Endoscopic subcutaneous surgery: a new surgical approach.

The purpose of this experiment was to develop a minimally invasive endoscopic technique that utilizes the assistance of carbon dioxide gas insufflation to perform reconstructive and aesthetic procedures within the subcutaneous, fascial, and muscular tissue planes. A standard laparoscopic setup, like that used for laparoscopic cholecystectomy, was utilized to dissect within the subcutaneous, fascial, and muscular tissue planes of swine. Specific instrumentation adapted to this technique includes blunt-tip inflatable ring trocars, a balloon tissue dissector, an ultrasonic scalpel (harmonic), and an endoscopic retrieval bag. The fundamental steps of Endoscopic Subcutaneous Surgery (ESS) were developed by performing reconstructive and aesthetic procedures on swine. Dissection is easier and more precise with this ESS approach because of improved visualization and flexible tissue manipulation. The blunt-tip inflatable ring trocars maintain tight portals of entry, preventing loss of gas and collapse of the functional optical cavity. The ultrasonic scalpel improves visualization by avoiding electrocautery smoke. When compared with endoscopic techniques that use external mechanical retraction devices or primary balloon dissection to perform ESS, this approach offers several advantages, such as (1) it creates a dome-shaped functional optical cavity, not a tent-shaped cavity; (2) it frees the hands of the surgeon and assistant to allow for less cumbersome and more precise dissection; (3) it improves visualization by avoiding instrument crowding; (4) it is less traumatic to the overlying and dissected tissues; (5) it eliminates time-consuming adjustment of external supporting devices; (6) it utilizes the skin's intrinsic elasticity to create a larger functional workspace, (7) it uses carbon dioxide insufflation to delineate the proper plane of dissection; and (8) it utilizes endoscopic equipment and instrumentation that are generally available at most medical centers.