Minimally Invasive Spine Surgery (eBook)

Preface to the Second Edition 6
Foreword to the First Edition 7
Preface to the First Edition 9
Contents 11
List of Contributors 15
General 22
1 Minimally Invasive Spine Surgery 23
1.1 Goals of Minimally Invasive Spine Surgery ( MISS) 23
1.2 Access Principles 23
1.3 Preoperative Planning 25
1.4 Positioning of the Patient 26
1.5 Localization of Skin Incision 26
1.6 Surgical Dissection Techniques 26
1.7 Instruments and Implants 26
1.8 Summary 27
2 Technological Advances of Surgical Microscopes for Spine Surgery 28
2.1 History of the Surgical Microscope 28
2.2 The Surgical Microscope 28
2.3 Advantages 30
2.4 Disadvantages 31
References 31
3 Spinal Microsurgery 32
3.1 Terminology 32
3.2 Surgical Principle 32
3.3 History 32
3.4 The Surgical Microscope 32
3.5 Advantages 34
3.6 Disadvantages 34
References 35
4 Microsurgical Instruments 36
4.1 Classification of Instruments 36
4.2 Summary 42
4.3 Comment 42
References 42
5 Operating Room Setup and Handling of Surgical Microscopes 43
5.1 Introduction 43
5.2 Room and Microscope Setup 43
5.3 Microscope Handling 44
5.4 Transporting the Microscope 45
References 45
6 Computer-assisted Minimally Invasive Spine Surgery 46
6.1 Introduction 46
6.2 Computer-assisted Orthopaedic Surgery 46
6.3 Minimizing Invasiveness 47
6.4 Further Clinical Applications 50
6.5 Discussion and Conclusion 51
References 51
Cervical Spine 54
7 Technique of Transoral Odontoidectomy 55
7.1 Terminology 55
7.2 Surgical Principle 55
7.3 History 56
7.4 Advantages 56
7.5 Disadvantages 56
7.6 Indications and Contraindications 56
7.7 Patient’s Informed Consent 56
7.8 Surgical Technique 56
7.9 Postoperative Care 60
7.10 Hazards and Complications 60
7.11 Conclusions 60
References 60
8 Microsurgical Treatment of Odontoid Fractures 62
8.1 Terminology 62
8.2 Surgical Principle 62
8.3 History 63
8.4 Advantages 63
8.5 Disadvantages 64
8.6 Indications 64
8.7 Contraindications 64
8.8 Patient’s Informed Consent 65
8.9 Surgical Technique 65
8.10 Postoperative Care and Complications 69
8.11 Results 70
8.12 Critical Evaluations 71
References 71
9 Microsurgery of the Cervical Spine: The Anterior Approach 74
9.1 Terminology 74
9.2 Surgical Principle 74
9.3 History 75
9.4 Advantages 75
9.5 Disadvantages 75
9.6 Indications 76
9.7 Contraindications 80
9.8 Patient’s Informed Consent 80
9.9 Surgical Technique 81
9.10 Postoperative Care 96
9.11 Results 98
9.12 Critical Evaluation 99
References 99
10 Anterior Cervical Foraminotomy (Microsurgical and Endoscopic) 102
10.1 Terminology 102
10.2 Surgical Principle 102
10.3 History 102
10.4 Advantages 103
10.5 Disadvantages 103
10.6 Indications 103
10.7 Contraindications 103
10.8 Patient’s Informed Consent 103
10.9 Surgical Technique 103
10.10 Postoperative Care and Complications 109
10.11 Results 109
10.12 Critical Evaluation 109
References 111
11 Functional Segmental Reconstruction with the Bryan Cervical Disc Prosthesis 112
11.1 Introduction 112
11.2 Theoretical considerations 112
11.3 History 112
11.4 Structural and Functional Objectives of the Bryan Cervical Disc Prosthesis 114
11.5 Description of the Bryan Cervical Disc Prosthesis 114
11.6 Biocompatibility of the Bryan Cervical Disc Prosthesis 115
11.7 Mechanical Testing of the Bryan Cervical Disc Prosthesis 115
11.8 Animal Testing of the Bryan Cervical Disc Prosthesis 115
11.9 Surgical Technique 115
11.10 Preliminary Clinical Experience with the Bryan Cervical Disc Prosthesis 117
11.11 Conclusions 119
References 119
12 Microsurgical Total Cervical Disc Replacement 120
12.1 Terminology 120
12.2 Surgical Principle 120
12.3 History 120
12.4 Advantages 120
12.5 Disadvantages 120
12.6 Indications 121
12.7 Contraindications 121
12.8 Patient’s Informed Consent (see also Chapter 9) 121
12.9 Surgical Technique 121
12.10 Postoperative Care 125
12.11 Hazards and Complications 125
12.12 Conclusions 125
References 126
13 Microsurgical Posterior Approaches to the Cervical Spine 127
13.1 Terminology 127
13.2 Surgical Principle 127
13.3 History 127
13.4 Advantages 128
13.5 Disadvantages 128
13.6 Indications 128
13.7 Patient’s Informed Consent 128
13.8 Surgical Technique 128
13.9 Postoperative Care 135
13.10 Hazards and Complications 136
13.11 Results 136
13.12 Critical Evaluation 136
References 137
14 Microsurgical C1-2 Stabilization 138
14.1 Terminology 138
14.2 Surgical Principle 138
14.3 History 138
14.4 Advantages 139
14.5 Disadvantages 139
14.6 Indications 139
14.7 Contraindications 140
14.8 Patient’s Informed Consent 140
14.9 Surgical Technique 140
14.10 Postoperative Care 144
14.11 Hazards and Complications 145
14.12 Conclusions 145
References 145
Thoracic/ Thoracolumbar Spine 148
15 Microsurgical Anterior Approach to T5–10 (Mini-TTA) 149
15.1 Terminology 149
15.2 Surgical Principle 149
15.3 History 149
15.4 Advantages 149
15.5 Disadvantages 149
15.6 Indications 149
15.7 Contraindications 150
15.8 Patient’s Informed Consent 150
15.9 Surgical Technique 150
15.10 Surgical Strategies 154
15.11 Postoperative Care 156
15.12 Complications and Hazards 156
15.13 Critical Evaluation 156
Suggested Reading 157
16 Microsurgical Anterior Approach to the Thoracolumbar Junction 158
16.1 Terminology 158
16.2 Surgical Principle 158
16.3 History 158
16.4 Advantages 158
16.5 Disadvantages 158
16.6 Indications 158
16.7 Contraindications 159
16.8 Surgical Technique 159
16.9 Surgical Strategies 161
16.10 Postoperative Care 163
16.11 Complications and Hazards 163
16.12 Critical Evaluation 163
Suggested Reading 163
17 Anatomic Principles of Thoracoscopic Spine Surgery 164
17.1. Anatomy of the Thoracic Wall with Respect to Endoscopic Approaches 164
17.2. Thoracoscopic Anatomy 166
18 Principles of Endoscopic Techniques to the Thoracic and Lumbar Spine 169
18.1 Terminology 169
18.2 Surgical Principle 169
18.3 History 169
18.4 Technical Equipment 170
18.5 Advantages 171
18.6 Disadvantages 171
18.7 Indications 171
18.8 Contraindications 172
18.9 Complications 172
18.10 Conclusions and Critical Evaluation 172
References 173
19 Biomechanical Requirements in Minimally Invasive Spinal Fracture Treatment 176
19.1 Anterior Spinal Stabilization 176
19.2 Minimally Invasive Anterior Techniques 176
19.3 Biomechanical Aspects 177
19.4 Biomechanical Testing: Overview 177
References 182
20 Thoracoscopic Approaches in Spinal Deformities and Trauma 184
20.1 Terminology 184
20.2 Surgical Principle 184
20.3 History 185
20.4 Advantages 185
20.5 Disadvantages 185
20.6 Indications 186
20.7 Contraindications 186
20.8 Patient’s Informed Consent 186
20.9 Surgical Technique 186
20.10 Postoperative Care 193
20.11 Hazards and Complications 193
20.12 Conclusion and Critical Evaluation 193
References 194
21 Thoracoscopic Techniques in Spinal Deformity 196
21.1 Terminology 196
21.2 Surgical Principle 196
21.3 History 196
21.4 Advantages 196
21.5 Disadvantages 198
21.6 Indications 198
21.7 Contraindications 21.8 Patient’s Informed Consent 203
21.9 Surgical Technique 203
21.10 Postoperative Care 211
21.11 Complications 212
21.12 Results 214
References 214
22 Mini-open Endoscopic Excision of Hemivertebrae 217
22.1 Endoscopic Excision of Hemivertebra 217
22.2 Terminology 217
22.3 Surgical Principle 217
22.4 History 217
22.5 Advantages 217
22.6 Disadvantages 218
22.7 Indications and Contraindications 218
22.8 Patient’s Informed Consent 218
22.9 Surgical Technique 218
22.10 Postoperative Care and Complications 220
22.11 Patients 220
22.12 Results 220
22.13 Critical Evaluation 220
22.14 Conclusions 221
References 221
23 Thoracoscopically Assisted Anterior Approach to Thoracolumbar Fractures 223
23.1 Terminology 223
23.2 Surgical Principle 223
23.3 History 223
23.4 Advantages 223
23.5 Disadvantages 224
23.6 Indications 224
23.7 Contraindications 224
23.8 Patient’s Informed Consent 224
23.9 Surgical Technique 224
23.10 Postoperative Care 230
23.11 Complications, Hazards, and Pitfalls 231
23.12 Conclusion and Critical Evaluations 232
References 233
24 A Minimally Invasive Open Approach for Reconstruction of the Anterior Column of the Thoracic and Lumbar Spine 235
24.1 Terminology 235
24.2 Surgical Principle 235
24.3 History 235
24.4 Advantages 236
24.5 Disadvantages 236
24.6 Indications 236
24.7 Contraindications 237
24.8 Patient’s Informed Consent 237
24.9 Surgical Technique 237
24.10 Postoperative Care and Complications 239
24.11 Results 240
24.12 Critical Evaluations 240
References 241
25 Percutaneous Vertebroplasty in Osteoporotic Vertebral Fractures 242
25.1 Terminology 242
25.2 Surgical Principle 242
25.3 History 242
25.4 Advantages 242
25.5 Disadvantages 242
25.6 Indications 242
25.7 Contraindications 243
25.8 Patient’s Informed Consent 244
25.9 Surgical Technique 244
25.10 Postoperative Care and Complications 246
25.11 Results 247
25.12 Critical Evaluations 248
References 248
26 Microsurgical Open Vertebroplasty and Kyphoplasty 250
26.1 Terminology 250
26.2 Surgical Principle 250
26.3 History 250
26.4 Advantages 250
26.5 Disadvantages 251
26.6 Indications 251
26.7 Contraindications 251
26.8 Patient’s Informed Consent 251
26.9 Surgical Technique 252
26.10 Postoperative Care 255
26.11 Hazards, Pitfalls and Complications 255
26.12 Results and Conclusion 255
References 258
27 Percutaneous Kyphoplasty in Traumatic Fractures 259
27.1 Terminology 259
27.2 Surgical Principle 259
27.3 History 260
27.4 Advantages 260
27.5 Disadvantages 260
27.6 Indications 260
27.7 Contraindications 260
27.8 Surgical Technique 260
27.9 Postoperative Care 262
27.10 Results 262
27.11 Critical Evaluation 266
References 266
Lumbar Spine 268
28 Interventional and Semi-invasive Procedures for Low Back Pain and Disc Herniation 269
28.1 Terminology 269
28.2 Surgical Principle 269
28.3 History 270
28.4 Advantages 270
28.5 Disadvantages 270
28.6 Indications 270
28.7 Contraindications 270
28.8 Patient’s Informed Consent 271
28.9 Surgical Technique 271
28.10 Postoperative Care and Complications 276
28.11 Results 276
28.12 Critical Evaluation 278
References 278
29 Intradiscal Electrothermal Therapy 280
29.1 Terminology 280
29.2 Surgical Principle 280
29.3 History 280
29.4 Pathophysiology of Internal Disc Derangement 280
29.5 Thermal Impact Upon Tissue 280
29.6 Patient Selection for IDET 281
29.7 Surgical Technique 283
29.8 Postoperative Care 283
29.9 Postoperative Exercises 283
29.10 Results 284
29.11 Complications 284
29.12 Conclusion 285
References 285
30 Microtherapy in Low Back Pain 287
30.1 Terminology 287
30.2 Surgical Principle 288
30.3 History 289
30.4 Advantages 290
30.5 Disadvantages 291
30.6 Indications 291
30.7 Contraindications 291
30.8 Patient’s Informed Consent 292
30.9 Surgical Technique 292
30.10 Postoperative Care and Complications 293
30.11 Results 30.12 Critical Evaluations 295
30.13 Conclusions 296
References 296
31 Principles of Microsurgical Discectomy in Lumbar Disc Herniations 298
31.1 Terminology 298
31.2 Surgical Principle 298
31.3 History 298
31.4 Advantages 299
31.5 Disadvantages 299
31.6 Indications 299
31.7 Contraindications 299
31.8 Surgical Technique, Postoperative Care, and Complications 299
31.9 Results 299
31.10 Critical Evaluation 300
Bibliography 301
32 The Microsurgical Interlaminar, Paramedian Approach 303
32.1 Terminology 303
32.2 Surgical Principle 303
32.3 History 303
32.4 Advantages 303
32.5 Disadvantages 304
32.6 Indications (see also Chapter 31) 304
32.7 Contraindications 305
32.8 Patient’s Informed Consent 305
32.9 Surgical Technique 306
32.10 Postoperative Care 315
32.11 Complications 315
32.12 Critical Evaluation 315
References 315
33 The Translaminar Approach 317
33.1 Terminology 317
33.2 Surgical Principle 317
33.3 History 317
33.4 Advantages 317
33.5 Disadvantages 318
33.6 Indications 318
33.7 Contraindications 318
33.8 Patient’s Informed Consent 319
33.9 Surgical Technique 319
33.10 Postoperative Care and Complications 33.11 Results 321
33.12 Critical Evaluations 322
References 323
34 The Lateral, Extraforaminal Approach 324
34.1 Terminology 324
34.2 Surgical Principle 325
34.3 History 326
34.4 Advantages 327
34.5 Disadvantages 327
34.6 Indications 327
34.7 Contraindications 327
34.8 Patient’s Informed Consent 327
34.9 Surgical Technique 327
34.10 Postoperative Care 331
34.11 Complications 331
34.12 Results 332
34.13 Critical Evaluation 333
References 333
35 Transforaminal Endoscopic Discectomy 335
35.1 Terminology 335
35.2 Surgical Principle 335
35.3 History 336
35.4 Advantages 337
35.5 Disadvantages 337
35.6 Indications 338
35.7 Contraindications 338
35.8 Surgical Technique 338
35.9 Postoperative Treatment 340
35.10 Complications 340
35.11 Critical Evaluation 340
References 341
36 Microscopically Assisted Percutaneous Technique as a Minimally Invasive Approach to the Posterior Spine 342
36.1 Terminology 342
36.2 Surgical Principle 342
36.3 History 342
36.4 Advantages 342
36.5 Disadvantages 343
36.6 Indications 343
36.7 Contraindications 343
36.8 Patient’s Informed Consent 343
36.9 Surgical Technique 343
36.10 Postoperative Care and Complications 36.11 Results 346
36.12 Critical Evaluations 349
References 350
37 Arthroscopic and Endoscopic Spine Surgery via a Posterolateral Approach 351
37.1 Terminology 351
37.2 Surgical Principle 351
37.3 History 351
37.4 Advantages 352
37.5 Disadvantages 352
37.6 Indications and Contraindications 352
37.7 Patient Education and Preoperative Consent 353
37.8 Anatomical Consideration 353
37.10 Postoperative Care 361
37.11 Results 362
37.12 Critical Evaluation and Discussion References 363
38 The Full-endoscopic Interlaminar Approach for Lumbar Disc Herniations 366
38.1 Terminology 366
38.2 Surgical Principle 366
38.3 History 366
38.4 Advantages 366
38.5 Disadvantages 367
38.6 Indications 367
38.7 Contraindications 367
38.8 Patient’s Informed Consent 368
38.9 Surgical Technique 368
38.10 Postoperative Care and Complications 370
38.11 Results 371
38.12 Critical Evaluations 372
References 373
39 Outpatient Microsurgical Lumbar Discectomy and Microdecompression Laminoplasty 376
39.1 Terminology 376
39.2 History 376
39.3 Surgical Principle 376
39.4 Advantages 39.5 Disadvantages (see also Chapters 31 and 32) 377
39.6 Indications 377
39.7 Contraindications 378
39.8 Patient’s Informed Consent 378
39.9 Microsurgical Technique 379
39.10 Postoperative Care 382
39.11 Complications (see Chapters 32 and 44) 39.12 Conclusion 382
References 382
40 Nucleus Reconstruction by Autologous Chondrocyte Transplantation 384
40.1 Terminology 384
40.2 Surgical Principle 384
40.3 Cell-culturing Technique 385
40.4 Canine Preclinical Study 385
40.5 Clinical Studies 388
40.6 Critical Evaluation 390
References 392
41 Autologous Disc Chondrocyte Transplantation 394
41.1 Terminology 394
41.2 Principle 394
41.3 History 395
41.4 Advantages 395
41.5 Disadvantages 395
41.6 Inclusion criteria 395
41.7 Exclusion criteria 395
41.8 Patient’s Informed Consent 396
41.9 Surgical Technique 396
41.10 Postoperative Care 397
41.11 Results 397
41.12 Critical Evaluation 397
References 398
42 The ALPA Approach for Minimally Invasive Nucleus Pulposus Replacement 399
42.1 Terminology 399
42.2 Surgical Principle 399
42.3 History 399
42.4 Advantages 400
42.5 Disadvantages 400
42.6 Indications 400
42.7 Contraindications 400
42.8 Patient’s Informed Consent 400
42.9 Surgical Technique 400
42.10 Postoperative Care 403
42.11 Hazards and Complications ( see also Chapters 44 – 48) 403
42.12 Conclusion 403
References 403
43 Mini-open Midline Accesses for Lumbar Total Disc Replacement 405
43.1 Terminology 405
43.2 Surgical Principle 405
43.3 History 405
43.4 Advantages 405
43.5 Disadvantages 405
43.6 Indications 405
43.7 Contraindications 406
43.8 Patient’s Informed Consent 406
43.9 Surgical Techniques 406
43.10 Postoperative Care 415
43.11 Hazards and Complications 43.12 Conclusions 416
References 416
44 Microsurgical Decompression of Acquired (Degenerative) Central and Lateral Spinal Canal Stenosis 417
44.1 Terminology 417
44.2 Surgical Principle 417
44.3 History 417
44.4 Advantages 417
44.5 Disadvantages 418
44.6 Indications 418
44.7 Contraindications 419
44.8 Patient’s Informed Consent 419
44.9 Surgical Technique 419
44.10 Postoperative Care 426
44.11 Complications 426
44.12 Results 426
44.13 Critical Evaluation 427
References 428
45 Microsurgical Anterior Lumbar Interbody Fusion (Mini-ALIF): The Lateral Retroperitoneal Approach to L2/3, L3/4, and L4/5 429
45.1 Terminology 429
45.2 Surgical Principle 429
45.3 History 429
45.4 Advantages 429
45.5 Disadvantages 430
45.6 Indications 430
45.7 Contraindications 430
45.8 Patient’s Informed Consent 430
45.9 Surgical Technique 430
45.10 Postoperative Care 439
45.11 Complications, Pitfalls, and Hazards 440
45.12 Results 440
45.13 Critical Evaluation 441
References 442
46 Microsurgical Anterior Lumbar Interbody Fusion (Mini-ALIF): The Transperitoneal Approach to L5/S1 443
46.1 Terminology 443
46.2 Surgical Principle 443
46.3 History 443
46.4 Advantages 443
46.5 Disadvantages 443
46.6 Indications 444
46.7 Contraindications 444
46.8 Patient’s Informed Consent 444
46.9 Surgical Technique 444
46.10 Postoperative Care 450
46.11 Complications, Pitfalls, and Hazards 450
46.12 Results 452
46.13 Critical Evaluation 452
Bibliography 453
47 Minimally Invasive 360° Lumbar Fusion 455
47.1 Terminology 455
47.2 Surgical Principle 455
47.3 History 455
47.4 Advantages 456
47.5 Disadvantages 456
47.6 Indications 456
47.7 Contraindications 457
47.8 Patient’s Informed Consent 457
47.9 Surgical Technique 457
47.10 Closure of the Operating Field and Postoperative Care 467
47.11 Complications, Pitfalls, and Hazards 467
47.12 Results 468
47.13 Critical Evaluation 469
References 469
48 The Anterior Extraperitoneal Video-assisted Approach to the Lumbar Spine 470
48.1 Terminology 470
48.2 Surgical Principle 470
48.3 History 470
48.4 Advantages 470
48.5 Disadvantages 471
48.6 Indications and Contraindications 471
48.7 Patient’s Informed Consent 472
48.8 Surgical Technique 472
48.9 Postoperative Care 476
48.10 Hazards and Complications 476
48.11 Critical Evaluation 476
References 478
49 Minimally Invasive Dynamic Stabilization of the Lumbar Motion Segment with an Interspinous Implant 479
49.1 Terminology 479
49.2 Surgical Principle 479
49.3 History 479
49.4 Advantages 481
49.5 Disadvantages 481
49.6 Indications 482
49.7 Contraindications 482
49.8 Patient’s Informed Consent 482
49.9 Surgical Technique 482
49.10 Postoperative Care 483
49.11 Results 483
49.12 Critical Evaluations 484
References 485
50 Technical and Anatomical Considerations for the Placement of a Posterior Interspinous Stabilizer 486
50.1 Terminology 486
50.2 Surgical Principles 486
50.3 History, Advantages, and Disadvantages ( see also Chapter 45) 486
50.4 Indications 486
50.5 Contraindications 488
50.6 Patient’s Informed Consent 488
50.7 Surgical Technique 488
50.8 Postoperative Care 493
50.9 Hazards and Complications 493
50.10 Conclusion 493
Suggested Reading 494
51 Elastic Microsurgical Stabilization with a Posterior Shock Absorber 496
51.1 Terminology and Surgical Principle 496
51.2 History 496
51.3 Indications 499
51.4 Contraindications 499
51.5 Surgical Technique 499
51.6 Results 500
51.7 Hazards and Complications 501
51.8 Conclusions 501
References 503
Subject Index 505

4 Microsurgical Instruments ( p. 16)

A. Korge
As in all surgical fields, an enormous tendency has occurred recently toward minimizing both surgical procedures as well as surgical approaches. The reasons for miniaturized approaches include a reduced infection rate due to shortened skin incisions, less cosmetic alterations, as well as the fact that in the majority of cases, small and localized pathologies only need small and limited approaches.

In addition, small incisions need less time for wound closure, thus reducing the overall time of surgery [4]. This tendency is also found in spine surgery with an increasing shift frommacrosurgery tomicrosurgery [1, 2, 3, 5]. Microsurgery has become quite popular, especially in surgical procedures within the spinal canal [3], and has been established within recent decades basically due to the development of efficient optical aids such as powerful and effective surgical microscopes which are being continuously improved.

However, the use of microscopes in spine surgery delivered a new intermedium between the surgeon’s eye and the operating field, thus influencing simultaneously the individual visual axis between the surgeon’s eye and his hands. Therefore, the surgeon’s line of vision was restricted and the field of vision became smaller and limited. In addition, the line of vision of a microscope is perpendicular to the surgical area to be operated on.

Consequently, the configuration of surgical instruments had to be modified (e.g., bayonet-shaped), as well as their basic dimensions (e.g., smaller and longer), in order to fulfill the specific requirements of microscope-assisted surgery. Depending on the anatomical area and the number of segments being approached, surgery can be started with either microscopic or macroscopic techniques. Usually, mono- or bisegmental pathologies on the lumbar spine (disc herniation, lumbar spinal stenosis) can be done by a skin-to-skin technique with microscope assistance from beginning to end.

In multisegmental decompression surgery, for example due to lumbar spinal stenosis, initial macroscopic preparation down to the interlaminar windows and subsequent use of the microscope might save time.

4.1 Classification of Instruments
Instruments for spinal microsurgery can usually be divided into two major groups:

1. The first group is especially related to the approach from the skin down to the spinal canal, including skin opening, traversing soft tissue subcutaneous, transfascial, and paravertebral to the interlaminar window, and entering the spinal canal.

2. The second group is related to surgical procedures within the spinal canal and within the intervertebral disc space. Some instruments are effective in both groups (cautery, high-speed drills, suction devices), as ismentioned later on.

4.1.1 Instruments Related to the Approach

4.1.1.1 Instruments for Wound Opening
There is basically no big difference betweenmicroscopic and macroscopic instruments for opening the skin even when using the microscope from the beginning. Standardized incision scalpels serve to open the skin and to traverse the subcutaneous tissue. Forceps of standard size and length can be used for skin and tissue retraction, however, delicate forceps such as Adson forceps are more comfortable under microscope assistance.