Pediatric intracapsular tonsillectomy with bipolar electrosurgical scissors.

Abstract

This article describes the benefits of performing intracapsular tonsillectomy with bipolar electrosurgical scissors as an alternative to the powered microdebrider. These scissors are used to excise approximately 90% of the tonsillar 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 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, 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 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 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 magnification nor an operating 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 tips are in view throughout the dissection to avoid entering the extracapsular plane between the tonsillar capsule and the superior constrictor muscle. 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 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 of hypotonic 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 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 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 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 lesions and for powered adenoidectomy. (13,14) How ever, these instruments do not provide for simultaneous hemostasis 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.

References

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(2.) Colclasure JB, Graham SS. Complications of outpatient tonsillectomy and adenoidectomy: A review of 3,340 cases. Ear Nose Throat J 1990;69:155-60.

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(4.) Koltai PJ, Solares CA, Koempel JA, et al. Intracapsular tonsillar reduction (partial tonsillectomy): Reviving a historical procedure for obstructive sleep disordered breathing in children. Otolaryngol Head Neck Surg 2003;129:532-8.

(5.) Koltai PJ, Solares CA, Mascha EJ, Xu M. Intracapsular partial tonsillectomy for tonsillar hypertrophy in children. Laryngoscope 2002;112(8 Pt 2 suppl 100):17-19.

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(10.) Densert O, Desai H, Eliasson A, et al. Tonsillotomy in children with tonsillar hypertrophy. Acta Otolaryngol 2001;121:854-8.

(11.) Sorin A, Bent JP, April MM, Ward RE Complications of microdebrider-assisted powered intracapsular tonsillectomy and adenoidectomy. Laryngoscope 2004;114:297-300.

(12). Ferguson BJ, DiBiase PA, D'Amico F. Quantitative analysis of microdebriders used in endoscopic sinus surgery. Am J Otolaryngol 1999;20:294-7.

(13.) Murray N, Fitzpatrick P, Guarisco JL. Powered partial adenoidectomy. Arch Otolaryngol Head Neck Surg 2002; 128:792-6.

(14.) Patel N, Rowe M, Tunkel D. Treatment of recurrent respiratory papillomatosis in children with the microdebrider. Ann Otol Rhinol Laryngol 2003;112:7-10.

(15.) Baggish MS, Tucker RD. Tissue actions of bipolar scissors compared with monopolar devices. Fertil Steril 1995;63:422-6.

(16.) Forestier D, Slim K, Joubert-Zakcyh J, et al. [Do bipolar scissors increase postoperative adhesions? An experimental double-blind randomized trial]. Ann Chir 2002;127:680-4.

(17.) Uchida M, Wada Y, Hisa Y. Usefulness of bipolar scissors during superficial lobectomy of the parotid gland. Laryngoscope 2002;112: 1119-21.

(18.) Yamada T, Sasaki Y, Yokoyama S, et al. Practical usefulness of bipolar scissors in hepatectomy. Hepatogastroenterology 2002;49: 597-600.

(19.) Wax MK, Winslow C, Desyamikova S, et al. A prospective comparison of scalpel versus bipolar scissors in the elevation of radial forearm fasciocutaneous free flaps. Laryngoscope 2001;111(4 Pt 1):568-71.

From the Department of Otolaryngology-Head and Neck Surgery, the Temple University School of Medicine 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: [phone]; fax: [phone]; e-mail: [e-mail]