Pediatric intracapsular tonsillectomy with bipolar

electrosurgical scissors.
Abstract
This article describes the benefits of performing intracapsular tonsillectomy
tonsillectomy /tonsillectomy/ (ton?si-lektah-me) excision of a tonsil.
tonsillectomy
n.
Surgical removal of tonsils or a tonsil. with bipolar electrosurgical scissors scissors
Cutting instrument or tool consisting of a pair of opposed metal blades that meet and cut when the
handles at their ends are brought together. Modern scissors are of two types: the more usual pivoted
blades have a rivet or screw connection between the cutting ends
as an alternative to the powered microdebrider. These scissors are used to excise approximately
90% of the tonsillar tonsillar /tonsillar/ (tonsi-lar) of or pertaining to a tonsil.
tonsillar or tonsillary
adj.
Of or relating to a tonsil, especially the palatine tonsil. mass en bloc. The remaining tonsillar tissue
is electrodesiccated by monopolar suction cauterv, while the anterior and posterior pillars are
completely preserved. The procedure leaves a smaller surgical wound than do extracapsular
techniques. Surgical time averages 6 minutes. There is typically no intraoperative blood loss. Bipolar
electrosurgical scissors are an efficient and low-cost tool for performing pediatric
pediatric /pediatric/ (pe?de-atrik) pertaining to the health of children.
pediatric
adj.
Of or relating to pediatrics. intracapsular tonsillectomy.
Introduction
Despite a century of technical refinement, pediatric tonsillectomy still causes a significant amount of
morbidity. (1) Immediate (<24 hr) postoperative bleeding complicates 0.2 to 3% of all cases, and
delayed (>24 hr) hemorrhage occurs in 1 to 7%. (2,3) Moreover, postoperative pain, dysphagia
dysphagia /dysphagia/ (-fajah) difficulty in swallowing.
dysphagia or dysphagy
n.
Difficulty in swallowing or inability to swallow. , and weight loss are nearly universal. (2,3)
In response to these continuing problems, Koltai et al. in 2003 advocated a revival of the abandoned
procedure of partial (intracapsular) tonsillectomy, a procedure in which the lateral portion of the
tonsil tonsil
Small mass of lymphoid tissue in the wall of the pharynx. The term usually refers to the palatine
tonsils on each side of the oropharynx. They are thought to produce antibodies to help prevent
respiratory and digestive tract infection but often become infected and its capsule are preserved.
(4) They reported their first cases in 2002 (5) and subsequently described a large series of
intracapsular tonsillectomies for the tratment o f upper airway upper airway
n.
The portion of the respiratory tract that extends from the nostrils or mouth through the larynx.
obstruction. (6) They found that the intracapsular procedure was associated with less morbidity
and bleeding than was classic total (extracapsular) tonsillectomy.
Most authors use a powered microdebrider for intracapsular tonsillectomy followed by
electrodesiccation of the tonsillar remnant. (6) Although this technique has proved to be workable,
resection proceeds slowly, blood loss occurs during dissection, and the microdebrider tips are
expensive.
Bipolar electrosurgical scissors were introduced to the United States market in the spring of 1997.
Since then, we at the Temple University Children's Medical Center in Philadelphia have used these
scissors for all of our tonsillectomies. (7) In more than 1,000 extracapsular tonsillectomies, they
have proved to be a safe and efficient instrument for achieving bloodless dissection with minimal
damage to surrounding tissues. The length of surgical time has averaged 6 minutes. In this article,
the author describes the use of bipolar electrosurgical scissors for intracapsular tonsillectomy.
Surgical technique
Surgeons at the author's institution use 7-inch bipolar Metzenbaum electrosurgical scissors
(PowerStar BP-320; Ethicon Endo-Surgery; Cincinnati) (figure 1). Patients are orotracheally
intubated and placed in the Rose position. The mouth is opened with an appropriately sized Crowe-
Davis gag, and a headlight is used for illumination. We have found that neither loupe
loupe (lldbomacp) [Fr.] a magnifying lens.
loupe
n.
A small magnifying lens.
loupe
a magnifying lens. magnification nor an operating microscope operating microscope
n.
See surgical microscope. is helpful.
[FIGURE 1 OMITTED]
The tonsil is grasped near its superior pole with a DeBakey forceps and drawn medially (figure 2, A).
By drawing the tonsil in and out, it is possible to estimate its lateral extent beneath the anterior
tonsillar pillar and to determine the appropriate depth of the excision. A mucosal incision is made
parallel to and just medial to the anterior tonsillar pillar with the scissors in electrified mode (bipolar
power setting: 20; electrosurgical generator; Valley Lab, Boulder, Colo.) (figure 2, B).
[FIGURE 2 OMITTED]
The surgeon then aims the tips of the scissors into the substance of the tonsil with the intent of
excising approximately 90% of the tonsillar mass (figure 2, C). Care must be taken to ensure that the
scissor scissor
pertaining to scissors; like scissors in effect.
scissor bite
see scissor bite.
scissor mouth
a narrow space between the rami of the mandible so that the molar arcades do not meet.
tips are in view throughout the dissection to avoid entering the extracapsular plane between the
tonsillar capsule and the superior constrictor muscle constrictor muscle
plain muscle surrounding cylindrical organs at orifices.
constrictor muscle pupillae muscle
muscle constricting the pupil.
constrictor muscle vestibuli muscle
muscles constricting the vagina.
. Dissection is carried through the tonsillar substance to the inferior pole, where the tonsil is
separated from the tongue base (figure 2, D).
If islands of tonsillar tissue remain, they are grasped individually with the DeBakey forceps and
excised with the bipolar scissors. Monopolar suction cautery cautery, searing or destruction of
living animal tissue by use of heat or caustic chemicals. In the past, cauterization of open wounds,
even those following amputation of a limb, was performed with hot irons; this served to close off the
bleeding vessels as well as is used to electrodesiccate the remaining tonsil (figure 2, E), leaving
behind only a shell of charred tissue (figure 2, F). Neither the anterior nor the posterior tonsillar
pillar is disturbed. A small, shallow wound results that heals quickly (figure 3). Ideally, the superior
constrictor muscle and the veins of the tonsillar plexus remain covered.
[FIGURE 3 OMITTED]
Discussion In all tonsillectomy procedures, the surgeon's goal is to remove the tonsil quickly with
minimal blood loss. Until the tonsillar fossae are fully mucosalized, patients experience pain and face
the risk of postoperative bleeding. Pain during the healing phase is the result of exposure of the
superior constrictor muscle and associated nerve endings to mechanical stretch, the ingestion
ingestion /ingestion/ (-chun) the taking of food, drugs, etc., into the body by mouth.
ingestion
n.
1. The act of taking food and drink into the body by the mouth.
2. of hypotonic hypotonic /hypotonic/ (-tonik)
1. denoting decreased tone or tension.
2. denoting a solution having less osmotic pressure than one with which it is compared. solutions,
and abrasion by food. (8) Posttonsillectomy bleeding can be caused by exposure of the thin-walled
veins of the tonsillar plexus to these mechanical forces and to the inflammation associated with
secondary healing.
Healing time can be shortened by limiting thermal damage to extratonsillar tissue, preserving the
tonsillar pillars, and minimizing the size of the oropharyngeal
oropharyngeal /oropharyngeal/ (-fah-rinje-al)
1. pertaining to the mouth and pharynx.
2. pertaining to the oropharynx. wound. Also, leaving a coating layer of semiviable tonsillar tissue
may reduce exposure of the veins in the tonsillar plexus and superior constrictor muscle. These
principles have guided the development of the intracapsular tonsillectomy technique.
Several authors have described their experiences with intracapsular tonsillectomy. (6,9-11) In each
series, the pain and bleeding associated with the intracapsular procedure were less than that
associated with extracapsular techniques. Widespread acceptance of intracapsular tonsillectomy has
been delayed by historical cautions against partial tonsillectomy in children with recurrent sore
throat, the potential risk of subsequent peritonsillar abscess when the peritonsillar space is
preserved, and possible regrowth Re`growth
n. 1. The act of regrowing; a second or new growth.
The regrowth of limbs which had been cut off.
- A. B. Buckley. of tonsillar remnants. However, some large clinical series have shown that cases of
tonsillar regrowth and peritonsillar abscess formation are infrequent. (6,9-11)
Otolaryngologists are familiar with powered microdebriders because they are widely used in
endoscopic endoscope
n.
An instrument for examining visually the interior of a bodily canal or a hollow organ such as the
colon, bladder, or stomach.
en sinus surgery. These devices allow the surgeon to execute a controlled removal of soft tissue
with little risk of penetrating bone. (12) With less aggressive tips, they provide modest soft-tissue
differentiation. Some authors have advocated the use of the microdebrider for the removal of
laryngeal laryngeal /laryngeal/ (lah-rinje-al) pertaining to the larynx.
laryngeal or laryngal
adj.
Of, relating to, affecting, or near the larynx. lesions and for powered adenoidectomy. (13,14) How
ever, these instruments do not provide for simultaneous hemostasis hemostasis /hemostasis/
(he?mo-stasis) (he-mostah-sis)
1. the arrest of bleeding by the physiological properties of vasoconstriction and coagulation or by
surgical means.
2.
during tissue excision, and therefore their usefulness in bloody fields is limited. Furthermore, the
disposable tips cost between $75 and $150, which substantially increases the cost of the procedure.
A patent was granted for bipolar electrosurgical scissors in 1994 (U.S. Patent #5,324,289). Based on
this patent, the manufacturer received approval from the federal Food and Drug Administration in
1997 to market four commercial products under the brand name PowerStar. These devices were
very favorably received, as basic research (15,16) and clinical series (17-19) demonstrated their
utility and documented their favorable effects on tissue. With the first PowerStar model, some
deterioration of the anodized aluminum screw that connected the scissor blades occurred, and this
resulted in the leakage of electrical current into the moist oral cavity. (7) An improved model
(PowerStar BP-320) with a better-insulated screw is now available in Canada, Great Britain, and
mainland Europe. However, the manufacturer has withheld this relatively inexpensive (~$500 ea.)
model from the U.S. market because its excellent durability limits sales of new instruments.
Moreover, the BP-320 scissors competes with the company's harmonic scalpel, which is sold with a
disposable tip for tonsillectomy. As a result, surgeons who wish to use the BP-320 scissors must
import them.
In conclusion, bipolar electrosurgical scissors are an excellent instrument for performing surgical
excision of soft tissue. Because they minimize bleeding and damage to surrounding tissues, they are
a low-cost alternative to powered instrumentation for intracapsular tonsillectomy. THe author hopes
that the manufacturer will make these scissors easier to purchase in the United States.
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To make random in arrangement, especially in order to control the variables in an experiment.
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From the Department of Otolaryngology-Head and Neck Surgery, the Temple University School of
Medicine The Temple University School of Medicine (TUSM), located on the Health Science Campus
of Temple University in Philadelphia, PA, is one of 6 schools of medicine in Pennsylvania conferring
the doctor of medicine (M.D.) degree. and the Temple University Children's Medical Center,
Philadelphia.
Reprint requests: Glenn Isaacson, MD, Department of Otolaryngology--Head and Neck Surgery,
Temple University School of Medicine, 3400 N. Broad St., Philadelphia, PA 19140. Phone: (215) 707-
3665; fax: (215) 707-7523; e-mail: glenn@ent.temple.edu
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