2 Instrumentation, Set-Up, and Patient Positioning

Very few instruments are actually required to perform basic ESS in the laboratory (Fig. 2.1). As one gains more surgical experience with advanced procedures or proceeds with live cases, however, additional instrumentation may be needed depending on the type of procedure or the surgeon’s personal preferences. In addition to a 30-degree telescope, the minimum instrumentation required for most of the basic dissections in this manual include the following:

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  3.5-mm straight non-through-cut forceps (A)

  
  
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  3.5-mm straight through-cut forceps (B)

  
  
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  3.5-mm upbiting non-through-cut forceps (C)

  
  
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  3.5-mm upbiting through-cut forceps (D)

  
  
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  Cottle periosteal elevator (E)

  
  
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  Ostium seeker or ball probe (F)

  
  
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  4-mm long curved suction (G)

  
  
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  Calibrated straight (Frazier) suction (H)

  
  
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  360-degree sphenoid punch or forceps (I)

  
  
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  360-degree backbiting forceps (J)

Powered instrumentation (microdebrider) with a 4-mm straight and/or 60° cannula can be used in lieu of forceps for most of the dissections

For advanced procedures, a 70-degree telescope is useful to visualize lateral or superior recesses of the frontal, maxillary, or sphenoid sinus. Curettes of various sizes are useful for removing thick bone, especially around the frontal ostium or sphenoid rostrum (Fig. 2.2A,B). Powered instrumentation with cutting or diamond burrs may also be necessary to carefully remove bone around critical structures, such as the lacrimal sac, skull base, optic nerve, or carotid artery.

The surgeon should be sitting or standing comfortably at the patient’s side. A right-handed surgeon typically stands on the right side of the patient. If the surgeon chooses to sit, then a Mayo stand (cushioned with a pillow) is used to rest the arm holding the telescope at a comfortable height over the patient’s head. The video tower and any intraoperative imaging devices are positioned at the head of the table, facing the surgeon. The surgeon’s neck should be in a comfortable neutral position to avoid long-term strain on his/her C-spine, which can result neck pain.

In live patients, a clear adhesive dressing (e.g., OpSite) is placed over the eyes for protection. This allows the surgeon to visualize and palpate the eyes during the surgical procedure. The patient’s face is draped to expose only the forehead, eyes, nose, and upper lip. The mouth and endotracheal tube are typically draped unless a concomitant sublabial or oral procedure is planned.

The manner in which the telescope is grasped or instrumentation introduced into the nose may vary depending on the surgeon’s preference, the specific length and type of telescope and/or camera, and the specific anatomical area being addressed. Generally, the surgeon determines which manner is best suited for his or her hand.

A 30-degree telescope looking laterally is all that is typically necessary for most of the dissections described in this manual. A zero-degree telescope may also be used, but it may limit adequate visualization of the lateral nasal structures (i.e., maxillary natural ostium, maxillary sinus, supraorbital ethmoidal cells, etc.). The axis of the telescope is directed toward the occipital area of the head. and the superior border of the inferior turbinate is kept in view during the initial part of the procedure until the medial orbital floor is identified through the antrostomy. This keeps the surgeon directed toward the choanal arch and superior nasopharynx. The telescope is positioned at the nasoseptal angle with gentle superior retraction of the nasal tip, and the surgical instrumentation is inserted inferior to the telescope (Fig. 2.3).

A 70-degree telescope can be used if further visualization is required into the superior or lateral recesses of the frontal, maxillary, or sphenoid sinus. The 30-degree or 70-degree telescope is placed along the floor of the vestibule looking superiorly (as when working around the frontal ostium) or medi-ally (as when performing a septoplasty). In these cases, the instruments are introduced superior to the telescope (Fig. 2.4).

In some advanced skull base procedures, where drilling of bone or manipulating tissue around critical neurovascular structures is necessary, it is helpful to have the telescope fixed in place with the help of an assistant, or by utilizing a specially designed telescope holder, allowing the surgeon to operate with both hands simultaneously (Fig. 2.5).