Table 1 shows two hernia recurrences after bilateral repair in 22 patients (10%). This incidence appears inordinately high. Possibly in bilateral cases, the abdominal wall is inherently weak [4], or alternatively, there remains an underlying cause for persistently elevated intraabdominal pressure. Under such circumstances, a stronger repair is advisable.