surgical technique

RADenoid Blade from Xomed

Powered Partial Adenoidectomy Using the RADenoid Blade

presented by L. Nicole Murray, MD and J. Lindhe Guarisco, MD

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Powered Partial Adenoidectomy

Philosophy
Surgical technique presented by L. Nicole Murray, MD and J. Lindhe Guarisco, MD The powered microdebrider has become widely utilized in the practice of otolaryngology due to its efficiency and safety in functional endoscopic sinus surgery. Historically, the tool has undergone an evolution from its original inception by Jack Urban as a rotating dissector for acoustic neuroma removal, to a small joint arthroplasty tool common in orthopedic surgery, to its current position in endonasal surgery1. Expanded uses in rhinologic surgery include removal of both benign and malignant tumors, choanal atresia repair and adenoidectomy2. The microdebrider consists of an outer windowed sheath surrounding an inner rotating hollow blade (or bur) which is connected to standard in-line continuous suction. The window is directed by the surgeon toward the desired tissue which will be drawn in by the vacuum, and the rotating blade then shaves the tissue. Specimens may be collected for pathologic evaluation by the insertion of a filter sock in the suction canister. The rising popularity of the microdebrider is in large part due to the ability to precisely remove desired tissue under direct visualization while leaving adjacent important structures undisturbed. The importance of precise operative control is well recognized in the arena of endoscopic sinus surgery, where vital orbital and intracranial structures must be preserved. Complications of adenoidectomy are less common and less life-threatening than those of FESS, however, the morbidity of velopharyngeal insufficiency, nasopharyngeal stenosis or eustachian tube orifice stenosis after adenoidectomy is not to be underestimated. Iatrogenic injury to the velopharyngeal sphincter or to the eustachian tube orifice is notoriously difficult to repair, and thus is best prevented rather than treated. In his appraisal of the microdebriders utility in FESS, Setliff states the remedy for surgical anxiety is precision3. We have also found this to be true of adenoidectomy, and thus we became interested in the use of the microdebrider for this purpose. One retrospective series, comparing adenoidectomy with the microdebrider versus conventional adenoidectomy with curettes, showed a reduced operative time with the microdebrider4. In a prospective nonrandomized study at our institutions, we have also found adenoidectomy with the microdebrider to be faster than that

Nota Bene: The technique description herein and the use of instructions for the related procedures are made available by Xomed Surgical Products, Inc. to the health care professional to illustrate the authors suggested treatment for the uncomplicated procedure. In the final analysis, the preferred treatment is that which, in the health care professionals judgment, addresses the needs of the individual patient.

Powered Partial Adenoidectomy

with curettes. The average total operative time for adenoidectomy with the microdebrider in over 100 patients was 3 minutes and 21 seconds. The actual tissue removal was completed in under one minute (average 50 seconds) and the majority of time was spent achieving hemostasis (average 2 minutes 31 seconds). Blood loss and complications were comparable with both techniques 5. In our experience, besides the obvious advantage of speed, we found the most important advantage of the microdebrider technique to be precision. The microdebrider affords a degree of control of tissue removal that cannot be matched by curettes, and therefore the risk of inadvertent tissue removal, with its aforementioned consequences, is greatly lessened. Adenoidectomy with the microdebrider is now our procedure of choice. Our operative technique is discussed.

Surgical Technique
After induction of general anesthesia the patient is orotracheally intubated with a midline oral ray tube. A shoulder roll is placed, and the appropriately sized Crowe-Davis mouth gag is placed, opened, and suspended. The opening of the mouth gag should face towards the surgeons dominant hand to allow unhindered motion of the microdebrider handpiece. At this time, the oral cavity is evaluated for signs of submucous cleft palate and the length of the palate is assessed. If the oral cavity is normal and the palate is not too short, then we prefer to remove roughly 66 to 75% of the adenoidal tissue, with the remainder left at Passavants ridge to ensure adequate velopharyngeal closure. If there are signs of submucous cleft palate or if the soft palate is unusually short, then less tissue is removed. With this method of tailoring our adenoidectomy to our patients individual anatomy (partial adenoidectomy), we have had good efficacy and no incidence of velopharyngeal insufficiency. A red rubber catheter is then placed through one nare and secured for palatal retraction. The adenoids are visualized with a defogged mirror, and the microdebrider is held in the dominant hand and positioned at the superior extent of the adenoid pad. With the shaver off and the blade positioned such that the window is open, the tool may be used to suction clear any secretions

Powered Partial Adenoidectomy

or blood from the field. The shaver blade is then positioned over the tissue to be removed and is activated in oscillate mode at 3,000 variable rpm. The variable setting allows the surgeon to regulate blade speed from the footswitch. Slight downward pressure may be applied to cleanly separate the adenoid tissue from the fascia underneath. A sweeping motion has worked the best for us and this motion is continued from superior to inferior to the desired stopping point above Passavants ridge (Figure 1). Blade speed may be regulated by the variable speed footswitch. The microdebrider is especially useful for precisely removing tissue against the tori or within the chaonae, as well as easily controlling the inferior extent of tissue removal. The adenoidectomy is then completed by achieving hemostasis, which we perform with the suction electrocautery (Figure 2).

Christmas DA, Drouse JH: Powered instrumentation in functional endoscopic sinus surgery I: Surgical technique. Ear, Nose, & Throat Journal 75:33-40; Jan 1996.
1 2 Parsons DS: Rhinologic uses of powered instrumentation in children beyond sinus surgery. The Otolaryngologic Clinics of North America 29(1): 93-104; Feb 1996.

Setliff, RC: The Hummer: A remedy for apprehension in functional endoscopic sinus surgery. The Otolaryngolic Clinics of North America 29(1): 93-104; Feb 1996.
3 4 Koltai PJ, Kalathia AS, Stanislaw P & Heras HA: Power-assisted adenoidectomy. Archives of , Otolaryngology Head and Neck Surgery 123:685-688; July 1997. 5 Murray LN, Fitzpatrick P Estrada L, & Guarisco JL: Powered Partial Adenoidectomy: A Clinical , Trial. Manuscript in preparation.

Figure 1

Figure 2

Powered Partial Adenoidectomy

Ordering Information

18-84008 RADenoid Blade

Single use, sterile packaged

Diameter
4.0mm

Speed
1,000-3,000RPM

Qty
5/box

XPS Model 2000: System 1 & System 2

System 1 includes: Console, STRAIGHTSHOT Handpiece, Multi-Function Footswitch, & Irrigator Pump System 2 includes: Console, STRAIGHTSHOT Handpiece, & Single-Function Footswitch

Product
18-96000 XPS Model 2000: System 1

Qty
1 ea

Product
18-96001 XPS Model 2000: System 2

Qty
1 ea

Xomed Mustard Table

Designed for improved suspension

Product
37-34500 Mustard Table

Qty
1 ea

Product
37-34510 Mustard Table Bed Adaptor

Qty
1 ea

Powered Adenoidectomy Surgical Technique Video

Product
18-84009 NTSC version (U.S.)

Qty
1 ea

Product
18-84009P PAL version (International)

Qty
1 ea

6743 Southpoint Drive North Jacksonville, FL USA 32216-0980 904/ 296-9600 800/ 874-5797 www.xomed.com

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In Germany 49/ 8105-37-550 In the U.K. 44/ 1454-619555

RADenoid & XOMED are registered trademarks of Xomed. Patents Pending. 1998 Xomed Surgical Products, Inc. LIT 11.63 08.98

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