LUMBAR ENDOSCOPIC SPINE SURGERY (LESS): Quick Guide

Interlaminar Approach

STEPS

SETUP

1. Position the patient prone. Make sure the abdomen is free.

2. Get a perfect AP.

• Start with the C-Arm rainbow at zero.

• Airplane the patient until you have a perfect AP at the operative level, relative to planet earth.

3. Get a perfect lateral once the AP is set.

ACCESS

4. Make a stab incision just lateral, using the perfect lateral X-ray, so your instruments don't collide.

5. Dissect down to the lamina under the lateral X-ray. Feel for:

• The spinous process

• The inferior edge of the lamina

• The interlaminar window

• Work by feel ("pretend you're Helen Keller").

6. Bring down the cannula and find your landing spot: the inferior half of the cephalad lamina, at the edge of the interlaminar window.

7. Burr the exposed bone. Keep the ligament intact, since it protects the dura.

SECOND PORT

8. Once you reach the ligamentum flavum, make a second stab incision at least 2.5 cm away.

9. While watching through the scope, create the submuscular pocket using direct uniportal views.

DISCECTOMY (IF NEEDED)

10. Mobilize the dural tube and release all adhesions.

11. Use the cannula to sweep and rotate the dura away from the disc.

12. With the disc in view, do the disc work.

CHECK BEFORE FINISHING

13. Don't celebrate yet. Be cautious and look all around before taking everything out.

14. Do the Valsalva maneuver with the irrigation off. Look for:

• Heavy bleeding

• Clear fluid (possible CSF leak)

15. Look in all directions as you pull the cannula out to confirm everything is A-OK.

CLOSING

16. No drain needed. Close with a 3-0 Vicryl stitch with a little Dermabond and a Band Aid.