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Tonsillectomy Using an Ultrasonically Activated Scalpel

2000; Wiley; Volume: 110; Issue: 7 Linguagem: Inglês

10.1097/00005537-200007000-00034

1531-4995

Kentaro Ochi, Toru Ohashi, Natsuki Sugiura, Yasushi Komatsuzaki, Atsushi Okamoto,

Voice and Speech Disorders

Tonsillectomy is one of the most popular surgeries in otorhinolaryngology. Although the progress of antibiotics enhances improvement of treatment for tonsillitis, there are still many indications for tonsillectomy. It is performed in adults and children and sometimes brings about lethal complications. Bleeding is an important, dangerous complication that limits operative indications. The establishment of a safe, bloodless operative procedure will increase the number of cases with operative indication. In 1992 an ultrasonically activated scalpel that achieves effective coagulation and safe cutting of tissue was introduced. 1 The ultrasonic activated scalpel is an instrument that potentially causes minimal tissue injury and provides good hemostasis. Ultrasonically activated vibrations (55,500 cycles per second) can cut the tissue. The ultrasonically activated scalpel is composed of a generator, handpiece, and blade (Fig. 1). The handpiece houses the acoustic system, which is composed of the transducer and the mount. There is no vibration in the handpiece when the system is activated. The three components of the acoustic system vibrate harmonically at 55,500 cycles per second. 2 The ultrasonically activated scalpel. The generator is a microprocessor-controlled, high-frequency–switching power source. In this report we introduce a method of tonsillectomy with the aid of an ultrasonically activated scalpel, especially stressing the effectiveness of this device. General anesthesia was employed in the operative room. The tissues surrounding the tonsils were infiltrated with a mixture of 0.5% lidocaine and 1:100,000 epinephrine. Three injections into both pillars were made in every patient, at the superior pole, at the inferior pole, and between the poles. These six injections displaced the tonsils toward the midline and helped to identify the plane of dissection. Each tonsil was grasped with an Allis clamp; the ultrasonically activated scalpel (Harmonic Scalpel, UltraCision, Smithfield, RI, and Ethicon, Somerville, NJ) was used at a power level of 3 to incise the mucosa and then to perform dissection toward the inferior pole; the coagulating shears were used to remove the remaining inferior portion of tonsil in some cases. We have applied this technique from July 1999 to December 1999 without any morbidity for 14 (8 male and 6 female) patients with chronic tonsillitis. The patients' ages ranged from 5 to 33 years (8 adults and 6 children). Surprisingly, there was no measurable bleeding during surgery in all cases. We could complete the surgery without use of suction for bleeding, although several cottonoid pledgets were used to remove blood stains. The Harmonic Scalpel was introduced in 1992, mainly for use in the laparoscopic surgery. It provided better visualization of the operative field without smoke, char, or odors. Because cutting and coagulation are accomplished with relatively low temperature, thermal injury appears to be minimal. The Harmonic Scalpel produces hemostasis, minimal contagious spread of tissue destruction, and faster healing than does electrosurgery or CO2 laser surgery in an animal study. 3 However, it has not been routinely applied for the general otorhinolaryngological surgery. We have used this device for surgery such as parotidectomy and conchotomy since July 1999, as well as tonsillectomy. There are four types of blade: coagulating shears, a ball coagulator, a hook, and a curved blade called a Katana (Fig. 2). Coagulating shears have strong hemostatic potential, while a Katana has strong cutting ability. A hook has both hemostatic potential and cutting ability. A ball coagulator is only used for coagulation. We prefer using a hook. We used coagulating shears in the initial two cases when removing the tonsil from tonsillar beds. However, it proved to be possible to remove the tonsil by means of a hook blade. The back side of the hook blade was used when the surgeon expected bleeding. As a result, we used only a hook throughout the procedure after the two initial cases. In addition to the type of blade, we are able to choose from five levels of function ranging from 1 to 5 for the operative procedure. These levels represent distance of blade movement. The blade moves 0.05 mm forward and backward longitudinally at level 1, and 0.08 mm at level 5. The longer distance of blade movement results in greater cutting ability at the expense of the risk of bleeding. We usually choose level 3 for the surgical maneuvers. There are four types of blade (from top to bottom): coagulating shears, a ball coagulator, a hook, and a curved blade called a Katana. We have found this technique to be safe, with advantages over other methods. We recommend it to surgeons who perform tonsillectomy.