OPERATIVE TECHNOLOGIES

Paul G van der Sloot & Runhua Hue

INTRODUCTION
The nature of surgery is such that operative technologies
provide impetus for change and progress with improved
operative outcomes. Operative technologies are numerous
and diverse.. maybe more so in otolaryngology than any
other surgical specialty. This chapter represents an overview
of operative technologies in otolaryngology. It is by
no means comprehensive. An array of technologies are presented
that include new technologies that have come into
widespread practice, developing technologies that are at
the cusp of general use and old technologies for which new
applications have been recently developed.

DISSECTION/HEMOSTASIS
TECHNOLOGIES
A number of recent tools have been developed that provide
the ability to dissect and achieve hemostasis virtually
simultaneously. These instruments tend to be most useful
in operative cases where space is limited and a dean operating
field is particularly important. These include cases
like parotidectomy, thyroidectomy, parathyroidectomy,
tonsillectomy, and microvascular free flap harvest.
Tonsillectomy
In the case of tonsillectomy, technologies have been
adopted that attempt to minimize pain associated with
conventional cautery without increasing the risk of posttonsillectomy
bleeding. Coblation involves the dissociation
of isotonic saline into sodium ions between the
electrodes of the coblator, which breaks molecular bonds
between cells. The temperatures generated by the coblator
are between 45"C and ssc as compared to 400"C and

Gooc with electrocautery. This, along with the fact that

coblation tonsillectomy is usually performed using an
intracapsular technique, has been shown to decrease the
duration of postoperative pain and speed the return to a
normal diet (1). The disposable coblator components do
create an added cost for the procedure. Coblation has also
been used for a variety of nasal surgeries like turbinate
reduction, hemostatic debulking of tumors to allow endoscopic
visualization, and the removal of encephaloceles.
Other techniques that have been used successfully
include argon plasma scalpels where argon gas is ionized
by an electrode creating a beam of argon plasma through
which current flows allowing for tissue dissection using
molecular resonance technology where alternate current
high-frequency electron waves at well-defined and varying
wavelengths create electron energy quanta, which, when in

resonance with cell molecular bonds, causes them to break

(2,3). The main thrust of these technologies is to decrease
pain without increasing the risk of hemorrhage in the postoperative
period.
Thyroidectomy and Parotidectomy
Ultrasonic shears (or the harmonic scalpel) involve the use
of ultrasonic blade vibrations at 55,000 Hz that denature
proteins and create a coagulum that seals vessels. Vessels of
up to 2-mm diameter can be sealed using this technique.
Because no electrical energy is transferred to the patient it
may be ideally suited for areas of dissection near nerves.
Some studies have suggested decreased blood loss and
decreased frequency of facial nerve injury are seen with
the use of ultrasonic shears for superficial parotidectomy
( 4 ). Similar results have been obtained for thyroidectomy.
Despite the common use of this instrument for these procedures,
basic science researchers have shown that activation
of the shears near the nerve, particularly closer than 2 mm
or when it is activated in the vicinity for greater than or
equal to 3 seconds, does result in a change in peak latency
for the recurrent laryngeal nerve in a rabbit model (5).

Microvascular Free Tissue Harvest

Several donor sites for free tissue harvest involve the harvest
or division of large muscle bellies. The fibular osteocutaneous
free flap and the anterolateral thigh m:yofasdocutaneous
flap with or without significant vastus lateralis muscle
are commonly used donor sites that require substantial
muscle division. Vascular perforators in the muscle at
irregular intervals make 1he muscle division tedious, and
conventional harvest can be prolonged with blood loss
hampering field visualization. Increasingly, ultrasonic
shears are used to limit time required to harvest decrease
blood loss, and improve field visualization.

TECHNOLOGIES TO
IMPROVE VISUALIZATION
OF THE OPERATIVE FIELD
Sinus Surgery
Endoscopes with variably angled lenses have been in conventional
use for sinus surgery for many years. They have
paved the way for less morbid swge:ry by allowing the sinus
swgeon to visualize 1he tissues more precisely. The swgeon
is thus able to limit trauma to 1hose areas of 1he nose and
sinuses that have no bearing on the desired outcome of
swgery. In this way, it has decreased the morbidity of sinus
swgery while improving outcomes.

Skull Base Surgery

The combination of improved endoscopes and cameras
coupled with image-guided navigation and even real-time
imaging has expanded the bounds of endoscopic skull
base swgery (6). Although 1he basic instruments are similar
to sinus surgery instruments, more varied angles for cutting

and grn.sping instruments, extended guards for drills,

and other modifications like endoscopic bipolar cautery
have all contributed to 1he advancement of endoscopic
skull base surgery. Self-irrigating endoscope technology
has also allowed for more efficient swgery by limiting the
need for scope removal and cleaning during 1he procedure.
Although robotic surgery has not become a standard for
skull base swgery at this point, increasing miniaturization
of instruments and cameras as well as work on multiply
articulated instruments may make robot-assisted surgery of
1he skull base a standard in 1he future (7).

Thyroid and Parathyroid Surgery

Minimally invasive procedures of the thyroid and parathyroid
glands have evolved as a result of a desire for
improved cosmesis, particularly in certain cultural groups,
and a desire to limit pain and hospital stay. Video-assisted
thyroidectomy involves a reduced central neck incision,
subsequent blunt dissection to divide 1he muscular raphein the midline,
blunt dissection over 1he capsule of the
thyroid, and subsequently the use of a 5-mm 30-degree
laparoscope combined with 1he harmonic scalpel to take
down the superior pole vessels and subsequently identify
the recurrent laryngeal ner:ve. The remainder of the lobe is
then separated from the parathyroids, Be:n:y's ligament is
divided, and the lobe is dissected off the trachea. Nodules
greater 1han 3 em and a history of 1hyroiditis may limit this
technique, but with appropriately selected patients, complication
rates 1hat are comparable to conventional swgery
are quoted in 1he literature (8,9).
An ex:tension of the desire to limit any visible scar is
the transaxillaJ:y thyroidectomy, often done with robotic
assistance. The da Vinci Surgical System (Intuitive Surgical,
Sunnyvale, CA) provides binocular (Fig. 4.1), threedimensional
(3D) magnification, tremor filtration, and
greater degrees of freedom in 1he mobility of instruments.
The surgeon, after preparing 1he swgical field, sits in a console
with 3D visualization of the field and agonomic hand
and foot controls. Scaling of movement up to 5 to 1 can be
set and any tremor is filtered as the swgeon's movements
in the console are transferred in real time to the instruments
in the patients (Fig. 4.2). Clutching of the wrist
rotational movements allows for 360 degreea of rotation
for a given instrument In the case of transaxillcu:y thyroidectomy,
the patient station is docked on the conttalateral
side. The 30-degree endoscope is used fadng downward
through 5- to 6-cm vertical incision in 1he ipsilateral axilla.
Dissection is in a subcutaneous plane until the sternocleidomastoid
muscle is identified. It is subsequently carried
down between the two heads of the muscle. Indications
for this approach include small nodules less than 2 an
including well-differentiated malignancies without extracapsular
spread High BMI may be a contraindication to
this approach (10).

Transoral Robotic Surgery

Historically, tumoiS of the oropharynx. particularly those

of the base of tongue. required mended access procedures
to be able to visualize and remove tumoD at these locations.
Often. a lip and mandibular split procedure was
required. Subsequent patient function and cosmesis was at
the very least temporarily impaired. This was one of the
driving forces behind the move toward organ-preserving
therapy. Robotic surgery has been used as a minimally
invasive approach for urologic su~ge:ry for some time. More
recently, this teclmology has been applied to tumoD of 1he
oropharynx. to provide a surgical alternative to nonsurgical
organ-preserving therapies. Transoral robotic swgery
(I'ORS) has been successfully used for tumors of the oropharynx
in particular. The potential benefits of the technology
are listed above.
Patient selection is critical for these cases. Mouth opening
must be adequate and paralysis intraoperatively is usually
required. Usually, a Feyh-Kastenbauer or Dingman
retractor is used to keep the mouth open. A second assistant
at the head of the bed is also required for additional
retraction and occasional help with hemostasis. Thirtydegree
binocular endoscopes are usually used for the
tongue base. Zero-degree endoscopes are often used for the
tonsillar fossa (Fig. 4.3). Recent studies have shown that
~n when combined with adjuvant therapy, functional
outcomes 12 months posttreatment including swallowing,
speech, and diet are not significantly different from
pre-op assessments (11). Human papillomavirus-related
oropharyngeal malignancy, with its increasing incidence
and brighter prognosis, has prompted work on deintensi:
fication of therapy. 10RS appealS to have a role to play in
maintaining oncologic outcomes while minimizing longterm
mo:rbidity.

VIDEO (ROBOTIC RESECTION ORO/

HYPOPHARYNGEAL LESION)
Oncologic Tools
Photodynamic Therapy
The basic idea behind photodynamic therapy is administration
of a photosensitizing drug followed by the
application of light causing a photochemical reaction
that results in tissue damage. Intraoperatively, needles
are placed in a tumor and optical fibers are threaded
through these needles. Guidance for needle placement

can include endoscopy, ultrasound, and cr and MRI

technologies. Temoporfin is a commonly used photosensitizing
agent that is typically given IV 90 minutes
prior to light therapy. A 652-nm diode laser is then used
at 20 J per location. This technique has been shown to
decrease tumor bulk and improve functional status in
unresectable and recurrent tumoiS (12). Photodynamic
therapy shows particular promise for dysplasia and carcinoma
in situ.

High-Resolution Microendoscopy and Confocal

Microscopy
High-resolution microendoscopy is showing promise
as an adjunctive measure for evaluation of margins in
head and neck epithelial malignancies. The technology
involves direct contact between a high-resolution endoscope
and an epithelial surface. Prior to contact. the epithelium
is painted with a contrast agent like proflavin.
Excitation light is delivered through the fiberoptic bWldle.
Fluorescence emission from the epithelial surface is then
captured by a chaige-sensitive camera, and digital images
are obtained. Differences in the obtained images allow for
differentiation of normal mucosa from dysplasia and carcinoma
with good histologic correlation (13). Laser scanning
microscopy (confocal microscopy) with endoscopes
has been combined with the utilization of laser light to
produce topographical images of the epithelium. When
combined with rigid endoscopes, evaluation of tissue
just below the surface epithelium can also be obtained.
Differentiation between normal, dysplastic, and cancerous
epithelium shows good correlation with histologic
analysis (14).

Lasers
Lasers have been utilized in a number of ways in the field
of otolaryngology. We focus on relatively recent developments
that have had an impact on the practice of otolaryngology

Ang;olyt;c Lasers
Photoangiolysis involves the ablation of small superficial
blood vessels by targeting hemoglobin. The potassium
titanyl phosphate (KTP) laser has a wavelength of
532 nm, which correlates closely with the peak absorbance
of hemoglobin. By ablating the supporting microcirculation
of a lesio~ whether it is benign or even malignant,
the growth of the lesion is terminated. Delivery through
flexible fibers permits use with rigid or flexible endoscopes.
This makes ideal for in-office procedures.
This technology has been particularly useful in the
treatment of a variety of laryngeal lesions including vascular
ectasias, papilloma, polyps, and granulomas. It shows
promise in the treatment of dysplasia and early glottic cancers
as well (15).

C02 Laser (Flexible Fiber Delivery)

Through the combination of C02 laser energy and nearperfect
mirrors, a flexible delivery system has been
designed that allows for broader application of the CO2
laser (Omniguide, Cambridge, MA). A hollow core delivering
a cooling flow of inert gas allows for a cleaner field,
improved ooagulatio~ and cooling of the treated tissues,
limiting thermal injury. Of course, it can be delivered with
a flexible scope but also with a variety of hand pieces. This
technology is used in variety of otolaryngologic procedures
from stapedectomy and cholesteatoma removal to laryngeal
papilloma and cancer removal. It also has proved very
useful in tracheal surgery to debulk tumors and to make
radial cuts for tracheal stenosis. Furthermore, work is currently
being done on coupling the flexible C02 laser with
robotic technology.

Image-Guided Navigation
Image guidance has now been used since the early 1980s
and has become routinely used in revision sinus surgery
and complex endoscopic skull base surgery. There
are several platforms available. In general, a preoperative

cr scan is performed and images are referenced to fixed

points placed dose to the surgical site. This provides for
an increased margin of safety relative critical structures at
risk during these procedures. In general, these systems do
not provide real-time evaluation of the patient's anatomy.
However, compact, portable cr scanners are available that
can couple real-time cr images with existing image guidance
systems to give up-to-date information as surgery
modifies existing anatomy (16).

Topical Hemostatic Agents

Topical hemostatic agents are commonly used in otolaryngology.
In general, they can be divided into four categories:
fibrin sealants, gelatin-based products, oxidized cellulose,
and collagen products. Fibrin sealants are now commonly
used in otolaryngologic surgeries. Tisseel (Baxter) is the
most commonly used product. It comes in two vials. The
first vial is composed of human fibrinogen and bovine
aprotini~ an inhibitor of proteases including plasmin. The
second vial contains human thrombin and calcium chloride.
The two vials are combined to form a solid fibring
sealant. Crosseal (Ethicon) is a more recently developed
product and contains human fibrinogen and thrombin but
no bovine aprotinin. These products have been successfully
used in the context of parotidectomy and rhytidectomy to
reduce the potential for hematoma and ecchymosis ( 17).
Gelatin-based products have hemostatic properties that
are not linked to the clotting cascade and are thought to be
physical rather in chemical in nature. Gelfoam (Baxter) is
made of purified pork skin gelatin and typically is used in
sponge form, often combined with purified thrombin. An
important property of gelatin sponge is its ability to absorb
up 40 times its weight in fluid and expand its volume up to
200o/o. Depending on the application, this may be a positive
or negative attribute. Floseal (Baxter) combines human
thrombin with bovine gelatin matrix granules. These are
mixed at the time of application. Volume expansion is
minimal, and because it comes in liquid form, it is easy to
apply in limited access procedures. Surgiflo (Ethicon) has a
similar constitution and utilization.
Oxidized cellulose, like Surgicel (Ethicon ), has long
been used as a topical hemostatic agent. It is produced as
a knitted fabric from regenerated plant-derived cellulose,
which is oxidized. It acts as a scaffold for dot formation.
Surgicel comes in a number of different forms, from a thick
woven product to lightweight tufted layers depending on
the nature of the application. Besides its hemostatic properties,
it has bacteriocidal properties. Surgicel is used extensively
as a topical hemostatic agent for epistaxis and with
intranasal surgical procedures.
Microfibrillar collagen products like Avitene (Davol,
Inc.) are made by purifying bovine collagen and processing

it into microcrystals. Collagen products induce the intrinsic

pathway of the coagulation cascade. They have been in use
since the 1970s. Developments have been made recently
in the format of these products. They are now available in
powder, woven-knit, and sponge form. In some randomized
control trials, microfibrillar collagen has been shown
to be a superior topical hemostatic agent than oxidized cellulose
(18).

Wound Adhesive/Hemostatic Agents

Cyanoacrylate adhesives were developed in the 1940s
by Kodak As early as 1965, they were used for tympanic

membrane repair. liquid cyanoacrylate monomers polymerize

to form long chains in the presence of hydroxyl ions.
Water from human tissues activates the polymerization
reaction and the glue rapidly sets. Although it is mainly
used for closure of small skin incisions, it has been used
for corneal perforations, varices, and other vascular repairs,
as well as skin grafting. Besides their adhesive properties,
cyanoacrylate adhesives also have good antimicrobial
properties.

TiHue Substitutes
Dural Substitutes
Repair of dural defects, although usually performed with
autologous tissues, is sometimes performed with engineered
tissues. In most cases, this is performed using
collagen-based dural substitutes. Duragen (Integra,
Life Sciences) is cross-linked collage foam produced
from bovine Achilles tendon. Duraguard (Synovis) is
a cross-linked collagen product produced from bovine
pericardium. Durarepair (Integra. Life Sciences) is a noncrosslinked bovine collagen implant derived from bovine
fetal dermis. Durarepair and Duraguard are stronger materials
that are usually sutured in place. Duragen is more fragile,
and although it can be sutured in place, it is usually
used as an onlay graft. Duragen is typically absorbed by
1 month, while both Durarepair and Duraguard are still
identifiable but integrated by 6 months implantation.
Duragen is quickly penetrated by native cells, whereas
Durarepair and Duraguard take much longer to integrate. In
short, the physical properties of Duraguard and Durarepair
are useful where a long-term dural substitute is required.
Duragen is more useful for the repair of small defects, not
requiring the mechanical strength of native dura (19).

Skin Substitutes
The definition of "skin substitutes varies widely. We define
them as materials containing normally occurring skin elements
that are incorporated into native skin. Skin substitutes
can be categorized into the skin layers being replaced.
Epidermal replacements contain keratinocytes. Allogenic
keratinocytes can be harvested from fresh human donor skin,
neonatal foreskin, and occasionally other harvested skin.
One to two months following placement. autologous keratinocytes
have replaced the allogenic cells. The use of these
epidermal substitutes is relatively limited. More commonly,
dermal skin substitutes are used for skin replacement These
can be divided into acellular and cellular substitutes, the latter

usually containing fibroblasts and endothelial cells. Alloderm

(life Cell Corporation) is a commonly used acellular dermal
replacement containing collagen and elastin derived from
human donor skin. Apligraf (Organogenesis) is an example
of a cellular product containing collagen, glycosaminoglycans,
allogenic keratinocytes, and allogenic fibroblasts
derived from bovine tendon and neonatal foreskin. Whether
acellular or cellular, these materials provide a scaffold for
the invasion of fibroblasts. These fibroblasts produce extracellular
matrix and cytokines, which eventually lead to the
replacement of the skin substitute. This substitution can
take place over weeks, months, or years depending on the
material (20).
HIGHLIGHTS
Temperatures generated by the coblator are about 1/ 10 those of electrocautery when used for tonsillectomy.
Ultrasonic shears denature proteins, creating a coagulum that seals vessels.
Video-assisted thyroidectomy may be limited to nodules less than 3 em in greatest dimension
Robotic surgery benefits from binocular magnification, 360 degrees of wristed motion, and scaled movements
with tremor suppression
TORS in selected oropharyngeal cancer patients reduces functional moroidity by avoiding lipsplitting,
mandible-splitting surgery and by reducing the dose of radiation or even eliminating it entirely.
Photodynamic therapy using light-sensitizing agents and light can reduce bulk in unresectable tumors and
shows promise in the treatment of dysplasia and carcinoma in situ.
Confocal and high-resolution microendoscopy show promise in identifying dysplasia and cancer on epithelial
surfaces.
Photoangiolysis with the KfP laser can be used to ablate the supporting microcirculation of an array of laryngeal
lesions by utilizing a wavelength that closely corresponds to the peak absoroance of hemoglobin.
Topical hemostatic agents can be divided into fibrin sealants, gelatin-based products, oxidized cellulose
preparations, and microfibrillar collagen products.
Dermal skin substitutes can be divided into cellular and acellular products. In both cases, the material provides a
matrix for invasion by native fibroblasts that induce further incorporation into the surrounding skin.

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