COBLATION ADENOIDECTOMY PROCEDURE UNDER TRANSNASAL VIDEO-ENDOSCOPY CONTROL

Dott.Lino Di Rienzo Businco, Rome – Italy

INTRODUCTION

-Coblator system is not a new tool to do an old procedure

-Always the hand (and the brain) moves the wand

-perfectionism of coblation surgery

-avoid FANS during preoperative days

-preservation of rhinopharyngeal mucosa with controlled coblation adenoidectomy

-reach and remove completely choanal intranasal adenoid, with no residual tissue (as happens with cold adenoidectomy)

-always think to a “selective and precise surgery” of the adenoid (saving normal adjacent mucosa and openings of Eustachian tubes) during procedure

-no thermal injury to the nasal-pharyngeal mucosa using coblator for adenoidectomy

EQUIPMENT PREPARATION

-Insert the Procise XP Wand into the connector end of the patient cable. Align the raised dot on the wand handle with the black dot on the patient cable

-set the controller power level to 7-8 for ablation of the adenoids, and 3 for coagulation, depending on surgeon preference as judged by adenoid volume

-Nasal endoscope 0°,  2.7 mm diameter, connected to video-camera,  for direct visualization of rhinopharynx cavity (no need of rubber catheter palatine retraction as when using mirror)

-Mc-Ivory open Mouth with proper size of pediatric tongue depressor

-Procise XP Wand malleable, curved till reach the superior portion of rhinopharynx and the opening to the Eustachian tubes

-Conformator to malleate and curve Procise Wand to the proper dimension of rhinopharynx without damage of suction function (see www.sidero.it)

-Cold saline solution flow connected to Wand for continue irrigation of operative field (if necessary drop saline solution also from nasal cavity)

-micro-suction tube for trans-nasal use

-surgical patties with local anesthetic

PATIENT PREPARATION

-anesthesiologist perform general anesthesia  

-patient rest in the bed with the head at the same level respect the body

-apply topical nasal anesthetic+vasoconstrictor   on surgical patties for 5-10 minutes on all long medial surface of the inferior turbinate to make easier the endoscope passage.

COBLATION ADENOIDECTOMY PROCEDURE UNDER TRANSNASAL VIDEO-ENDOSCOPY CONTROL

-Identify, with nasal endoscope 0°, the size of the adenoids and assess its border to reach

-place the open mouth on patient

-choose the correct double curve of Procise Wand able to reach all rhinopharynx

-activate foot pedal ablation when the wand is close but not in contact to the inferior edge of the adenoid

-Rhinopharynx always wet and clean to minimize pain and perform a very selective and precise adenoidectomy

-model proper the Procise wand  to reach and ablate all the adenoid with precise movements and continue rotation of the wand

-careful insert and  remove the wand in rhinopharynx cavity without trauma on uvula and soft palate

-perform an endoscopic check of all compartments to ensure to have removed all the adenoideal tissue

-verify the absence of any bleeding or mucosal damage 

-if necessary coagulate bleeding areas

COMPLICATION TO AVOID

-ablation with the tip of the wand the Eustachian openings, uvula, soft palate

-forget to ablate choanal adenoids

-ablate with the tip of the wand too deep under adenoids, with formation of fibrosis or mucosal damage

DON’T  FORGET

-Procise Wand adenoidectomy need quite a lot saline irrigation during procedure (no saline, no plasma field!)

-if the rhinopharynx is too deep and curved is possible that saline flow become few, then irrigate saline also form nasal opening

-if there is too much bleeding during adenoidectomy stop ablation and reach good bleeding control with coagulation before going on with the procedure

-do not activate the wand outside the cavity to prevent  any palate or mucosal damage

IMMEDIATELY AFTER PROCEDURE

-Clean gently with patties the choanal opening and all rhinopharynx

-administrate antibiotic/analgesic therapy if necessary

PATIENT POST-OP INSTRUCTION

-edema and postnasal congestion could appear during the first week postop

-avoid blowing nose for the first 24 hours

-minor  bleeding in nasal secretion is normal in the first 24 hours

-start nasal wash 3 times/day with saline nasal spray after 24 hours

-check the patient at 7-10 days post-op (last control after 1 month)

-inform the patient that increasing nasal flow after procedure will go on with better results during healing day after day till 15-20 days