Feasibility and Applicability of Portable Goose Neck System as a Third Arm for Holding Endoscope in Two Handed Endoscopic ENT Surgeries

Abstract

Endoscopes have revolutionised and have added a new dimension to the surgical domain. Many surgical techniques have reformed from the open surgical approach to a minimal access endoscopic one. In otolaryngology too, the indications and the use of endoscopes have been increasing in the last few decades. Even in otology, slowly and steadily Wulstein’s microscopic techniques have been changing to endoscopic techniques. The only disadvantage of endoscopic ear surgery is that it is a single handed technique as the non dominant hand is utilised in holding the endoscope. We have developed portable endoscope holder based on the Goose neck system with rack and pinion mechanism. The goose neck system acts as a third arm to hold the endoscope. The novel portable endoscope holder bears the potential to provide benefits for various endoscopic ear nose and throat surgeries. We present our experience of feasibility and applicability of this endoscope holder.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12070-023-03604-9.

Introduction

Endoscopes have been gradually replacing the open surgical approaches in almost all the surgical domains. Endoscopes allow the panoramic view and help in visualisation and evaluation of the hidden areas of the biological cavities inaccessible to the naked eye without a wider incision. In otolaryngology too, endoscopes have added a new dimension and added to the the overall improvisation of the visualisation of the structures. Initially endoscopes were used only for sinus surgeries and now gradually and steadily the indications have been extended. Endoscopic ear surgery is gaining popularity and there is a gradual shift from the conventional Wulstein’s microscopic ear surgery to endoscopic ear surgery. Initially the endoscopes were restricted in its use as an adjuvant to microscope during ear surgery. The use of two hands in any surgery is of immense importance. The only disadvantage of endoscopic surgery is that it is a single handed technique as the non dominant hand is involved in holding the endoscope. One handed technique is difficult in ear surgeries where the conventional teaching is two handed microscopic technique. Shifting from two handed microscopic ear surgery to single handed endoscopic ear surgery is cumbersome especially when both hands are required in certain steps of surgery like drilling, fogging, haemorrhage and ossiculoplasty. [1–13] To overcome this disadvantage, we have developed a portable unit of endoscope holder based on the goose neck principle. It is trademarked as Endohold GN 201™. It has 2 variants, one without rack and pinion called as Endohold GN 201 A and with rack and pinion mechanism called as Endohold GN 201B.

The human hand which is the most distal part of the upper limb, is a remarkable feat of engineering and evolution. Hand is capable of various movements like flexion, extension, abduction, adduction, supination and pronation. The main idea is to mimic more or less all the actions of the hand so as to have endoscope holder as efficient as a human hand which grips any object firmly. In accordance to the actions of human hand, we intend to impart to the endscope holder the movements such as Upward and downward movement, angular rotation, sidewise movement due to play of its various joints and attachments. Getting maximum 360 degree rotation in space for endoscope like left hand is the main idea for development of the endoscope holder.

Methods and Materials

It is a portable model of endoscope holder consisting of Goose neck arm provided with a slot to hold the endoscope. All flexible gooseneck arms are rigid and hollow. A gooseneck is a semi-rigid, flexible joining element made from a coiled metal hose. Similar to its natural counterpart, it can be bent in almost any direction and remain in that position. [14, 15]

• A.Idea and Concept of endoscope holder is based on:

1. Attachment of vertical rod to the gooseneck to modify it to hold on to the operation table.

2. Adjusting height of gooseneck in such a way so as to hold and sustain the weight of the endoscope, endoscopic camera and cable.

3. Attaching the goose neck sandwiched with other parts so as to achieve maximum 360 degree rotation in space for endoscope like left hand.

4. Incorporating the super clamp to hold the endoscope without rack and pinion (Endohold 201 A).

5. Incorporating the rack and pinion to achieve the millimetre wise downward and upward movement of the endoscope into any biological cavity (Endohold 201B).

• B.Technical details and Mechanism of working:

Based on the above concept, the Endoscope holder with Goose neck system was developed, the parts of which are described in detail below (Figs. 1, 2, 3, 4, 5 and 6 and supplementary videos 1–8):

Fig. 1.

Endohold™ GN 201B

Fig. 2.

Slot To Hold Endoscope

Fig. 3.

Attachment Of Camera

Fig. 4.

Camera Endoscope Assembly On Endohold™ GN

Fig. 5.

Goose Neck part of Endohold™

Fig. 6.

Diagrammatic design of the Endohold GN 201B

Description of Fig. 6

1. Vertical arm for holding assembly

2. Fixing screw for horizontal rotating arm

3. Extra Protector ring with fixing screw for inadvertent horizontal arm slipping

4. Gripping for Operation table

5. Mechanical fixing screw for vertical arm

6. 360 degree Horizontal Moving arm

7. Fixing screw for vertical adjustment tube

8. Fixing screw for goose neck through vertical adjustment tube

9. Flexible Gooseneck

10. Assembly to achieve 3 dimension movement of Rack and pinion system in xyz axis in space

11. Rack

12. Pinion

13. Rigid arm with magic clamp to hold any rigid endoscope

1. O.T. table gripping attachment which is fixed to the operation table.

   The vertical OT table gripping attachment is firmly fixed to rails of the operation table. The top end of it has a slot to grip the horizontal arm which can be affixed in any particular position with the tightening screw.

• 2.Horizontal Metallic rod adjuster to be attached to vertical rod.

  The horizontal arm can be adjusted in any direction in the horizontal plane. It has a slot to firmly grip the goose neck.

• 3.Goose neck attachment.

  A gooseneck contains a wire with a round cross-section inside, which is shaped like a spring in the shape of a helix. A wire with a triangular cross-section is wound around this, so that the tips of the triangle protrude between the round wires into the inner spiral. If the gooseneck is bent in one direction, the distance between the round wires is slightly larger on the outside and slightly smaller on the inside. Correspondingly, the tips of the triangles slip outside between the round wires or are pushed out inside. The bend in the gooseneck is retained due to the friction between the inner spiral and the outer casing, so that the gooseneck remains in the set position.[14, 16]

The characteristic of Gooseneck: The weight of gooseneck 18.6 ounces, outside diameter 18 mm, inside diameter 5/6 inches, minimum bend radius 3 inches, horizontal load capacity 2 − 1/2 pounds. [18].

Material details: Each of flexible gooseneck tube designs is a compromise between stiffness (ability to support weight) and flexibility. Flexible gooseneck tubes are strongest in the vertical orientation and weakest in the horizontal orientation. The goose neck has been checked for the maximum weight each flexible gooseneck tube can support in the weakest orientation (horizontal) without bending. The gooseneck tubing can support more weight in any orientation other than completely horizontal. (SnakeClamp Product USA) [18].

• 4.Rack and Pinion system [17].

  It is attached to the goose neck. It measures 4 cms in length. The pinion teeth mesh with the rack teeth and as the pinion is turned the rack moves. It allows the controlled motion of the endoscope into any biological cavity millimeterwise. The rack and pinion attachment is a part which plays a vital role in providing the mobility to achieve the magnification and depth perception after the magic arm is locked in its desired position.

• 5.Slot for holding the endoscope.

  The endoscope is held by its neck and mounted on the rack and pinion system for to and fro movement of endoscope.

The endoscope holder bases on Goose neck mechanism was developed in February 2020, however its application was tested in April 2021 (Due to suspension of routine Otorhinolaryngologic surgeries during the Covid Pandemic). Initailly after development, the feasibility and applicability of the endoscope holder was tested by practicing on minimum 5 Goat head temporal bones and septal dissections by both authors. After successful and comfortable application of the endoscope holder on goat head for endoscopic two handed Ear and nose surgeries, the use was extended to live surgeries (two handed otorhinolaryngologic surgeries).

Results

We have been using Endoscope holder based on Goose neck system for Two handed Endsocopic Otorhinolaryngologic surgeries. The surgical cases operated with Endohold GN 201 is detailed in Table 1. The ease and comfort of using the endoscope holder was also evaluated. The simple concept and working of the goose neck makes it user friendly. It holds the endoscope with the superclamp and simulates the action of the left hand. The rack and pinion action makes the progress and negotiation through the ear canal, nasal cavity and oral cavities easy to get a nearer view of the part to be visualised.

Table 1.

Surgeries operated with Endoscope Holder based on Goose neck system:

Name of Surgery	Number of Cases operated
Endoscopic tonsillectomy	43
Two handed Endoscopic septoplasty	49
Endoscopic dacryocystorhinostomy	09
Endoscopic Closed rhinoplasty	07
Endoscopic Open rhinoplasty	05
Endoscopic two handed ear surgery-Minor (FB removal, Grommet, Wax removal)	81
Endoscopic two handed ear surgery- Major (Tympanoplasties, atticotomies, atticoantrostomy)	22
TOTAL	216

Discussion

Why Goose Neck for Endoscope holder?

Typically Gooseneck are used for holding iPad, iPhone, any smartphone, Mike, smart lamps, machine guard, magnifying lense, mirror, mounting plate, signing holder. And they are freely available in open commercial market (SnakeClamp products, USA). We have extended its use to hold the endoscope and camera by adding vertical and horizontal adjustment which even add more strength to gooseneck. (Dr Khan’s Creations, India). The safety mechanism to achieve injury to soft tissues during inadvertent movement is through simple movement of gooseneck as its very flexible and by perfectly achieving balance through vertical adjustments.

The flexible gooseneck tube is a perfect balance between stiffness (ability to support weight) and flexibility. Flexible gooseneck tubes are strongest in the vertical orientation and weakest in the horizontal orientation. The gooseneck tubing can support more weight in any orientation other than completely horizontal. The goose neck is fitted into the horizontal arm in such a way so as to allow the height adjustment of the goose neck.

The Goose Neck endoscope holder is mounted on the rails of the operating tables by means of the tight firmly gripping clamp. Flexibility and maneuverability are facilitated by five individual joints, based on the well established Goose-Neck principle. The peculiarity of the endoscope holder is the incorporation of the rack and pinion system in addition to the goose neck. All flexible gooseneck and rigid arms are hollow, hence we have added adjustable vertical tube and horizontal rotating arm to hold the goose neck. (Dr Khan’s Creations, India)

Benefits Of Gooseneck Endoscope Holder

1. More Towing Capacity. The biggest advantage with a gooseneck is its high towing capacity.

2. Better Stability.

3. Better Weight Distribution.

4. Easier to Maneuver.

5. All components of the endoscope holder are made of a high-grade stainless steel.

6. The self-retaining joints rotate and twist in every desirable position.

7. Two different models of endoscope holders are available with and without rack and pinion.

8. Self-retaining and positioning.

9. Holds the endoscope with camera firmly and stablely in any desirable position.

10. Simple principle of operation without opening/tightening the friction joints.

How Goose Neck Endohold is Different from Other Endoscope Holders?

Kuka is robotic arm holding the endoscope [19, 20]. Even our previous endoscope holder using Gas Spring arm, Endohold GS 201B is different (US Patent Application no. 201,921,021,758) [21]. Our new gooseneck combined with vertical and horizontal adjustments and rack and pinion mechanism is unique mechanical endoscope holder achieving many function at very much economical cost. Comparing with existing products great amount of flexibility in motion is achieved in any direction by gooseneck and fine motion is achieved by rack and pinion holding endoscope. There is no conflict of interest as commercially available product is extrapolated with combination of our idea to hold the endoscope.

Applications

1. Endoscopic tonsillectomy (Fig. 7).

2. Two handed Endoscopic septoplasty (Figs. 8, 9 and 10), endoscopic dacryocystorhinostomy.

3. Endoscopic Closed rhinoplasty.

4. Endoscopic open rhinoplasty (Fig. 11).

5. Endoscopic oral surgeries.

6. Endohold GN 201 B with Rachet and pinion for Endoscopic two handed ear surgery (grommet, canalplasty, tympanoplasty, attticotomy, atticoantrostomy, mastoidectomy, ossiculoplasty, soft wall reconstruction).

Fig. 7.

Endohold Goose neck with Rack and Pinion For Two Handed Endoscopic Cobation Tonsillectomy

Fig. 8.

Endohold GN for endoscopic septal surgery

Fig. 9.

Incision on the septum during septoplasty

Fig. 10.

Septal flap elevation during endoscopic two handed septoplasty

Fig. 11.

Intraoperative pictures with Endohold GN for Open Rhinoplasty

Advantages of Endoscope Holder in Rhinoplasty (Closed and Open)

1. Documentation & recording of all steps in surgery.

2. Precise & Accurate septal deformity evaluation.

3. Thorough correction of septal deformity.

4. Precise elevation of mucoperichodrial & periosteal flap.

5. Accurate & intact septal graft harvestation.

6. Precise retention of L shaped septal strut.

7. Dorsum visualisation better.

8. Dorsal augmentation graft placement better.

9. Accuracy of placement of intranasal osteotomy incision.

10. Excellent teaching aid as every step of surgery documented.

11. No need of external surface camera for recording.

12. Allows two handed technique.

13. No need of assistant to hold endoscope during septal correction.

14. As endoscope is mounted on endoholder, stability of image is ensured throughout the surgery.

15. Surgical field is clearer as the suctioning of the blood and elevation of flap can be done simultaneously (two handed technique).

16. Whole surgical procedure can be recorded with recorder.

17. Recorded surgical procedure serves as teaching aid and for medicolegal evidence.

Limitations of Endoscopic Endoholder Assisted ENT Surgery

1. Training of surgeon to the use and handling/ manipulation.

2. Learning curve of the endoscope holder asssited endoscopic ENT surgery.

3. Patience required during initial surgeries as simultaneous coordination of surgical steps and manipulation of the endoholder.

4. Care of tip of endoscope (during nasal spine drilling, chisselling bony spur, intra nasal osteotomy).

5. Training for advancing the endoholder in and out of the surgical field.

6. Fogging of endoscope.

Potential Extended Uses in Other Speciality in the future:

1. Laparoscopic Surgeries.

2. Urosurgeries.

3. Laparoscopic gynaecologic surgeries.

4. Arthroscopies.

5. Neurosurgical procedures.

6. Lateral and anterior skull bases surgeries.

Ease of Use

The Goose neck is very simple in ergonomics and working is very comfortable and convenient. It can be mounted on the accessory bar of any operating room table by means of the clamp.

Sterilisation

1. Autoclave.

2. Cidex sterilization.

3. UV- C sterilization.

Limitations of the Study

1. Experience of one centre with small number of cases operated.

Future Studies

In the near future with the research and development, possibility of motorised rack pinion can be done.

Vision for Use of Endohold GN 201

1. Automated Endoholder like robot.

2. 3D endoscopy with automated Endoholder.

3. Automated cleaning of fogging.

4. Voice controlled Endoholder.

5. Motorised rack pinion action.

Conclusion

Endohold™ GN 201 is a good option for two handed endoscopic ear surgeries in cases with or without drilling due to its stable dynamic properties and can be used for two handed endoscopic nasal and throat surgeries. Use of the endoscope holder requires the training to acquire the skills.

Electronic Supplementary Material

Below is the link to the electronic supplementary material.

Author Contribution

Dr. Mubarak M. Khan: Instrument design and development, manuscript drafting, editing. Dr. Sapna R Parab: Instrument development, manuscript drafting, editing.

Funding

None. This study was not financially supported from external sources.

Declarations

Ethical Approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional committee and with the 1964 helsinski declaration and its later amendments or comparable ethical standards. Institutional Ethics Committee has approved the study.

Conflict of Interest

None.

Informed consent

Informed consent was obtained from all individual participants included in the study.