In this article, we compared endoscopy-assisted expander placement with open tissue expander placement in plastic and reconstructive surgery and found that the endoscopic technique can lower the complication rate and shorten surgery time, hospital stay, and time to full expansion.
In the early 1990s, plastic surgeons began using video-laparoscopy to aid placement of expanders.26,27 One way for establishing the cavity was facilitated by the continuous expansion and bulging by controlled injection of carbon dioxide27. Another way did not need the device of carbon dioxide insufflation. The special retractor with vertical and lateral movement was applied to keep the optical cavity open by separating the skin from the underlying fascia.10,28 Then, an endoscope (5-mm or 10-mm diameter, and 0°, 30°, or 45°) was inserted into the cavity and, under endoscopic vision, the plane of the area for placement of the expander was carefully dissected sharply or bluntly.29 Takeuchi et al. and Stephen et al. reported good results with a balloon dissector, with endoscopy used to facilitate extensive dissection through small incisions, especially in the trunk and limbs.30,31 After meticulous hemostasis, the expanders are placed in the specified area, and injected after a few days.
Endoscopic expander placement has been previously shown to lower risk of complications.8,11−16 In this meta-analysis, we demonstrated 28% lower pooled risk of complications after endoscopy-assisted expander placement than after traditional open expander placement. Subgroup analysis showed lower risk of haemotoma, infection, and dehiscence, which was probably mainly because of the precise hemostasis achieved under endoscopic visualization.11 In addition, the small remote incision used in the endoscopic technique reduces the possibility of cavity contamination by outside bacteria. Our previous study found that a haemotoma offers an ideal medium for bacterial proliferation and greatly increases the possibility of expander infection.32 Remote incision, far from the stress of the expansion, also minimizes the chances of wound dehiscence.12
Whether the risks of extrusion and deflation can be reduced by the endoscopic technique remain controversial.11–13 Although the use of an endoscope reduces the length of surgical incision, the pockets for expander placement are not narrowed. According to our experience in expander placement by both the endoscopic method and the open method, appropriate and uniform dissection of the plane depends on the degree of exposure. In addition, it must be noted that the incidence of deflation is closely related to the quality of expander, with poor quality expanders being prone to damage and leakage of injection ports.11
In this study, surgery time, hospital stay, and time to full expansion were significantly shorter in patients receiving endoscopy-assisted expander placement. Some early studies reported that endoscopy-assisted expander placement requires a longer operative time,27,28 but this was disproved by later research that showed that the endoscopic technique could significantly shorten placement time, especially when more than one expander had to be placed.11–13, 15 We believe that the contradictory conclusions were due to differences in the proficiency of the surgeons in endoscopic operation. The small and remote incision, and the earlier initiation of expansion, all contribute to shorten hospital stay and time to full expansion. Importantly, without complications to interfere with the process of expansion, fluid injection can be safely performed at an early stage.
The major advantages of endoscopy-assisted expander placement over open expander placement can be summarized as follows: 1) the endoscope allows the surgeon to dissect a wide area through a small, remote incision28; 2) the risk of wound dehiscence is reduced33,34; 3) expansion can be initiated earlier and expansion duration can be shortened33–35; 4) appearance of subcutaneous hemorrhage can be closely monitored because of the clear, magnified visualization28; and 5) under direct vision, the dissection planes and blood vessels can be better recognized.36 The disadvantages are 1) the application of endoscopy calls for a video system, a light source, and extra surgical instruments, which increases costs 27; and 2) the surgeon needs to be specially trained in the procedure.27,28
The indications are similar for endoscopic tissue expander placement and for traditional open expander placement.26 However, previous reports and our own experience suggest that the endoscopy-assisted technique may be particularly suited for pediatric patients (because of less surgical trauma),37–40 for treatment in the facial or cervical region (because of the better hemostasis),13,33 and for treatment of cases requiring wide dissection (because of the better visualization).10,41,42
This study has some limitations. First, in our cohort, the main indications for expander placement were scar and breast reconstruction, which may be an important source of the pooled results’ heterogeneity. Second, although we searched eight literature databases, the number of articles that met the eligibility criteria were relatively small, and only two were RCTs. However, the total number of patients was large and most studies were of good quality, with no evident publication bias.