1
Introduction
The first documented tonsillectomy was performed in the first century A.D. by Cornelius Celsus in Rome. He used his finger to bluntly dissect an inflamed tonsil. Over time, better instruments and technical advances have allowed for the development of new techniques although cold-knife dissection has been the standard procedure for many years and is still used among many practicing otolaryngologists today .
The reduction in the rate of post-tonsillectomy hemorrhage (PTH) is correlated with technical developments such as the use of diathermy for hemostasis first described in 1968 by Remington-Hobbs as “hot dissection,” for tonsillectomy. The rising use of electrocautery has resulted in a reduction in the rate of inpatient admissions due to hemorrhage after tonsillectomy . Traditionally early or primary hemorrhage is described as hemorrhage that occurs within first 24 h of the procedure. This is originally described by Fox as an arbitrary time-point that included the first two days . For whatever reasons, later references omit the second day and only consider the first 24 h as primary bleeds. According to the now common definition, secondary hemorrhage is known as hemorrhage that occurs after > 24 h from the procedure. It was in part developed perhaps to differentiate bleeding caused by technical issues (poor surgical hemostasis, breach of surgical planes etc.) from bleeding caused by patient related factors (co-morbidities, non-compliance etc.). The literature is unclear about the distinction.
Arbitrary in nature and more relevant to earlier practice of surgery, we feel this description of primary and secondary bleeding no longer is adequate or accurate.
The published rates of PTH mostly include secondary hemorrhage and range from 0.1% to 8.1% , and a universal rate of 4–5% at high-volume centers is generally accepted. However, the rates are usually lower outside training institutions presumably due to the honed skills of established surgeons and surgical technique as well as selection of a healthier patient demographic . If one agrees that a bleeding rate such as 4% is low enough, this does translate into 40 bleeding children in a high volume (1000 tonsillectomies/year) institution every year . The risk and cost associated with these admissions can be substantial. Based on the senior author’s teaching and operational experience across multiple institutions, our observation is that almost all bleeding in the first postoperative week can be attributed to poor surgical technique including dissection, hemostasis and wound management rather than poor patient compliance or pain management. When this perspective is taken, then, in principle, better technique should lead to lower rates of PTH regardless of the patient population or surgeon’s training level. To support our observation, a standard technique was developed and executed without exception in a residency training program including residents at all levels and unselected pediatric patients under the age of 18. For this purpose all PTH in the first week was considered primary and technical, while bleeding over 7 days after the surgery was considered secondary.
As most techniques for tonsillectomy are, our dissection is based on preservation of anatomical planes and serves to deliver the least amount of thermal damage from cautery to surrounding tissue. In addition to known surgical landmarks dictating conventional surgical planes, two additional anatomical landmarks are defined to effectively teach the conservative surgical technique presented.
2
Materials and methods
Institutional Review Board approval was obtained through the Louisiana State University Health Sciences Center-Shreveport for this retrospective chart review. Data was retrospectively collected from patients undergoing tonsillectomy and adenoidectomy from 2011 through 2015. All indications for tonsillectomy and adenoidectomy were included (e.g. obstructive sleep apnea, recurrent tonsillitis, asymmetric tonsil size, previous peritonsillar abscess, halitosis, tonsillolithiasis, strep throat etc.). The population consisted of all-comers with a variety of co-morbidities including sickle cell disease, coagulopathy, asthma, autism and Down syndrome among others. The majority of the procedures were performed by ENT residents, most of whom were third year residents. The number of PTH, the post-hemorrhage hemoglobin, and the number of days after surgery that the bleeding occurred were documented and evaluated. The patient’s age, sex, weight, and BMI were also recorded and included in the study.
2.1
Surgical technique and preparation
We request from our anesthesia colleagues that all patients are intubated with a RAE tube, preferably cuffed. As soon as an intravenous line is established, we request IV dexamethasone 1 mg/kg (up to 20 mg) be given. All patients are positioned supine, using a properly sized shoulder roll and a donut to stabilize the head in an extended position (except children with potential atlantoaxial instability – these are kept in the neutral position) – The Bovie electrocautery pad is applied on the abdomen (closer to the surgical field than it would be when applied to the thigh). A McIvor mouth gag is used and suspended from the corner of the Mayo table. After digital palpation and verification of absence of submucous clefting (hard palate notch) the oropharynx is first filled with cold saline solution. A Valsalva maneuver is requested from the anesthesiologist to test for a cuff leak. Cuff pressure is adjusted until there is no leak. If a cuffless tube is used and there is a leak, a gauze or ribbon strip is placed in the hypopharynx around the tube to prevent the leak (leak of anesthetic gas has to be stopped to prevent airway fires while using electrocautery). The oropharynx and the nose are irrigated and suctioned clear from mucus with cold saline. Frequent icy cold saline irrigations of the operative field helps reduce postoperative swelling, intraoperative bleeding and reduces thermal collateral damage from electrocautery in the author’s unpublished observations.
The first landmark we define is the triangular area above the tonsil upper pole, where the upper folds of the anterior and posterior pillars converge. This area is identified as our entry point and we term it the A Triangle ( Fig. 1 ). A small Allis clamp is used to grasp the mucosal lip at the base of the A Triangle ( Fig. 2 ) that is covering the upper pole of the tonsil. This grasping may include a small portion of the tonsil upper pole but is not required. This mucosal fold provides an adequate anchor point to apply traction to the tonsil, it is not as fragile as the tonsil tissue itself and is easy to identify. As medial and inferior traction is applied, the A Triangle comes into full view. This is entered in a posterolateral direction, right above the tip of the Allis clamp ( Fig. 3 ), using the needle-tip Bovie set at 8–10 W power (the Bovie pad is on the abdomen and since we are using a needle tipped Bovie, low power is sufficient). Immediately, an avascular space above the tonsil is entered. This tetrahedral space is named T Space ( Fig. 4 ), and is defined by the upper tonsil pole surface inferiorly, the anterior and posterior tonsillar pillars anteriorly and posteriorly, and the A Triangle medially. Continued inferomedial traction on the tonsil keeps the T Space open and the surgical dissection plane is visible. As the T space is followed anteriorly, it will lead to the anterior surgical plane between the tonsil and the anterior tonsil pillar. Posterior extension of the T Space leads to the posterior surgical plane between the tonsil and the posterior tonsil pillar. These planes are developed simultaneously by alternating the dissection between planes to proceed in a superior-to-inferior direction. As the dissection proceeds, inferomedial traction becomes medial traction and, as the inferior tonsil pole is approached, the traction becomes mostly superomedial. This continuous traction pulls the tonsil and attached pillar mucosa out of the tonsil fossa and everts the anterior and posterior pillars as their folded attachment to the tonsil surface is unfolded. By cutting while applying traction, the end result is a cut that is placed on the inside of the mucosal fold of the pillars (not visible when the traction is released) ( Fig. 2 ). This is particularly important in preserving the mucosa and the muscles of the anterior pillar. Both planes are followed through and joined laterally between the lateral pharyngeal wall and the tonsil while staying in the fibroareolar plane, under direct view, avoiding muscle penetration. The advancement has to be done through electrocoagulation and NOT through direct physical cuts by the tip of the Bovie blade. Any bleeders are immediately coagulated under full view. Once anterior, posterior and lateral dissection is completed, the tonsil is now attached to the bed through a narrow stalk inferiorly followed by pharyngeal and lingual extensions of lymphoid tissue. This area can be identified in most cases resembling an hourglass. Once identified, dissection should not proceed beyond that level and a slow, transverse electrocautery cut is employed in the stalk to remove the tonsil. (This is exactly the area where a snare would be employed if one is still performing cold cut tonsillectomies and using a snare). Once this cut is completed, the tonsil bed and cavity resemble an elongated diamond shape with the short sides at the bottom. A 3.0 Vicryl suture on an RB-1 (round atraumatic) needle is used to apply an inverted stitch at the widest portion of the diamond to bring the sides together along with the muscle. This inverted suture, when tied, will convert the diamond shape into a spindle shape (while the anterior and posterior pillars are still separate along their entire length) and accomplish several objectives:
