1	Lumbar Endoscopic Assisted System Microdecompression of Disc and Stenosis John C. Chiu, M.D., FRCS (US), D.Sc. Chief, Neurospine Surgery California Spine Institute Thousand Oaks, California, USA President, ISMISS/SICOT
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3	Introduction: New SMART Endolumbar System (endoscopic lumbar) (Karl Storz Endoskope) is designed to bridge the traditional spine surgery and minimally invasive endoscopic spinal surgery for treatment of degenerative spine disc disease Lumbar disc herniation is a common occurrence and some require surgical decompression Posterior laminectomy and discectomy with or without fusion is more traumatic and potentially destabilizing Therefore, the search for minimally invasive spinal surgery (MISS) began It can be an effective, safe, less traumatic and easier spinal surgery
4	Advantages: The SMART Endolumbar Spine Surgery Direct visualization of surgical field A microscope or loops can also be used through the SMART Endolumbar channel An Outpatient procedure MISS with small skin incision Local or brief general anesthesia. Procedure can be done for high risk anesthesia patients Reduced post surgical pain due to reduced tissue trauma More rapid recovery and earlier return to previous activity Exercise program begins same day as surgery Preservation of spinal motion Holding arm can be used with SMART system (optional)
5	Surgical Indications: Posterior/posterolateral Lumbar Spinal Approach: Microendoscopic Discectomy Microendoscopic Disc Decompression Microendoscopic Decompressive Foraminotomy Microendoscopic Hemilaminectomy and Lesion Removal (e.g. synovial cyst, intraspinal tumor) Microendoscopic Decompression of Lumbar Stenosis Microendoscopic Intertransverse Process Fusion Microendoscopic Transforaminal Lumbar Interbody Fusion Minimally Invasive Lumbar Pedicle Screw Fixation Providing an excellent access for spinal arthroplasty Positive 3 Legs of bar stool – symptoms, physical findings and testing (e.g. EMG, imaging and provocative discogram)
6	Surgical Instruments: Design based on tissue dilatation technology and not cutting tissue technology – much reduced tissue trauma Dilatation of soft tissue/muscle fibers by inserting the SMART operating dilators and the Endolumbar trocar (tubes)
7	Surgical Instruments: Bulls Eye Localizer (Target Device) Guidewire SMART gradual dilators (Obturator or Dilator), serial, progressive sizes, OD, 4.6mm, 8.1mm, 12.1mm, 14.5mm, 16.2mm, 18.5mm, 20.2mm SMART Serial Tubular retractors (SMART Endolumbar System Trocars) – Progressive sizes ID, 8.3mm 12.4mm, 16.5mm, 20.6mm
8	Surgical Instruments: Endoscopic Sheath with 2 rotatable stop cocks, 5.5 mm Obturator, Sharp Obturator, Blunt Hopkins Telescope II - 0 ° Hopkins Telescope II - 30 ° Kerrison Bone Punch Bayonet-shaped - 45 ° - 3 mm Kerrison Bone Punch Bayonet-shaped - 90 ° -3 mm Trephine 3 mm Trephine 4.5 mm
9	Surgical Instruments: Nerve Retractor 15 cm working length, 130 degree angle at handle - 4 mm Dissector, Bayonet shaped Bipolar Forceps, bayonet-shaped Bipolar Coagulating Forceps Spoon Curette Size 0 Rasp Nerve Hook 90 ° Width 4mm, 13 cm Elevator Freer Elevator double ended
10	Surgical Instruments: Grasping Forceps 7mm jaws -3.5 mm Forceps, Biopsy, 3mm Jaws Forceps, spoon oval - 5.5mm Forceps, spoon oval- 3.5mm Cutting Forceps
11	Surgical Instruments: Scissor Tissue Forceps Bayonette w teeth Fergusson Suction tube Osteotome - 7mm Osteotome -10 mm Chisel - 4 mm Periosteal Elevator -14mm Mallet
12	Technological Convergence - OR Control System OR Surgmatix^®
13	Surgical Equipment: Endoscopic video tower – AIDA (OR1 - Karl Storz Endoskope) With endo-video monitor, DVD recorder, Xenon light source, endoscope, camera, and printer Imaging/MRI HD video monitor behind endo-video tower
14	Surgical Procedure: Under local anesthesia and monitored IV conscious sedation Mild sedation, but is able to respond Two grams Ancef and 8 mg dexamethasone intravenously at the start of anesthesia Surface EEG monitoring (BIS) provides added precision of anesthesia Continuous neurophysiological – EMG monitoring to prevent undue trauma to the nerve root
15	Surgical Procedure: On a set of bolsters for lumbar spine surgery Head holder with reflective mirror for visualization of patient’s eyes and nasal/oral area
16	Surgical Procedure: In prone position
17	Surgical Procedure: Under fluoroscopic guidance Point of incision – by placing the “bull’s-eye” target device to determine the point of incision at the lateral recess
18	Surgical Procedure: Skin incision and approach – at the marked point, a skin incision is made (approximately 12-14 mm.) The lumbar fascia is opened with dissecting scissors The underlying paravertebral muscle is separated by the dilator without cutting A small periosteal elevator may be inserted until contact with lumbar lamina
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20	Surgical Procedure: A guide wire is first introduced into the lateral recess through the target point Through a small incision a series of gradual dilators are placed over the guide wire to separate the muscle Dilatation surgical technique without cutting muscle SMART Endolumbar Trocar/cannular is pushed on to the lumbar lamina over the dilator
21	Surgical Procedure: Into the opening of the side arm, a endoscopic sheath with an obturator is inserted into the side opening of the Endolumbar trocar After removal of the obturator the endoscope can be inserted, and the dilator can be removed Any soft tissue into the operative field can be removed by using a rongeur The adjustable angle between the endoscope and the operating channel is 15-30°
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26	Surgical Procedure: SMART Endolumbar working tubular assembly is inserted and fixed to the lumbar area by a triangulated endoscopic sheath The Endolumbar Trocar/tubular channel (various size 9-23mm) with a endoscopic sheath (and a 4mm endoscope), in the side arm, for visualization of a distortion free view of the operating field and to have the surgical instruments always visible to avoid neural trauma
27	Surgical Procedure: Bone resection – this involves part of the superior lamina and part of the intervertebral articulation Opening of yellow ligament, and exposure of dural sac and nerve root Resecting the bone enables an easier access to the herniated lumbar disc without any traction on the nerve root and to avoid undue trauma to the nerve root
28	Surgical Procedure: Endoscope is inserted into the endoscopic channel for visualization of the operative area The 0° or 30° endoscope may be utilized to achieve a distortion free view of the operating field The tubular retractor allows working of the surgical instruments of suction, forceps, rongeurs, bipolar coagulation and the nerve root retractor, in the operative area The working tip of the surgical instruments is always visible which avoids the risk of undue neurologic trauma
29	Surgical Procedure: Resecting the bone with a bone punch allows access to the yellow ligament through the Endolumbar Trocar/tubular retractor The yellow ligament is dissected
30	Surgical Procedure: Dissection of the nerve root and resection of the herniated disc Nerve root retractor is utilized to dissect and retract The epidural veins may be bipolar coagulated if needed After retraction of the nerve root, the herniated disc is visualized, for microdiscectomy
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34	Surgical Procedure: Hemostasis is secured under direct vision with bipolar coagulation 25% Marcaine is applied intramuscularly prior to wound closure Suturing of the lumbar fascia, subcutaneous layer, and skin Small dressing is applied afterwards
35	Discussion and Comment: Additional advantages of the SMART Endolumbar system: This procedure also can be performed under direct vision With a magnifying loop or surgical microscope Postoperatively patient is ambulatory and discharged in an hour Provocative discography is optional SMART Endolumbar system provides an excellent access for future spinal arthroplasty and new spinal innovations
36	Conclusion: New SMART Endolumbar System using dilatation surgical technology, is designed to bridge the traditional spine surgery and endoscopic spinal surgery Less traumatic Smart Endolumbar spine surgery is an, effective, safe, and easier MISS for treatment of herniated discs, intraspinal lesions, and spinal stenosis It preserves spinal segmental motion and also provides an excellent access for spinal fixation, fusion and spinal arthroplasty
37	Hope you enjoyed this presentation!