The operation of tonsillectomy (tonsillectomy)

Tonsillectomy (removal of tonsils) requires special operational skills, accuracy of manipulation, ability to operate with an increased pharyngeal reflex and often with heavy bleeding. Each experienced surgeon has his own style of operating and his own techniques developed in the course of practical work. 

Preparing for tonsillectomy

Preparation for tonsillectomy involves the examination of the state of the coagulation system (coagulogram, bleeding time, hemogram parameters, including platelet counts, etc.), along with a set of other laboratory tests standard for any surgical intervention that represents a certain risk factor for possible bleeding and other possible complications. If these indicators deviate from the normal limits, they investigate their cause and take measures to restore them to the normal level.

Anesthesia

In the overwhelming majority of cases in adolescents and adults tonsillectomy is produced under local anesthesia. Modern technology of general anesthesia allows to carry out this operation at any age. For local anesthesia apply 1% solution of novocaine, trimecaine or lidocaine. Before the operation, an intradermal test is carried out on the sensitivity of the anesthetic used. With increased sensitivity, the operation can be performed under pressure infiltration of the near-mandelic region with isotonic sodium chloride solution. If possible, avoid anesthesia, especially pulverization, as it blocks the tactile receptors of the laryngopharynx, which contributes to the flow of blood into the larynx and esophagus. The addition of adrenaline to the anesthetic solution is also undesirable because it causes a temporary vasospasm and, after removal of the tonsil, creates the illusion of no bleeding that may already occur in the room due to the cessation of adrenaline.

Infiltration anesthesia is performed using a 10 ml syringe and the length of the needle on the thread fixed to the fourth finger of the surgeon (preventing the needle from falling into the throat when it accidentally jumps off the syringe). At each injection inject 3 ml of anesthetic, while trying to create a depot of this substance behind the capsule of the amygdala. Additionally, it is recommended to inject the anesthetic into the area of the lower pole (the area in whose projection the palatal tonsils are cut off) and into the middle part of the posterior arch. Carefully produced anesthesia makes it virtually painless and in no hurry to perform an operation on both palatine tonsils and carry out subsequent hemostasis. Some authors recommend to perform the operation "in a dry field", instead of using a spoon-raspberry, a gauze ball fixed in the Mikulich clamp is used to separate the palatine tonsils, which separates the amygdala from the underlying tissues and is simultaneously used to dry the surgical field.

[1], [2], [3], [4], [5],

Techniques for removing tonsils

Below we dwell on the generalized rules of tonsillectomy, which can serve as beginning ENT surgeons. Technically, tonsillectomy consists of several stages. After 5-7 minutes after anesthesia with a pointed scalpel, a cut is made for the entire thickness of the mucous membrane (but not deeper!) Between the anterior arch (at its posterior margin) and the palatine tonsils. For this, the amygdala is grasped with a clamp with a Brunings forceps or forceps closer to the upper pole and pulled it inward and backward. By this method, the fold of the mucous membrane, located between the arch and the amygdala, is straightened and stretched, which facilitates the conduct of the cut at a given depth. The incision is made along this crease from the upper pole of the amygdala to the root of the tongue, trying not to "jump off" the scalpel on the arch to avoid injury. At the same time, the triangular fold of the mucosa, located at the lower end of the anterior palatal arch, is dissected. If it is not cut with a scalpel, then to release the lower pole it is cut with scissors before cutting the amygdala with a loop. After the incision of the mucosa along the anterior arch is performed, a similar effect is performed with respect to the mucosa located at the upper pole of the tonsil with the transition to the fold of the mucosa lying between the posterior edge of the posterior palatine arch and the amygdala; This incision also leads to the lower pole of the amygdala.

The next stage is the separation of the amygdala from the bow. To do this, use the hook-shaped end of the spoon-rasporator, which is introduced into the previously made incision between the anterior arc and palatine tonsils, deepen it and "soft" movements up and down along the arch, gently pressing against the amygdala, separate it from the front arch. Here it should be noted that the correctly made incision and un-forcible separation of the arch from the amygdala allow avoiding the rush of the arch, which often occurs in inexperienced surgeons with scarring of the arch with the amygdala capsule. In these cases, it is not necessary to accelerate the separation of the arch from the amygdala with the help of a hook-shaped raspator, since this inevitably leads to rupture of the arch. When a cicatricial fusion of the arch with the amygdala is found, the scar with a scissors is dissected, pressing against the amygdala, first draining the operating cavity with a gauze ball. A similar manipulation is also carried out with respect to the back arch. The most important stage of this part of the surgical procedure is the extra-capsular secretion of the upper pole of the amygdala, since all the further does not present any special technical difficulties. With the usual structure of palatine tonsils, the upper pole is separated by preliminary cutting it off from the arch of the niche with a hook-shaped raspator and then lowering it with a spoon-raspberry. Certain difficulties with the allocation of the upper pole arise in the presence of a supramaxel fossa in which the lobe of the amygdala is located. In this case, the spoon of the rasper is injected high along the lateral wall of the pharynx between the palatine archs laterally, and the above-mentioned lobule is removed medially and downward by raking the medial and downward movements. Further, fixing the amygdala with clamps 1 or 2, slightly pulling it medially and downwards, is vyseparovyvayut of his niche with a spoon-raspora, gradually moving the spoon between it and the wall of the niche and pushing it in the medial direction. At this stage, no rush is required. Moreover, in the case of disturbing bleeding, vysepakurovka should be suspended and dried the liberated part of the niche with a dry gauze ball, clamped with the help of a clamp with Mikulich's clamp. In order to avoid aspiration of gauze or cotton balls, cut amygdala, etc., all "free" objects in the mouth and pharynx must be securely fixed with clips with locks. You can not, for example, cut the palatal tonsils with a loop, fixing it only with the force of the hand by the forceps of Brunigs who do not have a lock. If necessary, the bleeding vessel is clamped by the clamp of Pehan or Kocher, if necessary, ligated or subjected to diathermocoagulation. Next, the discharge of the amygdala is completed to the very bottom, including the lower pole, so that it remains fixed only on the flap of the mucosa. After that, to achieve hemostasis, some authors recommend that the palpated (but not yet removed) palatine tonsil be re-placed back to its niche and pressed for 2-3 minutes. The explanation for this technique is based on the assumption that biologically active substances are released on the surface of the removed amygdala (it's the back of the removed tonsil that faces the niche), which increase blood coagulability and promote faster thrombogenesis.

The final step in the removal of tonsils is the excision of the amygdala by means of a loop tonzillotoma. For this, a clip with a cremalier is inserted into the loop of the tonsillotomy, with the help of which the palatine amygdala hanging on the foot is securely seized. When pulling it with a clip, the loop is worn on it and advanced to the lateral wall of the pharynx, while ensuring that the loop does not clamp a part of the amygdala, but covers only the flap of the mucous membrane. Then the loop is slowly tightened, crushing and crushing the vessels in its path, and the final effort is cut off and directed to the histological examination. Further, hemostasis is produced. To do this, a large dry cotton ball fixed with a Mikulich clamp is inserted into the niche and pressed against its walls for 3-5 minutes, during which, as a rule, bleeding from small arterioles and capillaries ceases. Some authors practice the processing of niches with a gauze ball with ethyl alcohol, motivating this technique by the ability of alcohol to coagulate small vessels.

Complications

If bleeding occurs from larger vessels, which is manifested by a thin pulsating blood stream, the place of bleeding along with the surrounding tissues, in which the end of the bleeding vessel should be located, is clamped and bandaged with a silk thread (which is not so reliable) or is stitched, bringing the end of the clamp over the ligature . If the source of bleeding is not established or bleeding several small vessels at the same time, or the entire wall of the niche, the niche is plastered with a gauze swab folded into a ball in the size of a niche impregnated with a solution of novocaine with adrenaline, and tightly fixed by stitching above it palatal arms - another , in addition to functional, the reason for the need to carefully preserve the palatine arch in its entirety. If the operation is performed in such a way that one or both palatine arms are removed together with the amygdala and there is a need to stop bleeding from the niche, one can use a special clamp, one end of which is inserted into the niche of the amygdala with a fixed gauze ball in it, and the other submaxillary region in the projection of the bleeding niche and pressed against the skin. The clamp causes significant inconvenience for the patient, therefore it is imposed for no more than 2 hours. If the above procedures do not lead to a stoppage of bleeding, which assumes a threatening character, then resort to a bandaging of the external carotid artery.

[6], [7], [8]

Dressing of the external carotid artery

When the external carotid artery is ligated, the operating space is located mainly in the region of the carotid fossa or the triangle of the carotid artery, bounded inside and below by the upper abdomen of the scapula, from the inside from above - by the abdominal abdomen of the digastric muscle, which is the continuation of the anterior abdomen of this muscle interconnected by an intermediate tendon, attached to the hyoid bone, and from behind - the anterior edge of the sternocleidomastoid muscle.

The operation is performed under local infiltration anesthesia in the position of the patient lying on the back with the head turned in the opposite direction to the operated side. The incision of the skin and subcutaneous muscle of the neck is made along the outer edge of the sternocleidomastoid muscle in the region of the carotid triangle, starting from the top of the angle of the lower jaw to the middle of the thyroid cartilage. Under the cut off flaps of the skin and subcutaneous muscle of the neck, an external jugular vein is found, which is either pushed aside or resected between the two ligatures. Next, the superficial fascia of the neck is dissected, and the sternocleidomastoid muscle is distinguished starting from the anterior margin, which is moved to the outside by a convenient retractor (for example, the Farabef expander).

The deep fascia of the sternocleidomastoid muscle is dissected from the jelly-like probe from the bottom upwards throughout the entire wound. At the level of the large horn of the hyoid bone, which is determined by the palpation, which is in the middle part of the wound, two blunt hooks are established, and after retreating to the outside of the sternocleidomastoid muscle, a sublingual nerve is revealed in the upper part and a venous trunk, and to the inside. In the triangle formed by the sublingual nerve, the internal jugular vein and the indicated venous trunk at the level of the large horn of the hyoid bone, an external carotid artery is seen along the collateral and branch branches that leave it. Under the artery in an oblique direction there is a peritoneal nerve. After the artery is isolated, it is verified by clamping it with a soft clamp and checking for lack of blood flow in the facial and superficial temporal arteries. The absence of pulsations in these arteries testifies to the correct definition of the external carotid artery. After this, the external carotid artery is ligated with two ligatures.

[9], [10], [11]