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Surgical intervention of palatine tonsils, particularly tonsillectomy, remains a standard practice in the field of otorhinolaryngology (ENT practice). It is a success due to the application of instruments that are specifically designed to facilitate dissection, exposure, and excision with minimum trauma. Examples are tonsil dissectors and anterior pillar retractors. Due to their non-obtrusive nature, they enable surgeons to pass through a vascular and confined space without side effects of postoperative pain, tissue trauma, or hemorrhage
One must be cognizant of the elementary anatomy of the
oropharyngeal complex to appreciate the usefulness of dissectors and retractors
in surgery and tissue handling.
Key Anatomical Structures
Situated in tonsillar fossa between anterior palatoglossal
and posterior palatopharyngeal pillars.
Supplied by branches of facial, lingual, and ascending
pharyngeal arteries.
Contains palatoglossus muscle and mucosal covering.
Shielding tonsil from the anterior aspect and must be
retracted intraoperatively carefully.
Fibrous tonsillar capsule: plane between capsule and pharyngeal muscle is where one should dissect.
Courses close to the inferior pole of the tonsil, which demand protection in manipulation of instruments.
Historical development of tonsillectomy as a technique over
centuries from the ancient extractions to current advanced and minimally
invasive techniques.
•Chronic or recurrent tonsillitis
•Obstructive sleep apnea secondary to tonsillar hypertrophy
•Peritonsillar abscess not conservatively treatable
•Susception or biopsy of tonsillar neoplasm
•Cold steel dissection (traditional technique with
dissectors)
•Electrocautery dissection
• Coblation-aided tonsillectomy
• Laser and harmonic scalpel methods
Cold dissection method—in which tonsil dissector is in a top position—is yet to be the method of choice in cases where clean planes and less heat damage are required.
Tonsil dissector is a very sensitive instrument with which
to dissect between tonsil and surrounding muscular and fibrous tissues. It is
used with an anatomical and sense of feel so that border tissues are not
injured.
• Dissect peritonsillar plane cleanly
• Ergonomically designed to
• Reduce trauma to pharyngeal musculature
• Facilitate complete tonsillar removal without capsular rupture
• Allow hemostatic control by excluding major vessels
Tonsil dissectors are not permanent. They exist in variants
for surgeon technique, operating conditions, and patient anatomy.
Two-ended: retractor end and dissecting blade.
One-hand manipulation is well-balanced.
Blade-like shape with cutting edge to dissect fibrous
tissues.
Carried normally in a second retractor.
Used in enucleation surgery.
Blunt edge minimizes laceration of muscles.
Designed for deliberate blunt dissection with minimum blood
loss.
Suitable for pediatric use.
Corrosion and sterilization-resistant high-carbon stainless
steel
Ergonomic handle configurations for hand stability
Non-reflective surface for decreased light glare
Successful tonsillectomy with low postoperative complication
can be achieved through effective technique of dissection by tonsil dissector.
• Mucosal incision over anterior pillar to expose tonsil.
• Dissector into peritonsillar space to release tonsil.
• Dissection taken inferiorly to lower pole.
• Lower pole clamped and transected after dissection.
• Keep dissection in avascular plane.
• Avoid capsular violation of the tonsillar capsule.
• Protect the glossopharyngeal nerve.
• Reduce muscle trauma to minimize postoperative pain.
Dissectors are a part of cold steel tonsillectomy, but their
usage is subject to considerations that influence surgical preference.
• No thermal damage, healthy tissue preservation
• Clear definition of planes of anatomy
• Most suitable in malignancy or biopsy cases when integrity
of margins is required
• More intraoperative bleeding than with electrosurgical
techniques
• More time consuming in operating room than energy-assisted
techniques
•Slanting learning curve in surgery of dissection technique
Dissectors perform simple tissue separation, but exposure
and fixation depend on anterior pillar retractors. Anterior pillar retractors
allow visualization of deep oropharyngeal spaces by retracting soft tissue and
palatoglossal arch.
•Retract anterior pillar so tonsillar bed becomes obvious
clearly
•to group working area for hemostasis and dissection
•Increases visibility to lower poles and vessels that bleed
• Stabilize soft tissues on suction cautery or suture
Anterior pillar retractors find application in ENT surgery,
excluding tonsillectomy, where soft tissue retraction is required in
oropharyngeal procedures.
• Cold steel and electrocautery tonsillectomy
• Visualization of adenoidectomy procedures around close
structures
• Foreign body removal in the oropharynx
• Uvulopalatopharyngoplasty (UPPP) exposure
Understanding the anatomy of the anterior pillar guarantees
that one can retract intraoperatively safely and effectively.
• Made of palatoglossus fibers and overlying mucosa
• Strongly attached to tonsillar capsule medially
• Such an instrument must be retracted with minimum tension so that post-operative fibrosis or dysphagia is prevented
Retractors vary in degree of retraction required, in
direction of entry and in compatibility.
Hooked end for lateral retraction of pillar.
Usually double-ended.
Increased blade width for greater retraction.
Good for adult tonsillectomy.
Retractor and tongue depressor combined.
Used fairly often with suction cautery.
Pediatric profile.
Allows controlled movement in restricted areas.
Anterior pillar retractor during tonsillectomy is an
important but secondary function. Without good exposure, tonsil dissection is
dangerous and impossible.
•Inserted after incision of mucosa
•Retracts anterior pillar to side and slightly anterior
•Allows viewing of tonsillar capsule and posterior pillar
•Allows room for cauterization or ligation of vessels
Although more specifically used in tonsillectomy, anterior
pillar retractors also provide access to overlying pharyngeal tissue and
adenoid tissue.
•As uvular and soft palate retractor in transoral
adenoidectomy
•Used for nasopharynx exposure in children
•Used sporadically for base-of-tongue procedures for additional exposure
Good instrument technique, especially during high-stress ENT
operations, is to be applauded in avoiding complications and operator fatigue.
• Should be comfortably well-balanced in the hand without
twisting the wrist
• Should permit one-hand use if being used for suction or
cautery
• Should permit firm grasp without straining
• Light-weight stainless steel to reduce fatigue
• Textured handle to prevent slippage when wet
• Angulation to reach oropharynx without getting in the way of vision
Since dissectors and retractors are being reused as
repeat-use instruments, they are subject to sterilizing agents and heat
repeatedly.
• Surgical stainless-steel resistant to corrosion and
pitting
• Heat-tempering of joints (where applicable) to ensure
shape retention between autoclave cycles
• Inert surface coatings to resist biofilm adhesion
• Pre-rinse to remove organic material
• Ultrasonic cleaning in case of serrated tips or hooked
tips
• Steam autoclave at 134°C for 15–20 minutes
• Routine inspection for tip integrity and deformation
Surgical removal of the palatine tonsils is an anatomically
delicate and technologically demanding procedure that requires finesse,
controlled force, and unobstructed visibility of the surgical field. To this
end, in this procedure, the tonsil dissector and anterior pillar retractor are
minimalist instruments that are absolutely critical in the safe and successful
performance of a tonsillectomy.
Tonsil dissectors provide thermal-free, haptic dissection of
pharyngeal musculature off the tonsillar capsule. They are created from the
necessity to be pliable to more than one plane of dissection, patient anatomy,
and surgeon preference. No less significant, anterior pillar retractors provide
unobstructed exposure for surgeons to the peritonsillar structures without
compromise of adjacent structures.
Together as a team, they are consonant with otolaryngologic
surgical principles—technical proficiency, preservation of anatomy, and
minimality. Together, as used as it pertains to superior technique, they are
playing an invaluable role in:
• Improved surgical outcomes
• Postoperative complications avoided
• Improved procedural efficacy
• Operative exposure in refractory cases was accomplished safely
Technological advances in material science, design
ergonomics, and technique continue to challenge the design of these
instruments. But their underlying usefulness is rock-solid based on decades of
OR experience building principles.
Finally, skill in these instruments is an index of anatomic delicacy, technical facility, and sensibility of the exquisite balance between exposure and conservation possessed by a surgeon. They are not operative instruments but instruments of intelligent extensibility—the keystone of the technique of operating otolaryngology.
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