Laparoscope- and Endoscope-Assisted Oblique Lumbar Interbody Fusion

26 Laparoscope- and Endoscope-Assisted Oblique Lumbar Interbody Fusion

Ji-Hoon Seong and Jin-Sung Luke Kim

26.1 Laparoscope-Assisted OLIF

26.1.1 Background

Laparoscope-assisted spine surgery via a retroperitoneal approach is not a new surgical technique. Peretti et al 1 presented a technical description of laparoscope-assisted lumbar interbody fusion with a lateral retroperitoneal approach in four patients in 1996. Henry² and Regan³ demonstrated that anterior lumbar fusion via a laparoscope-assisted retroperitoneal approach was safe and effective.

The laparoscope had been used for minimally invasive surgery, but recently the popularity of the laparoscope has decreased, perhaps because of development of surgical devices and instruments for lumbar spinal surgery, especially the tubular retractor system for an anterior or lateral retroperitoneal approach. However, there may be cases requiring a laparoscope, such as when a tubular retractor would be positioned at a dangerous location in the oblique lumbar interbody fusion (OLIF) procedure. If the OLIF corridor is blocked by retroperitoneal vessels or if the ureter or a nerve has an abnormal course, a tubular retractor in the OLIF procedure can injure the anatomic structures. In these cases, a laparoscope-assisted surgical procedure can give a surgical field of vision and decrease approach-related complications.

26.1.2 Clinical Findings

A 72-year-old female presented with long-standing low back pain and right leg radiating pain. Preoperative imaging studies were performed. Plain radiographs showed lumbar degenerative kyphotic and scoliotic change (Fig. 26.1). MRI sagittal and axial views showed degenerative lumbar kyphosis, degenerative spondylolisthesis of L2 on L3, and central canal stenosis with foraminal stenosis at the L3–L4 and L4–L5 levels (Fig. 26.2).

Fig. 26.1 (a,b) Plain radiographs showing lumbar degenerative kyphosis and scoliosis.

Fig. 26.2 (a–f) Sagittal and axial MRIs showing multilevel degeneration of lumbar spine.

26.1.3 Preoperative Plan

It was determined that the patient would undergo a laparoscope-assisted OLIF via a retroperitoneal approach. A right-sided approach was selected.

26.1.4 Surgical Procedures

The first skin incision, for the laparoscopic port, was made, and the Veress needle was inserted. Next, that CO₂ gas filled the retroperitoneal space was confirmed through the Veress needle.

The 10-mm diameter trocar was carefully placed, and the laparoscope was introduced through the trocar. The retroperitoneal space was inspected and it was determined that there was no intraperitoneal injury. The second and third trocar sites were incised and two 5-mm trocars were placed.

Under C-arm and laparoscopic guidance, serial dilators and the retractor for OLIF were introduced above the disk space (Fig. 26.3, Fig. 26.4, Fig. 26.5).

26.1.5 Results

The procedure resulted in sufficient decompression, and improvement of scoliosis and kyphosis were shown on postoperative radiographs (Fig. 26.6).

26.2 Endoscope-Assisted OLIF

26.2.1 Background

The advantages of direct lateral interbody fusion (DLIF) include indirect decompression based on a wide interbody graft, with less tissue damage, preservation of the posterior ligaments and muscles, minimal blood loss, short duration of surgery, and rapid recovery.^4,5

Therefore, many investigators promoted the use of DLIF in the elderly and debilitated patients. However, many authors do not agree on the effectiveness of transpsoas DLIF due to the disadvantages of a lateral approach: a high risk of lumbar plexus injury during the procedure, abdominal wall paresis, and the impossibility of direct decompression of lumbar stenosis.⁶

OLIF, as a variant of DLIF, was introduced to decrease lumbar plexus injury by using the oblique trajectory, even though its clinical results are still under evaluation.

Fig. 26.3 (a–d) C-arm fluoroscopic view during laparoscope-assisted OLIF.

Fig. 26.4 Laparoscopic trocars.

To overcome the drawbacks of DLIF, the authors use spinal endoscopic systems through the OLIF corridor. With the specialized aid of the spinal endoscope, spine surgeons can remove the disk fragments directly under endoscopic visualization. The oblique trajectory of OLIF may help spine surgeons to directly access the target lesion and to decompress intracanal or contralateral foraminal lesions.

26.2.2 Preoperative Plan

OLIF was recommended to the patient for restoration of the disk heights and correction of the anterolisthesis.

Before the insertion of the OLIF cage, endoscopic removal of the ruptured disk was planned. It is impossible to directly remove herniated disk during DLIF or OLIF. The deeply located disk and shallow diameter of the tubular retractor interfere with direct decompression and removal of ruptured disk material.

26.2.3 Surgical Procedures

The procedure is performed with the patient under general anesthesia, in the right true lateral decubitus position. The intervertebral disk and anterior margin of the vertebrae are marked using a sterile marking pen using C-arm fluoroscopic guidance. In contrast to DLIF, OLIF procedures are always performed with the surgeon in front of the patient. An oblique skin incision of about 2.0 to 2.5 cm is made for one segmental fusion, and serial muscle dissection is performed parallel to muscle fibers from the external oblique, internal oblique, and transversalis abdominis muscles. The retroperitoneal fat and psoas muscle are identified, and the anterior portion of psoas muscle is palpated and retracted to prevent lumbar plexus injury. A guide pin is inserted into the intervertebral disk space under fluoroscopic guidance, and serial dilators of increasing diameter are sequentially applied. A 22-mm-diameter tubular retractor is attached to the table using a flexible arm.