Minimally Invasive Surgery
Minimally Invasive Surgery of the Head & Neck (MISHN)
A variety of conditions affecting the head & neck region, including nasal and anterior skull base lesions, can be addressed via an entirely endoscopic (scarless) surgical procedure, or via a cosmetic, mini-incision approach that involves a smaller incision and hence faster healing. This is now possible mainly because of the tremendous advances in technology. Current imaging techniques offer accurate data on tumor location and extent, allowing the surgeon to reliably plan MISHN. At the same time, advances in optical, illumination (LED), high-definition camera and powered instrument technology now allow the surgeon unparalleled access to even deep seated skull base tumors and ability to safely remove them with minimal complications. Further, the advent of various innovations in the delivery of CO2 lasers now make it possible to completely remove small and medium sized tumors of the mouth, throat and voice box with excellent healing and recovery. This section outlines the type of procedures that can be done with MISHN.
Thyroid
The traditional technique of removing thyroid masses involves a large incision in the neck which can measure 6 to 8 cm in length and extensive tissue dissection. The big incision often does not heal well and leaves a long lasting scar. Innovative new concepts such as extracapsular dissection now allow identification and preservation of the recurrent laryngeal nerve (that is responsible for normal voice) and parathyroid glands with a minimal dissection technique. This has now opened up the possibility of small and medium sized thyroid nodules to be removed via a tiny incision located in the lower skin crease of the neck. This incision heals extremely well and in time the scar becomes barely noticeable.
Parathyroid
In most cases only one gland is abnormally enlarged to produce excess parathormone. The traditional technique involves giving a large incision in the neck to explore all 4 glands to identify the abnormal one. Nowadays, a special scan called sestambi scan can help localize which one of the 4 glands is abnormally enlarged. Then, during surgery, a radio probe is used to “seek” this abnormal gland which emits more radio activity than the other 3 glands. Thus, a small 2 cm incision is adequate for the targeted removal of the abnormal gland with minimal dissection of the surrounding tissues. This procedure is called Minimally Invasive Radio-guided Parathyroidectomy (MIRP).
Neck dissection
Traditionally, malignancy involving the neck is removed by an extensive operation called radical or modified radical neck dissection that involves dissecting all 5 levels of the neck and also removing the major jugular vein and sternomastoid muscle if necessary. Such a radical procedure involves an extensive scar, causes considerable pain, is more likely to injure critical vessels and nerves and delays recovery. Recently, we have better understood the pathways by which cancers spread and which levels of the neck are more likely to be affected. It is now increasingly recognized that targeted removal of these “at-risk” nodal levels is adequate. This minimally invasive procedure is called Selective Neck Dissection (SND). SND is cosmetically superior with a much smaller incision that heals very well, takes much less time to complete, is almost complication free and heals fast. Dr. M. Dhiwakar is one of the pioneers of this new concept and has published several journal articles on this subject. Electrocautery instrumentations have also improved, making more precise and “bloodless” dissection of the tissue planes now possible.
Removal of head and neck tumors with the CO2 laser
Tumors of the tongue, tonsils, throat and voice box have traditionally been addressed by open surgery or radiation. CO2 laser resection is an attractive new option for the scarless surgical removal of these small-to-medium sized tumors. Under microscopic control, the laser beam is directed via the mouth (transoral) and with special gadgets for access and removal, the tumor can be completely removed. In many situations radiotherapy can be avoided. This surgery involves no scar, tissue healing is excellent and the patient can return to good speech and swallowing in a matter of days. This procedure can also be repeated if necessary for tumor recurrence.
Endoscopic Sinus Surgery (ESS)
The days of open surgery (that cause obvious scars in the face) for simple sinusitis and nasal polyps are over. With the rigid optical telescope, camera and high definition monitor, fine endoscopic instruments and powered instruments such as microdebrider and drill systems, even complicated and extensive cases of sinusitis and nasal polyps can be adequately and safely addressed endoscopically. There is no scar involved and patients make a fast recovery and are usually able to go home the next day.
Expanded Endoscopic Sinus Surgery (EESS)
The scarless ESS procedure can now be also expanded and applied to conditions beyond the confines of the paranasal sinuses, which traditionally have been addressed by open surgery. Examples include pituitary tumors, CSF rhinorrhea, anterior skull base tumors and a variety of orbital procedures such as dacryocystorhinostomy (for teary eye), orbital decompression (for protruding eyes due to thyroid disorder) and optic nerve decompression (in trauma and tumors). In many situations, a craniotomy (opening the skull) can be avoided and the patient makes a much faster recovery with minimal complications.