Balloon-assisted endoscopic retroperitoneal gasless (BERG) technique for anterior lumbar interbody fusion (ALIF)

Background: The objective of this study was to determine the utility of balloon-assisted endoscopic retroperitoneal gasless (BERG) exposure for anterior lumbar interbody fusion (ALIF) with a variety of interbody fusion devices. Methods: Between January 1998 and February 2002, 46 individuals underwent (ALIF) with a variety of devices, including cylindrical cages, femoral ring allografts, and Synmesh (Synthes, Philadelphia, PA, USA) cages. There were 34 men and 12 women in the group. The average age was 40 years. The average hospital stay was 3 days. The operations were performed for severe back and leg pains in individuals who did not obtain relief of their pain with nonsurgical treatments for a period of ?1 one year. The surgical conditions for fusion were degenerative disc disease with back and leg pain, grade 1 spondylolisthesis, retrospondylolisthesis, and disc space infection with and without neurological deficit. Lumbar discs L5, L4, and L3 were approached 30, 21, and three times, respectively. The procedures were performed with the patients positioned supine on a radiolucent table. Access to the retroperitoneal space was gained in a manner similar to a totally extraperitoneal (TEP) hernia repair. The rest of the procedure was performed in a gasless fashion using standard orthopedic and laparoscopic instruments. A Harmonic Scalpel (Ethicon Endosurgery, USA) was used to coagulate and divide the ascending lumbar vein to mobilize the left common iliac vein for access to the L4 disc. The segmental arteries were dealt with in a similar fashion to permit retraction of the great vessels. Results: Complications included a left common iliac vein injury not requiring operative repair and a far lateral placement of a BAK (Bagby and Kuslich) cage at the L5 level that required removal 2 days later. One patient reported retrograde ejaculation after two-level ALIF at L3 and L5. Conclusion: BERG/ALIF is a viable alternative to the conventional open procedure and gas laparoscopy for ALIF. BERG permits the use of most open orthopedic instruments and any implant. The anterior approach preserves the musculo-skeletal spine anatomy. Postsurgical scarring in and around the spinal canal and nerve roots is avoided, and average blood loss is less than 223 cc.