Cold Steel Dissection in Phonosurgery: How I Do It

INTRODUCTION

Phonomicrosurgery places specific demands on the otolaryngologist. The requirement for fine skills and dexterity means that there is a learning curve which requires patience to overcome. One of the key skills requiring mastery in phonosurgery is cold steel dissection. One can cut short this long learning curve by holding the instrument in the following way.

TECHNIQUE

Phonosurgical instruments used for cutting/grasping have a proximal mechanism that requires a thumb and a finger through the two holes. However, holding the device with thumb and finger does not allow good control and one need to support it with another finger (Fig. 1A). Furthermore, if the fingers are used in this way, rotation or movement of the instrument requires movement of the whole arm; this can result in unstable or sudden movements of the distal instrument. Significantly, when using two instruments in a narrow laryngoscope, the fingers and thumbs of each hand can impede each other’s movements (Fig. 2A).

Holding the instruments in the way suggested—thumb and index finger holding one arm and two fingers holding another arm (Fig. 1B)—allows for more precise control. An additional advantage of using the technique suggested is that control of both the arms can be achieved separately rather than one being dependent on other (Fig. 1B compared with Fig. 1A).

Advantages of holding instruments in this method:

• Excellent control of the instrument by the surgeon.
• Easy maneuverability and rotation while operating on the medial edge of the vocal fold, when compared with the traditional style (Fig. 2B).
• The fingers of each hand do not obstruct each other.
• It is easy to rotate the instrument without needing the operator move their whole arm (Fig. 2B compared with Fig. 1B).

DISCUSSION

The literature thus far has always focused on techniques of surgical dissection and less on the means of holding the instruments. It is well recognized that phonomicrosurgical instruments are difficult to manipulate because of their length, because the fulcrum effect of the instrument (resting proximally on the laryngoscope) amplifies movement of the tip of the instrument distally.

The trainee otolaryngologist will often have an opportunity to excise relatively straightforward lesions such as polyps on the free edge of the vocal fold. One of the key skills to master is in controlling the movement of the tips of the instruments (whether grasping forceps, dissectors, blades, or scissors). We have previously described a technique for improving stability by resting the elbows.¹ We now describe a technique for holding the microsurgical instruments, which gives further stability for fine-control vocal fold surgery.

CONCLUSION

Phonomicrosurgery is technically demanding. There is a learning curve to acquire the fine skills and dexterity. Holding phonomicrosurgery instruments in the described technique is helpful. Stability and fine control at the tip of the instruments is easily achieved.

ETHICAL APPROVAL

For this type of study, formal consent is not required. All procedures performed in this study were in accordance with the ethical standards of the National Research Committee and with the 1964 Helsinki Declaration and its later amendments.

REFERENCE

1. Osborne MS, Mitchell-Innes A, Costello D. A helpful technique for manual stability and avoiding fatigue during microlaryngoscopy. Clin Otolaryngol 2015;40(2):169–170. DOI: 10.1111/coa.12292.