Pediatric Tonsillectomy: modern coblation vs traditional electrocautery

 

Surgical removal of the tonsils and adenoids (known as a T&A) is one of the most common operations performed on children in the U.S. As noted in the illustration above, tonsils are located on either side of the throat and adenoids are located behind the nose. When these are enlarged they can block flow of air through the nose and the mouth. Additionally recurrent infections can lead to recurrent sore throat (known as recurrent or chronic tonsillitis). Adenoids are located behind the nose and can also cause nasal airflow obstruction and are often removed in conjunction with the tonsils.

As one of the oldest described surgical procedures on record, tonsillectomy was described as early as 1000 B.C. It was popularized in the 1800s as life saving procedure to remove obstruction from severe cases of Diphtheria. Given its history and popularity, the technique for performing the procedure is constantly undergoing refinement from its early days using cold steel scissors or knife and electrocautery to modern days of plasma field dissection.

The major points of concern for tonsillectomy include length of surgery (shorter anesthesia time means less exposure to anesthesia drugs and lower risks of complication), amount of bleeding during surgery, risk of bleeding after surgery and amount of pain after surgery.

The two techniques that I want to compare are cold steel and/or electrocautery technique versus coblation. Cold steel technique essentially involves cutting the tonsils using various sharp cutting instruments, often knife, snares etc. This is often followed by “cauterizing” or burning the bleeding vessels using electrical current (electrocautery). So in fact the “cold” technique is not cold at all and can get as hot as 1200 degree celsius due current that needs to be delivered after tonsils are removed to stop the bleeding. The amount of heat delivered makes a difference. Any heat applied to surrounding muscles and tissues outside of the tonsils can be considered “collateral damage” and will contribute to increased post-operative pain and tougher recovery period.

Coblation on the other hand uses the Coblator wand by Arthrocare(TM), that cuts through tissues by creating a plasma field (created by running current through a continuously flushing salt water medium) while coagulating blood vessels (to stop bleeding) at the same time. Temperature typically range in the 40-65 degree celsius range so collateral tissue damage is often minimal.

Several studies have shown benefits in terms of operating time, bleeding and post-operative pain and recovery from use of coblator (1, 2, 3). Because of this, I almost uniformly use this device for tonsillectomies in children under 12 years of age. In teenagers and adults, larger blood vessels and presence of thick scar tissue from years of infection often necessitates use of stronger currents delivered by electrocautery. Although there is certainly a role for electrocautery and or even cold steel tonsillectomy, I find that coblator is a suitable technology for performing tonsillectomies in younger children that may offer benefits of a faster surgery with lower blood loss and faster post-operative recovery.

Have you or your child had a tonsillectomy experience in recent months or years with a particular technology that you would like to share? Please do so in the comment section below. Note: comments are visible to the public.

 

 

September 15th, 2017 by