ESP Step by Step:Tips & Trick Cartoon

Transcription

1 Step by Step:Tips & Trick Cartoon 02/05/ Evolution of Technique Pang & Tucker Woodson STUCK Sorrenti Vicini 02/05/

2 Tonsillectomy if TS in site, any size Otherwise TS fossa mucosectomy Maximum posterior pillars sparing Meticolous hemostasis Perfect exposition Step 1: after TS ectomy or Mucosectomy: local situation analysis 02/05/ Bowie, monopolar, scissors, cold scalpel, special instruments Needle Tip (Colorado) Bipolar Hemostasis Key Point: spare mucosal surface Step 2: medial incision Upper Usually starts at the junction between superior 1/3 and middle 1/3 It allows posterior pillar steal technique (see below) 02/05/

3 Step 2: medial incision Keep far from mucosa surface, avoid mucosal injury Spare medially a sufficientv amount of muscle for stable suturing Upper Distance To mucosa 02/05/ Step 2: medial incision Depht of about 5 mm Key: develop a cilindric flap of sufficient diameter Upper Distance To mucosa Depht 02/05/

4 Step 2: medial incision Stop at the inferior limit of dissected posterior pillar Upper Distance To mucosa Depht Inferior Limit 02/05/ Step 3: lateral incision Bowie Bipolar dissection Scalpel, scissors, special instruments Key Point: avoid major vessels injury Needle Tipe Tip (Colorado) Bipolar Hemostasis 02/05/

5 Step 3: lateral incision Start more superiorly than the lateral incision, at the junction between anterior pillar and palate Upper 02/05/ Step 3: lateral incision Locate lateral incision at about 5 mm from the medial incision ( more lateral in large palate structures) Upper Flap Widht 02/05/

6 Step 3: lateral incision Same depht than lateral incision Upper Flap Widht Flap Depht 02/05/ Step 3: lateral incision Same inferior limit than medial incision Upper Flap Widht Flap Depht Inferior Limit 02/05/

7 Step 4: raising flap Curved Forceps Blunt + sharp dissection Hemostasis! Key Point: avoid flap damage Dissect free the posterior aspect of the muscular flap by monopolar; complete by a curved forcep, spreading gently the tips 02/05/ Flap Manipulation Step 4b: flap suturing 30 Dexon Bite the flap and wrap the suture around Key: this suture will prevent any slippery movement of the pulling suture (see below) 02/05/

8 Flap Manipulation Step 5: flap coagulation Bipolar Very accurate! Key: prevent any bleeding in the most bloody area of the inferior dissection Area of Bipolar Coagulation 02/05/ Flap Manipulation Step 6: flap section Bowie section 02/05/

9 Flap Manipulation Step 7: flap detachment and second flap suture Bowie Keep muscle attachment where required Put a second suture around the base of the flap Key: avoid to dissct too muche in the superior and medial area, where the flap will produce most of its traction 02/05/ Palate Tunelling Step 8: palate tunnelling Blunt curved forcep Spread gently Possible bleeding at tunnel end Key: keep inside the muscle, introduce and spread the tips gently and step by step 02/05/

10 Palate Tunelling Step 8: palate tunnelling Angle 45 Blunt curved forcep Spread gently Bleeding at tunnel end Try to keep at 45 02/05/ Palate Tunelling Blunt curved forcep Spread gently Bleeding at tunnel end Step 8: palate tunnelling At the ogiva area 02/05/

11 Palate Tunelling Blunt curved forcep Spread gently Bleeding at tunnel end Within the soft palate muscolature Step 8: palate tunnelling Depht 02/05/ Palate Tunelling Blunt curved forcep Spread gently Bleeding at tunnel end Step 8: palate tunnelling End Point Depht Close to hamulus area 02/05/

12 Palate Tunelling Step 8: palate tunnelling Blunt curved forcep Spread gently Bleeding at tunnel end 02/05/ Pull Up Suture Step 9: flap suturing 2 0 Dexon flat wide needle Strong needle holder A long strong needle is required as well a strong needle driver Enter to the superior end of the tunnel 02/05/

13 Flap pull Up Step 9: flap pulling 2 0 Dexon flat wide needle Strong needle holder Escape at the inferior end of the tunnel, bite the flap over the suture, re-enter the tunnel at the inferior opening and escape from the superior end close to entrance of the suture Pull up the flap and stick it inside the tunnell to the end Traction must be related to the required action of letralisation and anteriorisation of the palate 02/05/ Flap Suturing 2 0 Dexon flat wide needle Strong needle holder Customised suture tenting Step 10: flap suturing Second suture Second suture of stabilisation around the flap base suture Addictional sutures in pillars area Pillar Sutures 02/05/

14 Main Lateral Vector Significant Anterior Vector Minimal Cephalic Vector Step 1O: vectors of UARWs enlargement; midline palate streching 02/05/ Step 11: uvuloplasty Uvula manipulation Mucosectomy & miectomy Suture Remove a strip of mucosa and muscle by cautery Suture the wound Remodelling of uvula 02/05/

15 COMPLICATIONS Topographically Related Complication Sites Bleeding Mucosal Injury Mucosal Creases -> Stenosis Bleeding 02/05/ Summarising: Minimally invasive Minimal mucosal Injury Muscle Manipulation More grip in muscles Lateral Vector Anterior Vector Cephalic Vector Reduced Pain Reduced Paraesthesia Reduced VPI Risk Longer More Tech demanding Longer training Flap Stability (?) Lomg Term Outcame (?) 02/05/

16 02/05/2012 Vicini Alex 2012 Snoring & OSA 31 02/05/