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A-1125 The Benefit of Small Incisions
Philippe Liverneaux, France
Thursday, June 14, 2018 · 9:49 a.m. · 18m 59s
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and your colleagues um when no mission but tina asked
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me to present through the benefit of small incision
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you didn't mention that i have to speak about the drawbacks of small incisions that's pretty comfortable
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so i've got some conflict of interest to discover so everybody says that a small is beautiful
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but
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do you think
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that
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this car is beautiful
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no no i would prefer a rapper to rappers copy than these ugly scar e. u. two
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i actually it was an emergency i was like dang i and we'll choice
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so what i want to say is that it's obvious that a small incisions
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are better than large incisions better for a couple of reasons first of all for
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for cosmetic reasons of course patients prefer small incision dialogue incisions like me
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also because of faster recovery because the healing process is faster
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if you have less tissue to to heal of course it's it's faster
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and the uh the heating is better and is faster anyway
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if you don't think these in case of any trouble if you make a small incision you got
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some problems just in last incision and that's all but if you start with a lot decision
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you can make it smaller
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so you know it's a trend in surgery in every kind
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of surgery to and to spread a minimally invasive surgery
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ending in hand surgery we can do it uh for
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all the shoes bones joints tendons muscles even nerves
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remember in any case of any trouble just convert it open
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so i will show use capital cases that we developed in our department but of course there
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are many many others probably all of you develop some uh meaning meaning many incisions for
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four nine surgery so i wouldn't choose one example for each tissue
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for bone
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look at the right look at the left for small plate you use at an extended approach of the f. c. r.
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and here for longer plate you can use very small incisions anything on the left you respect all the
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tissues you respect the pointed to a a quarter and uh uh all of the other tissues
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so the patient recover faster of course this is obvious you don't need to demonstrate
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that if you get out of a plane without a parachute is uh
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worse than getting a bashes because it's obvious we don't it's we
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don't need science sometimes we need you know common sense
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so i'll
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this is the assault video to show you how to perform a with a minimally invasive the
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incision the standby just factor you just have to put the plate just below the furniture
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and uh uh then you fix the plate to be start part of the rages you don't care about the shaft
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you navigate what take the plate make it's way to make sure that it's correct
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and they're uh then you put some screws and then you remove the key wires
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and then you would use are intractable frame and if you do have some
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and when it's done you just have to uh to insert the proximal screws just facts the waste
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push on the proximal part of the of the plate and then you got the reduction and uh so on
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and you don't need when age you don't need a cast and the patient can move immediately after we use of the
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n. s. t. v. i'd have to to reach the to which the patient of course they they move very fast
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so about the joints now you know i just this example because it's it's really interesting
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this example is about you know a fusion of the d. i. p. joint
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usually we use uh the i. p. join fusion for utterances
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and uh most of such on the user a wider porsche to get the tendons
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they removed it's a control bone sometimes they will use the you meant
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and then they use some care wires grew even plate and they it complains because they got nonunion
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but they got nonunion because the joint if you remove everything is very unstable
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it's very difficult to standardise the t. i. p. joint so why do you want to remove the canteen age
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for the i. p. fusion uh it in indication of opposes if it is enough was it's there
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is no cottage so why do you want to remove the cartilage just insert to school
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or uh what if we want compression screw uh in the joint and that's done takes a a less
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than ten minutes with the on air hundreds of cases like this in we got only one nonunion
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so all this is the technique
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so you can see that there is no calculate so why do you want to remove the
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cartilage and even if there is an inclination you can you can present inclination the snake
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when the when the result some constraint because of the of the of the inclination of
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the all the joint this make the stabilisation no stronger so with only this approach
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you can get very easy a very strong uh um a stabilisation and then you can get
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a good fusion
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that for the tendons when you get an infection of the tendencies
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of course this is kerry catch role here because in most of the cases you don't open like what i'd really like
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here because here it's because there is a whiting was invitees but when you want to clean that tendon sheath
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you open at the uh the approximately to the tendencies and then also you open a little bit but too much
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because some some most of the cage depression have some difficulty to to to get the the complete motion
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but the with this technique which has been described then you're all maybe thirty years ago but i knew the answer
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you only have to to to clean the joint with the ceilings and the guy feature
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a a half a meter and then you put some antibiotics and it works very well
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i hope that the videos will work yes so at the top this is
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the cleaning doing the operation we use it wasn't a referee to
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make sure that the needle is exactly in the didn't shave and this
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is the result here two days after the operation and this patient
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she is she's a plastic surgeon
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well not working but when we use all the video she's a plastic surgeon in our
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in our hospital and three days after the operation to get back to the or
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ah is there anybody to
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of course of course of course it only in stage uh one on stage too
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of course if you need to see the victim you can't do this or a e.
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but in in you know stage three is very very seldom
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in our
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i yes maybe you have a lot i don't know so you can't use this technique i'm sorry for
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you so all ball joint tendons and also muscles when you want to harvest or a flat
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you should only the a big amount off off of skin here the skin is only to check if the fact
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he's still alive why don't use you you open so wide early you can use this are very small in
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incision like here
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uh the extent yes so i'll of course you need a you need to train on the ladder
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still this is the first incision for something that has this is on the cat
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ever the first step is to notice where is the pinnacle of the fat
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and then you this act as far as possible this gene from the soft issue then you close the
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uh the score and then use or what bought or endoscopy or whatever you
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want and you can complete the section with this very very small incisions
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so will you know why we will be inside so that we do
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is not so good because this was not the h. t. video
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six almost six years ago and this is the ontario border are all the all the fat and
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uh this is the super early this is at the start and this is proxy mall
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and this is the superficial layer and this is the other you about all the fat you know from the yeah
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pressed to the accessory a area and then when you the the the section has been completed you just get
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the the the mass all the study and then you go of approximately you until you see their
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uh this is the tendon and do you see uh the tendon and then you can
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if you want to make it practical flat it's you you you leave
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a typical or if you want to free you just have to
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to get the tendons and the pinnacle and uh then to uh put the mass solar outside
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of this small incision for submit as incision you just have to to get again
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and uh just after this we have a simple case yes this is a very very oblique
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in clinical case uh operating fulltime fire the all
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to be surgeons the cats they they
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a newsgroup could use norton then they're dead to intervene that you got a fusion of the uh uh
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of the of the shorter saw this is this is the
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only to show you the the the the technique
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and this is the the final incision and this is doing the operation you just have to use the mess all
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first of all you have to be is the uh the d. player of
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the most or because if you start with a with a superficial layer
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the most all will be stuck on the re cajun it would be impossible to complete the the uh the the section
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and uh of course we use some c. o. two gas
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to get to a um a larger uh operating feel
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so now we are uh inside again this is that
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uh do you the most or is here
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and this is the no sorry the this is the d. player no this is the anti
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about all the muscle the the the read cages here and uh this is the scheme
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and uh we detach the mixer from the of first the t. player and then the superficial
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layer this is the star this is proximal so we use the scissors with quite relation
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and then when we detach all the mess all uh and uh uh
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from the distal part to the proximal part and uh when air
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when you feel that you the the second overmatched all i mean when
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you will see the the loop around medical but means that's the
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the uh uh this section is completed and then it's uh it
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you only have to open again the small incisions too
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to a withdrawal the the were bought open again the incision and
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then just uh get the muscle outside of the incision
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yeah in that case i didn't used when age uh and our um the patient got a very very small stars
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and uh so this is the the sectional all the mess on all this is the basic all
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so that means that we exactly the mess hall from uh the the stall it to the proximal part
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and then we just have to uh we use the uh we use the or
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the robot to check that everything is uh as being released and there
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then this is the muscle outside of the uh of the you can see the incisions which are here very very small
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you here we use it a typical but you can also use it uh um use it or a free
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so i'll i. e. bones johns cantons mass on an also norms
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when you want to uh are still intact on was for
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regular prices reconstruction uh why do uses such large incisions
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uh you can do exactly the same even faster uh and safer
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uh with the two microscopy you can see the incisions here one two three four
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small incisions here to get the uh the nor the the
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numbers and uh here is the way health too
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to put the nerves outside of the to write and then reuse it you use the interest on
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those uh to uh for the biceps uh a little branch of the of the biceps
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uh the again we train on uh on on cadaver on here
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on picked on pleasing in a life be and um
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so if you are interesting just uh uh sending an email and we organise a course
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uh at every year for a rubber to colonel micro surgery so all we
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are here inside the rib cage so what we have to do
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is just to notice where is the nerve by transparency and gently you get the part temper
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are and then when you get it is very easy this was our first try or
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um and uh uh so it's the reason why one not so keen at that time but
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you will see in the in the patients that it's uh it's it's very easy
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compared to in open procedure and so you have to open the part that
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program from the ontario border of the rib cage to the posterior border
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and uh this is the this is the one or and then you can clean or
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quite late around of course not the nerve and uh then
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you can perform the distinction very easy like these
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you know you can be second or one two three four the cost a lot
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then when the the section of the completed you jacket that the ontario border and then you
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can make some progression actually it's not necessary because the reading is a very very small
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it probably due to the pressure of the of the gas and here we
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have three into cost on wasn't that big is still alive she
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uh same for patients still lash uh so we have these design
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precisely because it's not so easy to beside precisely the um
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um the the spot of the other of the portals of course i
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i don't to uh not or substance until i i like
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like the to something more to to prepare their the uproar for
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that but it's actually it's very easy and our um
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uh also for for uh administration ration i don't do it by myself but when
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i training on peaks of course i do it it's very very easy
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and uh it's although you will have to dot the robot this is the
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uh this is the the can laugh although a fall uh the camera
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and uh um uh then you it's ready to go to and uh operate the third one is
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uh uh outside of the or operating shield and doesn't need to scrub for this step
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um uh so you can hear see that this is the uh the
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number of one of the note that we will uh a sec
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uh the uh of course the benefit is that you get small incision the patient is really
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the uh two days a later you don't have to be afraid about getting air um
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hair in the read cage because there is always a here it's all uh there is no risk
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and uh uh with a robot can perform that this section the easy sort of course um
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from a very simple or other procedures like it to start not
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to start with these factors not so simple but for
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the i. p. fusion to these of course you need a lot of
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different technologies uh you not to a different um
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uh skills and there isn't no inter for each uh operation but uh
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a minimally invasive surgery is of course the future because uh you know in there
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in interesting surgery not prescott big surgery um all the search
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on the new well gee they they're opening more
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only for special cases all why should we not push
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in this uh direction so here we all those two into cost
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on ours and uh we asked to their presents certain praise
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press it with your figure to notice where is the outside a portal okay when
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we agree just insert a a little card inside the the the thorax
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um that then a user forceps to get out the the the north
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please don't for onto to match the the the numbers of calls
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and then you put the no of the outside still
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uh this is a second case we operated about ten
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cases four or four way and another case
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here and then uh you can see that we have a very very cosmetic a scar
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so i didn't speak about our first copy because of course it's obvious
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the it's all yay everybody use options could be right now so it
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for the youngest one if you are interesting please come to stress were reorganise the course
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uh of mister actors could be a with or you want us so i'll remember a
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minimally invasive or a surgery is that train in every topic since surgery and um
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if you make small incision it's not difficult to make it larger but the country is not
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possible it takes time you have to develop new tools but um please uh try to uh
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to not to to try to catch the the
