Modified Endoscope Holder for Two Handed Endoscopic Ear Surgery

Abstract

We have been doing Endoscopic ear surgeries since 2013. Inorder to overcome the disadvantage of the single handed endoscopic ear surgery technique, we have developed the endoscope holders, Justtach^® and EndoHold^®. Due to its certain limitations, we modified the pre-existing, endoscope holder—Justtach, to add more features as well as to increase the comfort and ease of the technique. The aim of this paper is to describe the design of our modified endoscope holder and to report our preliminary experience of two handed endoscopic ear surgery with it. Descriptive study. A total number of 68 two handed endoscopic tympanoplasties have been operated with the modified endoscope holder from January 2017 to May 2018 with a minimum follow up period of 10 months. Our study reports the successful application of the modified endoscope holder for two handed endoscopic ear surgery, highlighting its advantages. Our modified endoscope holder, is a good option for two handed endoscopic tympanoplasties and mastoidectomies.

Level of Evidence Level 4.

Electronic supplementary material

The online version of this article (10.1007/s12070-020-01841-w) contains supplementary material, which is available to authorized users.

Introduction

The advent of endoscopes in the surgical field have revolutionised the surgical techniques due to its optics, extent and clarity of visualisation and minimal invasive approach. At present, endoscopes are being extensively used by otolaryngologists for sinus surgeries. The well-established techniques in tympanoplasty and middle ear surgery have been routinely performed with operating microscopes since many decades. Over the last one decade, the use of endoscopes has been extended to the middle ear. Since then, there is a gradual drift and inclination of otologists towards the use of endoscope in middle ear surgery. Initially, the role of endoscope was limited to that of an adjuvant one only to observe the hidden middle ear spaces. The use of endoscope for ear surgeries provides a minimally invasive approach to the middle ear and is an evolving science in the field of otology. Endoscopes have a lot of advantages in otology. It gives a panoramic view and allows a better understanding of the middle ear anatomy, physiology as well as pathology due to the wide angle view of the middle ear spaces [1, 2]. This allows the pathology to be treated without much bone removal. Endoscope has thus started making a niche in the world of microscopic ear surgery. The pioneering work of endoscopic ear surgery has been done by Prof. Muaaz Tarabichi, Prof Marchioni, Prof Presutti, Prof. Joao etc. The only short-coming of Endoscopic ear surgeries is due to its single handed technique. In the single handed technique, the endoscope is held in the left hand and the instrumentation in the right hand. However during drilling and haemorrhage, single handed technique poses a disadvantage as it absolutely impossible to do suctioning and drilling simultaneously, in addition to fatigue in long duration surgeries. Also in case of prosthesis fitting during endoscopic ossiculoplasty, there is need for the coordinated action and use of two hands. We have developed two endoscope holders, (2–5) to overcome the disadvantages of the single handed endoscopic ear surgery. We have been operating with our endoscope holders since 2013. The first endoscope holder is the modification of the otomicroscope by replacing the optics with the metallic plate with a slot to hold the endoscope thus converting the microscope into an endoscope holder stand (2, 3). The second endoscope holder, Justtach, (4, 5), is the universal attachment plate to the already existing microscope to convert it into the endoscope holder. We have been operating endoscopic ear surgeries using the two endoscope holders since 2013.

Why to hold endoscope in metallic plate grip it to microscope/Why Justtach?

1. To use both hands for surgery.

2. To apply all movements (not functions) of microscope optical body for endoscope movement.

3. By doing so endoscope can be moved more or less like using left hand which is important for any surgery.

4. We are not using both system (endoscope and microscope) simultaneously.

5. But both system can be used alternatively which give added advantages.

6. Every ENT surgeon owns microscope for ear surgery. Now by using our innovation he will be able to do EES with two hands (at present no body in the world is doing this) with simply fixing one endoscope holding metallic plate.

7. Anything which will be holding endoscope, if fixed to microscope optical body will automatically apply all movements of operating microscope for driving endoscope during surgery (this is the basis of our innovation).

Briefly to summarise the need for Justtach:

1. Simple innovation of holding endoscope in metallic plate and fixing it to microscope optical body.

2. By doing this idea is to use all microscope mechanical movements not functions for movement of endoscope in space.

3. Instead of developing separate stand to hold endoscope, it can be held as described in our innovation. Thus a very cheap but beneficial alternative

Both systems (endoscope and Microscope) works independently with their own advantages and disadvantage and not remotely related functionally. Only implementation of microscope stand actions for driving endoscope in space mechanically during surgery.

After developing and using Justtach for three years we realised that there were certain concerns related to its functions. The main concern of Justtach is that it could interfere with the long axis working distance during drilling. Hence in 2016, we modified Justtach so as to incorporate the rotating handle into it and made it more user friendly. The aim of this paper is to describe the modified endoscope holder, highlighting its peculiarities and to report our preliminary experience with it.

Materials and methods

In 2016, we modified our previously designed endoscope holder, Justtach (Patent number Application No. 3300/MUM/2013) to incorporate more features and advantages. It has been registered under the name of Justtach ASM2^® (Fig. 1). It has been applied for IPR to government of India under the Patent and Design Act. This retrospective study consists of 68 endoscopic ear surgeries with 51 endoscopic sliced cartilage tympanoplasties for pars tensa perforations and 17 endoscopic atticotomies with tympanoplasties operated in Sushrut ENT Hospital from January 2017 to May 2018 with a follow up period of 6 to 24 months. There was no ossicular chain involvement. There were 32 males and 36 females. The patients ranged from 11 to 59 years with mean age of 28.34 years. The average preoperative air bone gap was 30.14 ± 2.13 dB. Written consent was taken in all the patients. The details of the operative procedure was explained to the patients and to their parents (in case of paediatric patients). The Institutional review Ethics Committee has approved the study.

Fig. 1.

Justtach ASM2

Design of the Modified Endoscope Holder Justtach ASM2 (Figs. 1, 2, 3, 4, 5, 6)

Fig. 2.

Rotatable handle

Fig. 3.

Main body

Fig. 4.

Justtach ASM2 gripping onto microscope with endoscope in position

Fig. 5.

Closer view of the endoscope within Justtach ASM2

Fig. 6.

Assembly of endoscope within the Justtach ASM2

The objective of the modification is to overcome the difficulties encountered with the first generation of endoscope holder and to add more features. It has a rotatable arm (Fig. 2). It has 2 parts:

1. The main body (Fig. 3)

2. The rotatable handle (Fig. 2)

The main body is rectangular in shape and measures 130 × 80 × 10 mm in dimensions (Fig. 3) with a square slot is 110 mm × 60 mm × 10mm for gripping onto the microscope with a tightening screw (Fig. 4). The rotatable handle is thinner and measures 120 × 10 mm with a circular slot measuring 16mm × 16 mm in diameter (Figs. 5, 6). It is connected to the main body with a screw for tightening action. The advantage of the rotatable handle is that it can be fixed in any angle (away from the working long axis of the microscope) convenient to the surgeon so that the operating space is away from the axis of the microscope. Hence it is more beneficial in endoscopic ear surgery with drilling, where during mastoidectomies, the shaft of the drill could previously interfere with the body of Justtach. There is a protector sheath for the endoscope provided along with it.

Operating Theatre Requirements and Preparation of the Patient

The Zero degree 4 mm Karl Storz endoscope, triple charge coupled device Camera (Karl Storz, Germany) and our modified endoscope holder, Justtach ASM2 firmly fixed to optical system of microscope just above objective lens (Fig. 4). The endoscope is mounted on Justtach ASM2 using aseptic precautions. The endoscope is kept in glutaraldehyde solution to ensure asepsis.

The external ear canal is infiltrated with 2% lidocaine with 1 in 200,000 adrenaline. All the patients except 21 were operated under local anaesthesia with intravenous sedation. Preoperatively, all the patients were explained about the endoscopic procedure. Intraoperatively, the head of the patient is steadied by the assistant by placing the hand over the head of the patient to avoid any accidental movement of the head.

Procedure of endoscopic ear surgery with Justtach ASM2 (Figs. 7, 8, 9)

Fig. 7.

Middle ear endoscopy with Justtach ASM2

Fig. 8.

Flap elevation in minimal attic disease using Justtach ASM2

Fig. 9.

Sliced graft placement for TM reconstruction

Instruments used are the same as used in microscopic middle ear surgery.

Preparation of the ear canal To prevent soiling of the endoscope and to allow an unobstructed and clear view, the hair in the ear canal are removed with the 15 number surgical blade. The ear canal is irrigated with normal saline solution to clean the debris.

Incision and approach Transcanal.

Tragal cartilage harvest and graft preparation [2−12] Tragal cartilage is the graft of choice. It is harvested via the horizontal incision on the tragus by retaining 5 mm superiorly to retain cosmesis of the tragus and to prevent shrinkage and shrivelling of the tragal skin. The cartilage is sliced with Slice !t™ (Cartilage Slicer, Dr. Khan’s Creations, India).

Middle ear exploration Tympanomeatal flap is elevated to visualise the middle ear (Fig. 5). Outer attic wall drilling is done in case of limited attic disease and retraction pockets (Fig. 6). The tympanic membrane is then reconstructed in an underlay method with the sliced tragal cartilage (Fig. 7).

Results

A total of 68 two handed endoscopic surgeries were operated with Justtach ASM 2 from January 2017 to May 2018 with a minimum follow up period of 10 months. No middle ear injury was seen reported in our series. At 10 months follow up, the graft uptake was seen in 65 ears with three recurrent perforations giving a success rate of 95.588%. The average preoperative Air Bone Gap in the study group was 30.14 ± 2.13 dB and post-operative AB gap closed to 11.44 ± 3.54 dB at 6 months follow up.

Points of differences between Justtach and Justtach ASM 2 (Table 1)

Table 1.

Comparison between Justtach and Justtach ASM2

Features	Justtach	Justtach ASM2
Weight	454 g	376 g
Microscope gripping mechanism	Point gripping	Teflon 2 point
Fixing of endoscope	Neck of endoscope	By neck of endoscope
Structural difference	More useful for flat surface of microscope body	Flat as well as curved surface microscope body
Method of endoscope holding	Neck of the endoscope	Neck of the endoscope
Advantage and disadvanteges of endoscopic holding	Advantages: 1. Useful for endoscopic ear surgery 2. More working length 20 cm Disadvantages.: 1. As the endoscope is a one fixed position microscope Body may obstruct instrumentation	Advantages: 1. Useful for endoscopic nose, throats 2. Working length 20 cm 3. As endoscope is held by shaft with rotating arm does not obstruct instrumentation
Endoscope protection	Neck is protected with the silicon cap and for gripping (Note: Endoscope holding sheath is recommended for Protection of the shaft)	Shaft is protected with endoscope holding sheath (Note: Endoscopic sheath is already provided)
Ease of use	For endoscopic ear surgery very easy to use. For nose and throat bit cumbersome	Excellent for all endoscopic ear, nose and throat surgery
Gripping screw	Mechanical gripping by single point contact	Mechanical gripping 2 point teflon fixing
Movement of ENDOSCOPE in holder	No	More than 180° rotation
Compatibility	Zeiss 1FC PICO, all Indian microscopes, Takahashi, Karl Kaps, Sanma, Servell	Zeiss 1FC ECO, all Indian microscopes, Takahashi, Karl Kaps, Sanma, Servell
Sterility	Autoclavable	Autoclavable
Presentation	Box packed	Box packed

1. Lighter in weight

2. More user friendly due to rotatable handle

3. Does not interfere while drilling

Discussion

The introduction of endoscopes in middle ear surgery has not only changed the surgical approach but also has distinctly reduced the occurrence of residual cholesteatoma due to better visualization of the sinus tympani, facial recess and epitympanic recesses [1–6]. Minimal invasive endoscopic and endoscope assisted middle ear surgeries are increasingly being performed due to the obvious advantages. At present, the scenario of the endoscopic ear surgery is a single handed procedure with the endoscope being held in the non-dominant hand of the surgeon and the instrumentation in the dominant hand. Inorder to overcome the disadvantages of the single handed endoscopic ear surgery, we have developed endoscope holders. We have been operating with the two handed technique of ear surgery using Justtach [2−4] due to its obvious benefits. In 2016, we have modified Justtach to overcome some difficulties and to add more features. This modification is registered in the name of Justtach ASM2 and has been applied for IPR under the Patent and Design Act, Government of India. In our study, we did not have any trauma to the middle ear structures or to the tip of the endoscope due to any jerky movements.

All of us are trained in microscopic ear surgery during the post-graduation course of otolaryngology. The microscopic ear surgery is a two handed technique in which one holds the suction in the left hand and the micro ear instruments in the right hand. Our two handed technique also is similar to the microscopic ear surgery with the added advantages of the endoscope. With sufficient training and practice the technique may be adopted by all. It definitely has a learning curve. Many experienced with endoscopic surgeries will find the technique easy to master, but surgeons who have limited themselves to an entirely microscopic otology practice are likely to find endoscope holder aided endoscopic surgery more difficult or unnecessary to perform or master. We strongly recommend and advocate endoscopic temporal bone cadaveric dissections before starting with the endoscopic ear surgeries in patients. The selection of cases is very important during the early days. One should start with simpler procedures like otoendoscopies, grommet insertion and then proceed to tympanoplasties. In tympanoplasty too, start with small perforations with wide canals. Gradually as the confidence and the technique improves, one may resort to large perforation, limited attic disease and cholesteatoma surgeries. In the era of minimally invasive surgery, we have designed and developed the endoscope holder for overcoming the disadvantages of the single handed endoscopic ear surgery. The advantages and disadvantages of the endoscope holder for two handed endoscopic ear surgery are well highlighted.

The advantages of Justtach in endoscopic ear surgeries is already described [4, 5].

1. Stability of the endoscope, camera and image on the monitor is ensured throughout.

2. No surgeon fatigue in holding the endoscope (as compared with single handed endoscopic ear surgery).

3. When angled endoscope (30°, 45°, 70°) is used with the endoscope holders, it allows better visualization of sinus tympani, facial recess, anterior tympanic cavity and hypotympanum with just rotation of the endoscope within the Holder.

4. All the steps of the ear surgery are similar to Microscopic ear surgery as the left hand holds the suction cannula continuously and the instruments in the right hand.

5. No comprome of the surgical field.

6. Effective alternative for documentation and a useful teaching aid.

7. Minimizes the need for assistance.

8. As Justtach™ is designed as an attachment to the operating microscope, the fine focus of the microscopic stand can be utilized for additional advancing into the external auditory canal

9. No retro auricular incision

10. No Mastoid bandage is not required.

11. Lesser duration of surgery as the time required for the retro auricular incision and suturing is avoided.

12. Fogging of the endoscope is avoided by use of suction cannula and by irrigation.

13. Canalplasty can be done with the drill in the right hand and suction in the left hand.

The additional advantages of Justtach ASM2:

1. It is provided with a rotatable handle and hence doesn’t interfere with the working distance of the microscope stand

2. It is provided with a protective sheath for the endoscope

3. It is lighter

4. Gripping onto the microscope is firm

5. Can be conveniently be used in ear nose as well as throat surgeries.

The minimally invasive two handed endoscopic ear surgery (EES) allows better and panoramic view of the middle ear structures without much bone removal, no retroauricular incision and suturing. There is also no fatigue involved in long duration surgery as in single handed EES with the surgeon holding the endoscope in left hand.

Conclusion

Justtach ASM2 is a very good option for two handed endoscopic ear surgeries in cases with or without drilling. Endoscopic cartilage tympanoplasty is operated by using the sliced tragal cartilage. Use of the endoholder requires the training to acquire the skills [13].

Electronic supplementary material

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Funding

None.

Compliance with Ethical Standards

Conflict of interest

The authors declare that they have no conflict of interest.

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.

Informed Consent

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