endoscopic suturing in ent

[Jason Voorhees]

Hi this is my first post in this forum.
Im a MS3 trying to decide between urology and ent... I must say that ent seems more appealing to me in terms of anatomy, pathologies and patients... Also I love the procedures in ent, however urology procedures seem pretty fun too, especially laparoscopic surgery, I know endoscopic procedures are a huge part of ent practice and this should be somewhat similar to laparoscopy, so I wanted to ask if you have the oportunity to perfom endoscopic suturing as an ent? Or is it endoscopic surgery more about cutting with lasers (which seems awesome too), grasping with forceps, using microscissors, etc?? I know there is practically no suturing in FESS, but what about endoscopic surgery in the larynx and other anatomic regions pertinent to ent??

Thanks a lot for your time

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[OtoHNS]

I don't personally do any suturing during endoscopic sinus or laryngeal procedures. The only example I can think of is "Bolgerization" of the middle turbinates which is placing a suture through and through both middle turbinates and the septum to medialize the turbs following ethmoidectomy.

 

[DrBodacious]

Pretty uncommon. I did the endoscopic suturing on a laryngocele case, once (in residency), and I saw our laryngologist suture an upper esophageal perforation endoscopically . Those are pretty rare cases. Fun though.

A somewhat similar type of skill set to consider would be microsurgery. ENT uses microscopes pretty frequently for a lot of things (not sure if urology does at all). Ear surgery, microlaryngoscopy cases, micro vascular, nerve grafts. All good stuff.

 

[VisionaryTics]

I don't personally do any suturing during endoscopic sinus or laryngeal procedures. The only example I can think of is "Bolgerization" of the middle turbinates which is placing a suture through and through both middle turbinates and the septum to medialize the turbs following ethmoidectomy.

I saw one of the facial plastics guys do some suturing during an endoscopic septal perf repair that was pretty posterior.. He made bipedicled mucosal flaps superiorly and inferiorly on either side of the septum, advanced the flaps to cover the defect, and then sutured them together.

Pretty slick.

 

[Pir8DeacDoc]

But did it take? Perforations suck. Repair has at best a 50/50 chance of success. Plus that posteriorly they are less likely to by symptomatic. Silastic button rules!

 

[DoctwoB]

A somewhat similar type of skill set to consider would be microsurgery. ENT uses microscopes pretty frequently for a lot of things (not sure if urology does at all). Ear surgery, microlaryngoscopy cases, micro vascular, nerve grafts. All good stuff.

Urology does use the microscope, predominantly for infertility surgery, namely microscopic varicocelectomies and sperm extractions.

If you are interested in endoscopy, Urology is a good fit for that as well. A large percentage of bread and butter urology cases are performed cystoscopically (diagnostic cystos, stent placements/exchanges, TURPs, bladder tumor resections, ureteroscopy for stones, etc.) Both use endoscopes, microscopes, and open surgery. Urology adds laparoscopy and robotics to that. Both are great fields with a wide variety of pathology and modalities, but very different anatomy. Would you rather be operating in the head and neck or in the belly/pelvis?

 

[Jason Voorhees]

I feel more attracted towards head and neck anatomy... However, urology seems like an awesome field too... I loved being in the OR while the uros were performing laparoscopy or robotic surgery.
Luckily for ents, it seems like the use of robotics is getting more popular in head and neck surgery, I wonder if the probability of a given otolaryngologist getting his hands on robotics will ever be somewhat similar to the urology colleagues, especially considering that the prevalence of the pathologies that would justify the use of robotics in ent is way lower than the prevalence of urological pathologies... Institutions will consider mostly cost-effectiveness when it comes to buying a million dollar davinci robot... Well I must say that if I get to use the davinci robot once in a while as an ent it will play a significant role in my decision

This is getting so hard for me... I have always LOVED ent and my ent rotation rocked... But I recently completed an awesome rotation in urology and now I don't know which one should I choose

 

[Jason Voorhees]

I just realized I have the resident status!! How can I change it to medical student??? Haha don't want to be taken as a poser...

 

[resxn]

Bolgerization is not placing a turbinate suture. Bolgerization is roughing up the medial mucosa of the middle turbinate and an approximating mucosal surface of the septum to try to stimulate synechiae formation. A turbinate stitch is just another way of doing it. William Bolger, somewhat of a pal of mine (former USAF doc with me), used his method because the endoscopic turbinate stitch is a pain in the can to do, but probably more effective. Nowadays, I think many people just use the Propel Implant which is fast, awesome, effective, and has the benefit of being a dissolvable steroid spacer.

Another laryngeal stitch that has been called "The hardest stitch in show business" is the arytenoid adduction stitch. Having done several in residency, I have to say that it is probably the toughes stitch I've ever thrown. When done right, it's awesome. Others I've used include sutures through the cricopharyngeal bar to pull up the CP into the jaws of a stapler during an endo Zenker's. Recently, I've had the opportunity to do a bunch with the Da Vinci in TORS, but they are pretty easy, not hard at all.

 

[Leforte]

I stitch the TVF edges after reduction of Reinke's edema (the stitch is placed on the superior aspect of the TVF near the ventricle). That can be a bit tough.

A King suture for TVF lateralisation is pretty fun, too, albeit only used for a couple weeks, at most.