Comparison of insufflation vs retractional technique for laparoscopic-assisted intervertebral fusion of the lumbar spine

Abstract

Laparoscopic transperitoneal fusion of the L5-S1 spinal interspace has become a common procedure. Retroperitoneal retraction and laparoscopic instrumentation without insufflation also allows visualization of the upper lumbar spaces, but this procedure is much more difficult to accomplish. We review and compare our results using each of these techniques for the treatment of mechanical instability and chronic back pain. A total of 35 selected patients underwent intervertebral fusion between February 1996 and August 1998. Their mean age was 48 years. There were 22 female and 13 male patients. Standard CO2 insufflation was used in 10 patients with L5-S1 fusions. Retractional gasless technique was used in nine patients with fusions at L5-S1, 16 patients at L4-L5, one patient at L3-L4, three patients at L2-3, and one patient at L1-L2. Thus, we performed a total of 40 lumbar fusions in 35 patients. In the 19 patients with the gasless technique, a balloon dissector and retractor facilitated the retroperitoneal exposure. Seven of these 19 patients were converted to open procedures, most commonly due to lacerations of the peritoneal lining that prohibited visualization. None of the L5-S1 patients with insufflation were converted to open. Mean operative time in the insufflated patients was 152 min vs. 181 min for the retractional technique. There were seven complications in the transperitoneal group: one fusion device migration, one postoperative UTI, one intracerebral hemorrhage, one severe postoperative pancreatitis, and three iliac vein lacerations. There were 16 complications in the retroperitoneal group: one deep vein thromboses, one serosal bowel injury, one small tear in the spleen, one cage migration, one postoperative pulmonary atelectasis, one postoperative hydrocele, four postoperative ileus, and six peritoneal tears. The mean postoperative stay was three days for both groups. There were no deaths. The L5-S1 interspace is best approached transperitoneally for anterior fusion. Although the retroperitoneal retractional technique is much more difficult and has a longer and steeper learning curve, it does allow laparoscopic anterior fusion of the upper lumbar spine.

Minimally invasive lateral lumbar interbody fusion and transpsoas approach–related morbidity

“…Wide use and acceptance of the laparoscopic ALIF was deterred by the known challenges and complications of laparoscopic spine surgery. Reports of retrograde ejaculation, 4,7 vascular injury, 2 anesthetic complications, 9 need for an access surgeon, and steep learning curve all limited the popularity of this procedure. 13 The retroperitoneal approach to the lumbar spine was first reported by Harmon 10 in 1963.…”

Laparoscopic Anterior Lumbar Interbody Fusion: A Review of Outcome Studies

“…The rare complications of pituitary apoplexy [29] and intracereb− ral hemorrhage [14] have been reported in the literature, which might have resulted from the increased intra−abdominal pres− sure by CO 2 pneumoperitoneum and Trendelenburg position, not from the surgical procedure itself.…”

“…No prospective comparative studies have been conducted. Some authors differentially use the two techniques according to the operative disc level [14], or vascular configura− tion obtained by preoperative imaging studies [23]. Some sur− geons have switched from an endoscopic retroperitoneal ap− proach to LALIF [17], some from LALIF to the endoscopic retroper− itoneal approach [15,38], and some have attempted both tech− niques but abandoned them eventually [30].…”

“…Hannon et al [14] and Henry et al [15] presented a unique case series, in which patients with L5−S1 disc disease were treated ei− ther with LALIF or endoscopic retroperitoneal lumbar fusion. The placement of patients into either treatment arm was not ran− domized, the number of patients was small, and no comparison of each treatment arm was made.…”

Minimally Invasive Extreme Lateral Trans-Psoas Approach to the Lumbar Spine: Applications and Techniques

“…Laparoscopic procedures still share some complications of open surgery such as great vessel injury, retrograde ejaculation, and arterial thromboembolism [8][9][10] . In addition to the morbidity of open anterior surgery, laparoscopy introduces its own set of challenges such as bowel injury during the percutaneous approach, CO2 insufflation leading to low cardiac www.intechopen.com Spine Surgery 44 output 11 . In addition, depth perception is compromised with two dimensional imaging and most neurosurgeons are unfamiliar with the use of laparoscopic instruments.…”