Functional endoscopic sinus surgery chopstick technique

Authors


  • The authors have no funding, financial relationships, or conflicts of interest to disclose.

Abstract

We describe a functional endoscopic sinus surgery (FESS) technique that involves the simultaneous use of endoscope and suction in the nondominant hand that bears resemblance to chopstick use. The FESS chopstick technique reduces time for suction and improves operative field visualization. Laryngoscope, 2010

INTRODUCTION

Since the introduction of endoscopic sinus surgery, a number of technological advances, as well as an improved understanding of disease pathogenesis and management, have enabled major evolutions in surgical techniques. Modifications to surgical instruments, imaging, the development of the microdebrider and other newer instrumentation have all contributed to the current level of success associated with endoscopic intranasal techniques.1

Early instrument modifications included forceps and dissectors with built-in suction, which enabled procedures to continue despite significant bleeding. Suction irrigation systems and microdebriders with suction allow good visualization in even less than ideal conditions. However, suction microdebriders may also pose a significant risk should an inexperienced surgeon debride a wide area.1 In addition, some instruments with attached suction are larger in diameter, resulting in difficult manipulation. Endoscopic sinus surgery performed with instruments providing constant suction and intermittent irrigation (on demand) require the establishment of a sealed, protected airway.2

The orthodox technique involves the surgeon holding the endoscope in one hand and the other instruments, such as the suction device, in the other. In contrast, the bimanual technique in endoscopic sinus surgery requires two trained endoscopists, and is particularly useful when there is a lot of bleeding or when tension needs to be kept on tissue to cut it cleanly.3

During endoscopic sinus surgery, the dominant hand is used for instrumentation and the other hand solely for endoscope navigation. Conventionally, intermittent suction using the dominant hand is always needed to remove blood from the operative field. Alternating between operative instrument manipulation and suction by the dominant hand in an already-confined nasal space is time consuming.

CHOPSTICK TECHNIQUE

We describe a functional endoscopic sinus surgery (FESS) technique that involves the simultaneous use of endoscope and suction in the nondominant hand that bears resemblance to chopstick use. The FESS chopstick technique reduces time for suction and improves operative field visualization. In difficult circumstances, such as excessive bleeding, the maneuverability of the suction device can be increased by quick transfer to the dominant hand as the device is already within the nasal space.

The FESS chopstick technique is described below

Step 1

The endoscope is wedged in the first web space between the thumb and the palm.

Step 2

Step 2 step involves holding the endoscope and suction device in the nondominant hand. The surgeon is then able to hold the suction device in three different positions as shown in Figure 1A, 1B, and 1C. The three positions are: 1) With the endoscope already in place, hold the suction device between the thumb, index, and middle finger. The ring finger and little finger are used as support from front (variation 1). 2) Hold the suction device between the thumb, index, and middle finger. The ring finger and little finger are used as support from behind (variation 2). 3) Hold the suction device between the thumb, index, and middle finger. The lower end of sucker is wedged between the ring finger and little finger (variation 3).

Figure 1.

The FESS chopstick technique. (A) Variation 1 (endoscope: A, suction device: B). Hold suction device between thumb, index, and middle finger. The ring finger and little finger are used as support from front. (B) Variation 2 (endoscope: A, suction device: B). Hold suction device between thumb, index, and middle finger. The ring finger and little finger are used as support from behind. (C) Variation 3 (endoscope: A, suction device: B). Hold suction device between thumb, index, and middle finger. The lower end of the suction device is wedged between the ring finger and little finger. Instead of the ring finger, the little finger is now used as the fulcrum. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

Step 3

Similar to using chopsticks, where one chopstick is kept stationary (endoscope), practice moving the other chopstick (the suction device) in one direction and then the other direction. The suction device can effortlessly be moved from side to side and forward and backward. Vertical travel is possible; however, it is limited (Fig. 2).

Figure 2.

Demonstration of holding three instruments. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

The key element is holding the sucker in the nondominant hand. Wedging the suction in between the fingers aids effective movement of the device (Fig. 3 and Fig. 4). The suction device position is versatile and dependent on the surgeon's apostrophe. We routinely use the FESS chopstick technique to perform all endoscopic sinus surgery procedures, such as middle meatal antrostomies, ethmoidectomies, sphenoidectomies, frontal sinus surgery, sphenopalatine artery ligation, and endoscopic dacryocysto-rhinostomies. This technique may be difficult in certain situations where the available working space is very narrow. With sufficient practice, one can quickly master independent movement of the suction device relative to the stationary endoscope.

Figure 3.

Arrows demonstrates possible movements of the suction device in different directions. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

Figure 4.

Endoscopic view demonstrating three instruments in the operative field. [Color figure can be viewed in the online issue, which is available at www.interscience.wiley.com.]

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