Endoscopic Assisted Laparoscopic Transgastric Division of a Gastroesophageal Fistula in an Adolescent

Institution: University of Arkansas for Medical Sciences

Authors:

Thomas Heye – teheye@uams.edu

Lawrence Greiten MD – lgreiten@uams.edu

Christian Eisenring ACNP-BC -EisenringC@archildrens.org

CAC (Coblation Assisted Cordectomy) in Bilateral Vocal Cord Palsy –tips & tricks

Here, we have a 39 yrs old female with complaints of noisy breathing for last two years post thyroidectomy. Flexible laryngoscopy confirmed bilateral vocal cord paralysis. She was planned for coblation assisted cordectomy.

Patient was taken up for procedure under general anaesthesia. She also  started having stridor after induction. Nasopharyngeal intubation with spontaneous breathing technique was used. Entropy leads were placed over forehead to monitor the depth of anaesthesia. Tube position was confirmed with endoscopic view and Benjamin lindohlm laryngoscope was suspended. As the patient was spontaneously breathing, the stridor became more prominent, with stable vitals and  the procedure was continued. The vocal cord retractor was fixed and coblation wand was then used with 7:3 settings for ablation and coagulation respectively.  The surgical limits were-anteriorly the junction between ant 2/3 and post 1/3 of the vocal cord, posteriorly just anterior to the vocal process of arytenoid to prevent cartilage exposure and post operative granulations. Superely till the ventricle and inferioly till the medial most surface of the subglottis. Laterally approx. 5 mm depth was defined to prevent injury to the superior laryngeal artery branch and further bleeding. Once the final airway was achieved , the topical lignocaine was used to prevent laryngeal spasm post extubation.

The patient was shifted to the ward without oxygen, the voice was assessed on post op day 2.

Patient was called for follow up on post op day 14th and good voice outcomes were achieved.

So lets have a look on some tips & tricks for the safe procedure—–

Nasopharyngeal insufflation technique with entropy monitor will give adequate and safe surgical field

2. Appropriate exposure will help you to delineate the surgical margins

3. Topical anaesthesia before and after the procedure will prevent sudden laryngeal spasm

4. Firm holding of coblation device will help to prevent injury to surrounding structures like    anterior 2/3 vocal cord, opposite side  vocal cord, medial surface of vocal cord or aryteroid posteriorly

5. Do not ablate more laterally to prevent bleeding, if at all it happens, use patties or coagulation switch for hemostasis.

6. And at the end of the procedure ,use catheter suction to suck out blood clots or saline from the  airway if any….

To Conclude-Coblation Assisted Cordectomy( CAC) can be performed safely with good outcomes in case of bilateral vocal cord paralysis using tubeless anesthesia technique without tracheostomy !

Thank you

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