Endoscopic surgery is now widely used in all surgical fields. Its use in other surgical branches is older. It has been widely used in stomach and gallbladder surgery, most gynecological surgeries, urology and ENT surgeries, and its use in neurosurgery has started after the 1990s. Endoscopic disc surgery (endoscopic lumbar hernia surgery-closed lumbar hernia surgery) is a minimally invasive surgical method. The word endoscopy is derived from the Greek words endo (inside) and scopien (seeing by watching). Today, it has started to be preferred as the first option in terms of surgery, especially in spine diseases. This surgery, which is performed in a few centers in our country, has gained great popularity in the world. The surgery is performed with two different techniques. In our center, both techniques can be applied according to the needs of the patient. In order for the operation to be performed, special endoscopic surgical instruments and the surgeon who will perform it must be trained and internationally certified.
Which Patients Can It Be Applied To?
Endoscopic disc surgery can be applied to all patients who need surgery due to herniated disc. However, in addition to lumbar hernia, the patient has additional conditions such as slipped lumbar vertebrae and canal stenosis, and if these need to be corrected, then microsurgery should be performed instead of endoscopic disc surgery.
It can be applied to every age group. Especially in the elderly and patients with other problems such as diabetes and hypertension, the very short recovery period after surgery provides a great advantage. In addition, the herniated disc part is removed without causing additional anatomical damage due to the intervention. Thus, the duration of hospital stay and return to work of patients is shortened.
In patients who develop recurrence after microsurgery, the risk of complications is high in second surgeries due to adhesions in the operation area. Endoscopic disc surgery, on the other hand, can be safely performed in all patients who need a second operation due to recurrence.
Surgical Technique in Brief:
There are two different techniques that differ only in terms of the intervention site. A skin incision is made from the middle of the lumbar region in the posterior interlaminar procedure, and from the lateral side of the lumbar region in the posterolateral transforaminal procedure. The main difference between the two techniques, posterior interlaminal intervention and posterolateral transforaminal intervention, is the intervention sites and the body areas where the endoscope is passed during the intervention. In both techniques, a skin incision of approximately 0.5 (half) centimeter is made. Through this incision, an endoscope with a diameter of 4 mm is inserted into the herniated area under radiological control. Then the endoscopy unit is connected to the system. Physiological saline is continuously administered through the endoscope, just like in knee arthroscopy, and the given serum comes out, ensuring a clear view of the operation area. In the endoscope, there is a light source that illuminates the area entered, a camera that records the image, and a channel that allows the instruments to pass through. The surgeon sees the spinal cord, nerves and herniated disc on the screen through the camera inside the endoscope and removes the herniated disc with special instruments. If the entire disc is intact, only the herniated and damaged part is removed. The remaining part is strengthened by burning with a special Radiofrequency device. Thus, the functions of the remaining disk are ensured to continue.
Advantages:
• The operation is performed through an incision of approximately 0.5 cm. There is not much low back pain in the early postoperative period due to the minimal anatomical damage due to surgery.
• The risk of blood loss due to surgery, infection and blood accumulation that may occur in the surgical field is less.
• Access to lateral hernias is easier. In addition, multiple disc distances can be controlled with a single incision.
• Postoperative hospital stay and return to work are short. Short hospital stay also reduces the cost.
• Post-operative chronic low back pain is not seen (epidural fibrosis), which occurs as a result of the adhesion of the muscles to the spinal cord in the areas where bone and connective tissue are removed in microsurgery operations
• Lateral interventions (posterolateral transforaminal), if the patient desires, local It can be done with anesthesia. However, we prefer general anesthesia in all cases. Because, even if appropriate and effective local anesthesia is applied, we think that general anesthesia is especially important for the patient’s psychological comfort due to the fact that the patient feels a little pain and the operating room environment has a negative effect on the patient.
• It can be safely applied in patients with recurrence after microsurgery.
Disadvantages:
• It can be performed by experienced surgeons who have passed the necessary training and received certificates.
• It is necessary to use high-tech equipment for surgery.
In addition to lumbar hernia, patients with canal stenosis, vertebral slippage and congenital or acquired anatomical disorders may experience difficulties in practice.
Questions:
• What does endoscopic surgery mean?
Endoscopic surgery is to reach the sick area by opening a small hole to treat the disease in any part of the body, and to move the patient area to a screen by using advanced image systems, and to perform a surgical procedure by enlarging the visual field by using it in advanced lens systems. This procedure is also known as closed surgery among the people.
• Which surgeries are performed with endoscopic surgery in neurosurgery?
Endoscopic surgery is being used more and more frequently in spinal diseases. With newly developed techniques, neck hernia surgeries have started to be performed endoscopically. For a long time, lumbar hernia operations and widening of the grooves where the nerves exit the spine have been performed with endoscopic microsurgery in suitable cases. It is also used in the surgical treatment of dorsal spine diseases, together with the use of endoscopy in the thorax.
• Can endoscopic surgery be applied to every patient?
It can be applied to any patient, provided that the patient has a herniated disc. It is not applied to patients who only require screw and plate stabilization due to vertebral shift and who require canal expansion surgery due to canal stenosis.
• Why are two different techniques used?
The transforaminal technique, which is applied interventionally from the lateral side of the waist, is a widely used technique. However, it may be impossible to use the transforaminal route, especially for the L5-S1 distance, in patients with a higher than normal hip bone. In this case, an interlaminar technique is used with an incision in the middle of the waist.
• What is the difference between the two techniques?
It can be applied with local anesthesia in patients who want a transforaminal technique other than the intervention site or in patients who are inconvenient to receive anesthesia due to heart or kidney diseases. The interlaminar technique can only be applied under general anesthesia.
• How long is the hospital stay after endoscopic surgeries?
Generally, patients who are kept in the hospital for one night are discharged the next day.
• Is there a chance of recurrence of herniated disc in the same place after the operation?
Lumbar hernia surgery is performed with 3 different methods in the world. Open surgery, microsurgery/microendoscopic surgery and fully closed endoscopic surgery. In thousands of patients who were operated on in all 3 methods, it was determined that there was an average of 5% postoperative recurrence at the operating distance.
No matter which method is applied, the recurrence rate does not change. However, the risk of complications in the new surgery is higher in patients who relapse in other methods compared to endoscopic surgeries. Therefore, even if recurrence occurs in the endoscopic surgery, the complication risk of the second surgery is negligible.
• Can endoscopic surgery be performed in patients who underwent microsurgery or open surgery and re-formed herniated disc?
Endoscopic intervention can be safely performed in all relapsed cases. In patients who underwent microsurgery, the second operation is always more difficult and the risk of complications is higher due to the adhesions that develop after the operation. Therefore, endoscopic surgeries can be performed in such patients without the risk of complications.
