Minimally Invasive Surgery
Minimally Invasive Surgery
Faculty members in UCLA's Departmentf of Head and Neck Surgery use advanced technologies to perform a variety of minimally invasive surgeries, which have revolutionized treatment for many conditions. These minimally invasive procedures result in less discomfort, quicker recovery times and better outcomes for patients than traditional "open" surgery.
Minimally invasive techniques are being used in:
- Endoscopic skull-base tumor resection (selected tumors and locations)
- Endoscopic sinus surgery
- Pediatric endoscopic sinus surgery
- Pediatric endoscopic airway surgery (larynx/trachea)
- Minimally invasive office-based procedures in laryngology
Minimally Invasive Surgeries
Surgeries for disorders of the thyroid and parathyroid glands vary according to the disorder being treated. For example, partial removal of a thyroid gland for which diagnostic testing is not fully informative, is different than removal of the entire gland or associated lymph nodes for cancer.
In general, "minimally invasive surgery" means that the smallest possible incision is used to allow safe and effective removal of the gland without disrupting normal surrounding tissue. Not all patients nor all thyroid pathologies easily lend themselves to minimal surgery, but where appropriate and safe, our head and neck surgeons are very adept at using minimally invasive thyroidectomy techniques that minimize incisions and hospital stay and maximize clinical outcomes.
The parathyroid glands are involved in maintaining normal calcium function. Increasingly, disorders of these glands are being found on routine medical evaluation. When abnormal glands are localized by preoperative scans, the curative surgery to remove such glands can easily be performed in a minimally invasive fashion using small incisions and limited exploration of the neck. Such an approach has long been used by surgeons and can optimize patient outcomes with minimal scars and limited hospital stays.
Benign and malignant tumors involving the base of the skull —near vital structures such as the eyes and brain— have traditionally been approached using large facial incisions and often required retraction of the brain to optimize exposure and tumor removal. Our head and neck surgeons use less invasive means of tumor removal, eliminating the need for brain retraction. In selected cases, tumor removal can even be performed through the nose using microscopes and telescopes, without the need for facial incisions or brain retraction. This approach has been shown to decrease long-term side effects, and hospital stays.
UCLA head and neck surgeons have been performing endoscopic sinus surgery since 1987. Currently, over 400 procedures are performed each year with 90 percent of patients reporting significant improvement in their symptoms.
Endoscopic surgical techniques avoid facial incisions and the numbness typically associated with more conventional forms of sinus surgery and can be performed on an outpatient basis with minimal postoperative discomfort. New technologies, including computer-aided image guidance and balloon sinuplasty, have increased the accuracy and efficacy of endoscopic sinus surgery. Surgery for revision sinus cases, massive nasal polyposis, and sinus neoplasms can be performed with a greater degree of safety and precision than before.
Management of underlying allergies with appropriate medications, including immunotherapy, is maintained postoperatively. Surgeons work closely with referring physicians and appropriate consultants in allergy/immunology, infectious diseases, neurology, and pain management to coordinate each patient's treatment plan.
Pediatric patients with chronic sinus disease require careful diagnosis and therapy, often different from that of adults. Specialized techniques have been developed over years of clinical experience with chronic pediatric sinus disease.
Indications for sinus surgery in children include sinusitis refractory to medical therapy, and underlying disorders such as cystic fibrosis or ciliary dyskinesias. Other surgical candidates include those with anatomic abnormalities, such as choanal atresia/stenosis, nasal stenosis, septal deviation, or sinus wall defects.
Pediatric endoscopic sinus surgery is usually performed as an outpatient procedure. Children are back to school in less than 1 week and may resume all activities within 2 to 4 weeks, depending on the underlying illness.
Pediatric patients with airway disorders, either acquired or congenital, often require multiple airway surgeries and close follow-up care. The goal of treatment is to maximize results with minimal trauma to airway structures, preserving and/or restoring both anatomy and function.
Minimally invasive pediatric airway techniques have evolved over years of experience and research with the latest technology and the safest techniques.
Indications for airway surgery are many, and include congenital lesions such as subglottic hemangiomas, laryngomalacia, and congenital vocal cord paralysis, as well as acquired disorders such as subglottic stenosis, recurrent respiratory papillomatosis, and granulomas.
Recovery depends on the initial presentation of the disorder, the baseline health of the child, and the degree of airway surgery needed. Continuous postoperative monitoring in both the pediatric and neonatal ICUs is often an integral part of the treatment plan.
Over the past 25 years, advances in medical devices have enabled surgeons at UCLA to improve their ability to diagnose and treat head and neck disorders in an office setting. This has been particularly true in laryngology. Flexible fiberscopes used to evaluate the larynx became available in the 70's and were significantly improved with the addition of miniature cameras (the so called distal-chip-tip scopes) in the late 90's. With advances in technology, these cameras are becoming better and smaller, allowing increasingly advanced procedures to be performed in the office.
Office-based procedures are performed under local or topical anesthesia. In addition to offering fewer risks and side effects than general anesthesia, the use of local and topical anesthesia enables patients to drive themselves to and from their procedure appointments and to recover more rapidly. These procedures cost less money and cost patients less in missed work time. Office-based procedures have an excellent safety record and often prove more comfortable and convenient for patients than surgery in the OR.
Office-base procedures offered by the UCLA Department of Head and Neck Surgery include:
- Transnasal esophagoscopy
- Placement of TEP speaking valves
- Panendoscopy for cancer screening
- Therapeutic vocal fold injection (e.g. augmentation, Botox)
- Laryngeal, tracheal, and esophageal dilation
- Diagnostics: pH testing, FEES, Manometry
Overview & Development
Vocal fold medialization is a common procedure performed at both UCLA Voice Center and 200 Medical Plaza offices. UCLA is among the most experienced centers performing this procedure and achieves very positive outcomes. In many cases, a patient referred to Dr. Berke for vocal cord paralysis or weak vocal fold movement can go home the day of their first visit with an improved voice.
Most patients who are candidates for injection medialization have a history of vocal fold paralysis. This can occur secondary to injury during surgery by another physician, invasion of the nerve by cancer, or a viral infection. Diagnosis is performed with an analysis of the vocal fold movement and a medical evaluation of speech.
The injection of collagen or other materials is performed with a flexible scope evaluating the placement of the material. A small amount of lidocaine is applied to the nasal cavity to improve the comfort of the patient. Dr. Berke injects a small amount of collagen into the vocal fold through the neck. There is some mild discomfort and desire to swallow during the procedure, but this quickly passes and the patient is usually able to speak more clearly and with greater volume after the procedure. Often, we inject a little extra collagen into the cord to compensate for the slight decrease in size of the implanted material over the next few weeks.
Patients are able to leave the office 10 minutes after the procedure and can eat about 30 minutes after that. They may use their voice immediately. We frequently see these patients back in 2-3 months to discuss their voice and determine if any other intervention is necessary.
Overview & Development
Distal-chip scopes with channels on the side for instruments have enabled surgeons to perform biopsies or treat lesions of the vocal fold. The "working channel" is quite small (a few millimeters) but allows small graspers or fiber lasers to access the area of interest.
Anesthesia for the procedure is provided by topical lidocaine. First, the nose is anesthetized with a spray of lidocaine and small nasal packs are inserted to help decongest and numb the nose. Following this, the fiberscope is passed through the nose and into position above the vocal cords. From this location, lidocaine is dripped directly on to the cords. This is uncomfortable at first, but quickly improves as the lidocaine takes effect. This process is repeated several times until adequate anesthesia is achieved.
Biopsy of the vocal fold is performed with small cupped forceps that allow removal of extremely small lesions. In most cases, we take multiple biopsies to ensure the pathologist has enough tissue to evaluate the lesion. Pathology reports are usually returned to us within a week.
Laser treatment of lesions is performed with a Pulse Dye or KTP laser. These lasers treat the blood vessels that are "feeding" the lesion. These lasers are far less likely than operative procedures in the OR to cause complications such as webs or injury to the delicate lamina propria.
Candidates for biopsy or treatment with the PDL or KTP laser include those diagnosed with recurrent respiratory papillomas (RRP), leukoplakia, granulomas, or other concerning masses on the vocal folds. Although this technology is usually used for vocal fold masses, biopsy of other hard-to-reach areas in the nose or base of the tongue may also be treated in a similar way.
Patients who receive a biopsy or laser treatment are asked to refrain from speaking for 3-4 days while the area heals. In addition, patients are prescribed anti-reflux medications to improve healing. Tylenol may be taken for any post-procedure discomfort, but this is usually very mild. We frequently see patients back one week after biopsy to review the pathology report and several weeks after laser treatment to review the effects of treatment. Some patients will require multiple procedures to control their disorder.