Intraoperative and postoperative hemorrhage are severe complications following tonsillectomy. Intraoperative bleeding not only prolongs the operation time but also results in the need for repeated ligation or electrocautery, which increases postoperative pain and scarring. In addition, postoperative hemorrhage may prolong the hospital stay or may require frequent returns to the hospital. Severely, intraoperative and postoperative bleeding require blood transfusions and threat to life [14].
In recent years, surgical instruments of tonsillectomy have improved from the cold knife approach to electrocoagulation and the currently popular coblation method. However, postoperative bleeding still occurs in a certain proportion with approximately 1.4–11.9% [4–6].The factors influencing intraoperative and postoperative bleeding have been widely discussed. Some scholars believe that being obese, having a small mouth, and experiencing recurrent tonsillitis increases the likelihood of bleeding, whereas tonsillar hypertrophy reduces bleeding, particularly in younger patients [15]. Some suture the anterior and posterior pillars to reduce bleeding [7,8 ]. Others believe that bleeding occurs mainly in the inferior pole of the tonsil; as such, they recommend suturing the inferior pole and connective tissue to the tongue [9, 10]. Notably, none of these techniques have demonstrated a significant effect on reducing bleeding [10]. Despite intracapsular or partial tonsillectomy has been used to minimize bleeding issues [11–14], these methods ultimately result in the regrowth of tonsillar tissue, particularly for recurrent tonsillitis [11–13].
Recently, our department modified our conventional tonsillectomy procedure with a coblation revolving tonsillectomy with outside-in dissection. No intraoperative bleeding was observed in the tonsillar fossa of any of the patients, i.e., our approach was a bloodless procedure. The average operation time of bilateral surgery was 13.2 ± 1.9 min, which was significantly shortened compared with the literature reported by onther authors [10–14].
No postoperative hemorrhage which required any additional intervention occurred, although 3 (2.9%) patients experienced minimal PTH within the first 24 h after surgery. In addition, this technique didn’t increase the postoperative pain intensity compared with the literature reported by onther authors [10–14].
Traditional tonsillectomy was carried out with top-down dissection of the tonsil, with the pedicle on the inferior pole; then the pedicle was removed by electrocoagulation or ligation.
The inferior pole locating on the side of tongue easily form the blind zone in the circumstances and result in the excessive resection, with damage to the pharyngeal and lingual extensions of the lymphoid tissue, which contains a rich arterial vessel network [9, 14].
By contrast, with our approach, the tonsil tissue was firstly dissected in an arc with top-down dissection, in which the tonsillar tissue was gradually pulled medially along the posterior pillar, and then carefully dissected in outside-in approach. Finally, the pedicle of the tonsil is on the posterior pillar and dissected. The tonsil and the anterior pillar (lateral wall) show an arc structure in the tonsillar fossa [16]. There is peritonsillar space of loose fibrous tissue between the capsula tonsillaris and the posterior and lateral pharyngeal contraction muscle. The peritonsillar space was clearly visible, once the tonsillar tissue was pulled medially.
The capsula tonsillaris was ablated in an arc with repeated top-down dissection along the peritonsillar space and was exposed gradually with an outside-in movement (from the anterior pillar to the posterior pillars). Then the capsula tonsillaris was separated from the upper and inferior pole of the tonsil, which was attached to the posterior pillars. The anatomical levels between the tonsil and peritonsillar space and the inferior pole were clearly exposed to the surgeon’s field of view, thereby avoiding damage to the pharyngeal and lingual extensions of lymphoid tissue and reduce the intraoperative and postoperative hemorrhage. Previous studies showed that the most common sites of PTH are at the inferior pole[1–3]. Nevertheless, we emphasize the need to have extensive familiarity with the tonsil anatomy for safe and effective outcomes using the proposed method. The major deficiency of the study is the lack of control arm and small sample size, a case controlled study of large sample size should be considered in future.