Endoscopic Assisted Laparoscopic Transgastric Resection of GE Junction Gastrointestinal Stromal Tumor (GIST)

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 !

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Authors
Carol Li, MD1*, Apoorva T. Ramaswamy, MD1*, Sallie M. Long, MD 1 , Alexander Chern, MD 1 , Sei Chung, MD 1 , Brendon Stiles, MD 2 , Andrew B. Tassler, MD 1
1Department of Otolaryngology-Head and Neck Surgery, Weill Cornell Medicine, New York, NY 2Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
*Co-First authors

Overview

The COVID-19 pandemic is an unprecedented global healthcare emergency. The need for prolonged invasive ventilation is common amid this outbreak. Despite initial data suggesting high mortality rates among those requiring intubation, United States data suggests better outcomes for those requiring invasive ventilation. Thus, many of these patients requiring prolonged ventilation have become candidates for tracheotomy. Considered aerosol generating procedures (AGP), tracheotomies performed on COVID-19 patients theoretically put health care workers at high risk for contracting the virus. In this video, we present our institution’s multidisciplinary team-based methodology for the safe performance of tracheotomies on COVID-19 patients. During the month of April 2020, 32 tracheotomies were performed in this manner with no documented cases of COVID-19 transmission with nasopharyngeal swab and antibody testing among the surgical and anesthesia team.

Procedure Details

The patient is positioned with a shoulder roll to place the neck in extension. The neck is prepped and draped in a sterile fashion with a clear plastic drape across the jawline extending superiorly to cover the head. An institutional timeout is performed. The patient is pre-oxygenated on 100% FiO2. A 2-cm vertical incision is made extending inferiorly from the lower border of the palpated cricoid cartilage. Subcutaneous tissues and strap muscles are divided in the midline. When the thyroid isthmus is encountered, it is either retracted out of the field or divided using electrocautery. The remaining fascia is then cleared off the anterior face of the trachea.

Prior to airway entry, the anesthesiologist pauses all ventilation and turns off oxygen flow. The endotracheal tube (ETT) is advanced distally past the planned tracheotomy incision, without deflating the cuff, if possible. If necessary, the endotracheal cuff is deflated partially to advance the tube, with immediate reinflation once in position. The surgical team then creates a tracheotomy using cold steel instruments. The cricoid hook is placed in the tracheotomy incision and retracted superiorly for exposure of the lumen. The tube is withdrawn under direct visual guidance, without deflating the endotracheal cuff if possible. The tracheotomy tube is placed, and to minimize aerosolization of respiratory secretions, the cuff is inflated prior to re-initiation of ventilation. The tracheotomy tube is then sewn to the skin using 2-0 prolene suture. A total of five simple stitches are placed around the tube to prevent accidental decannulation.

Indications/Contraindications

Candidacy for tracheotomy was determined on a case by case basis with consideration for progression of ventilator weaning, viral load, and overall prognosis. All patients who underwent tracheotomy were intubated prior to the surgery for a minimum of 14 days, able to tolerate a 90-second period of apnea without significant desaturation or hemodynamic instability, and expected to recover. Optimal ventilator settings included FiO2

A 49-year-old female presented with a one-year history of right frontal headaches, not controlled despite OTC medication. Work up with head CT revealed an osteoma of the right frontal sinus. The patient experienced no improvement in headache severity and elected to have surgical intervention.

Methods: ENT Fusion Navigation system was used during the entire case.  A ball-tip probe was used to fracture out the uncinate bone and a backbiter was used to remove the uncinate in its entirety.  The natural ostium of the right maxillary sinus was then visualized.  Again, the backbiter was used to remove tissue anterior to the natural ostium. A straight Tru-Cut was used to remove the ostium towards the posterior fontanelle. The right middle turbinate was resected in order to gain sufficient access for the resection of the osteoma.  In order to remove the right middle turbinate, a turbinate scissors were used to make 3 cuts along the attachment of the middle turbinate and this was pulled down.  A down biter was used to open up the maxillary sinus inferiorly. There was no tissue seen in the maxillary sinus. After this was done, an ethmoidectomy was performed by placing a J-curette behind the ethmoid bulla point anteriorly.  This ethmoid bulla was removed along with several other anterior ethmoid cells.  After this was done, a frontal sinus seeker was used to identify the right frontal osteoma.  The patient did not have a right frontal sinus. Instead, an osteoma was in the area of what would have been the right frontal sinus or nasal frontal outflow tract.  Image guidance was meticulously used to identify the osteoma.  A 70-degree frontal drill was used and this osteoma was slowly drilled to remove as much as possible.   Drilling was done from the posterior edge of the osteoma up to the skull base superiorly, to the lamina papyracea laterally and all bone that could be safely removed was removed. A right frontal propel stent was placed in the bony cavity created by the drill out and after this, the sinus was irrigated and suctioned.

Results: The patient was sent to recovery in good condition and no adverse reactions were reported by the surgeon or patient.

Surgeons: Alissa Kanaan, MD. Zachary V. Anderson, MD.

Institution: Department of Otolaryngology – Head and Neck Surgery at the University of Arkansas for Medical Sciences.