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Coblation vs Microdebrider Intracapsular Tonsillectomy

Author Dana Schmitz covers Coblation vs Microdebrider Intracapsular Tonsillectomy on BackTable ENT

Dana Schmitz • Jul 26, 2023 • 252 hits

There are two predominant techniques for intracapsular tonsillectomy surgery: (1) the microdebrider technique and (2) the Coblation technique. Pediatric Otolaryngologist Dr. Kevin Huoh discusses the pros and cons of each technique, the importance of monitoring for rates of regrowth, and procedural suggestions for decreasing the risk of tonsillar regrowth. Dr. Huoh also explains how even experienced surgeons can smoothly make the transition from traditional methods of tonsillectomy surgery to the intracapsular tonsillectomy methods.

This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, but you can listen to the full podcast below.

The BackTable ENT Brief

• The microdebrider tonsillectomy method, while effective, tends to cause significant bleeding and may increase postoperative pain due to cauterization, whereas the Coblation tonsillectomy technique offers a gentler approach and reduces bleeding.

• Dr. Huoh encourages his fellow surgeons to follow regrowth rate, rather than bleed rate, as an indicator of procedure adequacy.

• Coagulating the whole tonsil bed after Coblation might contribute to a lower regrowth rate, according to Dr. Huoh.

• Transitioning to intracapsular tonsillectomy can lead to reduced postoperative complications and lower bleed rates, leading to improved patient recovery.

• Surgeons experienced with intracapsular tonsillectomy are often open to having learners join them in the operating room for first-hand experience and guidance, allowing even seasoned surgeons using the traditional method to effectively switch surgical approaches.

Intracapsular Tonsillectomy Surgery: Coblation vs Microdebrider

Table of Contents

(1) Advantages of Coblation in Intracapsular Tonsillectomy Surgery

(2) Transitioning to Intracapsular Tonsillectomy Surgery

Advantages of Coblation in Intracapsular Tonsillectomy Surgery

According to Dr. Huoh, the microdebrider tonsillectomy approach, though efficient, can cause significant bleeding requiring cauterization, which may then increase postoperative pain. The Coblation tonsillectomy method is now the preferred option amongst many tonsillectomy surgeons due to its potential for reduced tissue trauma and bleeding. Various wands can be used in Coblation, though it’s important to adjust the technique depending on the wand and the surgical experience. With careful application and understanding of the anatomy, Coblation allows for more precision and potential reduction in postoperative pain. Dr. Huoh explains his approach to coblation tonsillectomy surgery in detail below.

[Dr. Gopi Shah]
That's cool. In terms of techniques, I know there's microdebrider, there's the Coblation device. What are the different techniques out there and what do you like to use?

[Dr. Kevin Huoh]
I think the one that was earliest described by Dr. Kotai was a microdebrider. That's what I initially learned during my fellowship.

[Dr. Gopi Shah]
Those bleed. [chuckles]

[Dr. Kevin Huoh]
Yes, so they do.

[Dr. Gopi Shah]
That's how I learned. I was like, "What is this?"

[Dr. Kevin Huoh]
It's kind of a bloodbath, right?

[Dr. Gopi Shah]
Yes. It is.

[Dr. Kevin Huoh]
You take a specially designed tonsil blade and you set it I think at 1,500 rpm on your microdebrider machine. Then you just go at it. The tonsil is a big polyp, so you just go at it. What happens is it bleeds, and then you have to use a suction bovie to kind of to cauterize the base.

[Dr. Gopi Shah]
Yes. You're charring everything.

[Dr. Kevin Huoh]
Then by charring everything, you're almost defeating the purpose of reducing pain because you can get the diffusion of thermal energy when you're trying to char the whole tonsil bed. That's where I started with in practice, but I quickly changed to the Coblator. My partner, Nguyen Pham, learned the Coblator method during fellowship. We did the same fellowship, but he just learned from someone else.

The Coblator is what I use now. There's several wands that you can choose to do an intracapsular tonsillectomy. I use a Procise Max Wand. The Procise XP, I think, is a good one for beginners. When I have residents starting out with me, sometimes I'll reach for the Procise XP. It's less aggressive. The active area is smaller than the Procise Max. It's just a little bit slower. I'm all about speed for tonsillectomy.

Then the new product they have out is the Halo Wand, which is very promising. I've used it now for a few months. It's very promising addition to the Coblator system. That uses a different console. For the old ones, a Procise XP or Max, I'll use a setting of seven for Coblate and three for Coag. I'll just start at the medial aspect of the tonsil. For the left tonsil, I'll hold the wand in my right hand, so kind of opposite of what you would do for a bovie, and then start from medial to lateral. Then basically you want the tonsil bed to look like a total tonsillectomy except you have some tonsil tissue left, and that's when you know you're done.

[Dr. Gopi Shah]
You're definitely going more lateral than just the pillars?

[Dr. Kevin Huoh]
Correct.

[Dr. Gopi Shah]
When I think of tonsils, they're not just like round globes. I feel there's some areas that are a little bit more that frowned out a little bit, more lateral. You just have to know the plane that you're looking for to know how deep you want to go. What does it look like? Does it look lacy? Somebody used to tell me that it should look a little bit lacy or something.

[Dr. Kevin Huoh]
When you use a microdebrider, you start seeing more, I guess, lacy or thicker fibers. When you use a Coblator, it's a little harder. I think it looks more striated. You're not looking at muscle, but it starts to look more striated, more fibrous. Tonsil tissue itself is squishy, soft, that whitish stuff. When you're looking at more striated-type tissue appearance, then you know you're getting close to the capsule.

I always tell my residents it's fine to leave a little bit of extra tonsil tissue. I'd rather them do that than dig a hole into the pharyngeal wall. It's not a rocket science. I know that's the most common question I get asked. It's how do you know when you're done? Any surgeon who's done enough total tonsillectomies, you kind of have a feeling. When you get that scooped out concave appearance, you know like, "All right, I'm done."

I would encourage surgeons to follow the regrowth rate. You know we always encourage surgeons to follow your bleed rate. You don't have to follow your bleed rate anymore, I'll tell you that, but you should follow your regrowth rate. That will inform you on whether you're doing enough.

[Dr. Gopi Shah]
Just to get a little bit more granular into the technique, one, in terms of your preference. Do you like a red rubber, not a red rubber to lift up your soft palate?

[Dr. Kevin Huoh]
I do. I use two red rubber catheters, actually. I don't know if that's super common.

[Dr. Gopi Shah]
I think I do too as well.

[Dr. Kevin Huoh]
A lot of my partners use one. [crosstalk]

[Dr. Gopi Shah]
It just depends on the mouth.

[Dr. Kevin Huoh]
A lot of my partners use one.

[Dr. Gopi Shah]
It just depends on your exposure. I use one, too. Some people don't. That's why I asked. Again, this is 10, 15 years later. With the Coblator, the way I had learned was literally you're just lopping it off. What you're describing is with your wand lateral and just taking it down. Letting it melt through the-- [crosstalk]

[Dr. Kevin Huoh]
Medial to lateral.

[Dr. Gopi Shah]
Medial to lateral.

[Dr. Kevin Huoh]
Medial to lateral. You tap it. You just keep on tapping. You literally keep on tapping that tonsil or kind of scoop that tonsil. You don't want to stay on it too long because then you'll char it. You just tap, tap, tap, tap. A lot of people have used a Coblator for other things. I know it's probably for JNAs or other nasal masses. It's a similar thing.

[Dr. Gopi Shah]
Use the tip. How do you deal with clogging? Do they clog in the hole or is the Procise suction hole bigger than the slower XP wand?

[Dr. Kevin Huoh]
Early on, that was a problem for me. The way I've eliminated that is you have to remember, you have to turn up your suction. We have a [unintelligible 00:27:08]. I put it at like 250 to 300. The suction has to be pretty high. Your saline flow has to be pretty brisk. It's all reliant on that repetitive tapping motion. Just not staying on a tissue too long. Then, in my other hand, I hold a suction, actually. You can do a hurd or a suction.

[Dr. Gopi Shah]
I was going to ask you, is it a hurd?

[Dr. Kevin Huoh]
You can start with the hurd. That's what I first started with. Then one of my residents who is now one of my partners said, "Hey, why don't we hold a suction in the other hand?" I'm like, "Yes. It's a great idea." I can manipulate the tonsil with the suction, and it suctions all that excess saline from the oropharynx. I hold a suction in my other hand, and then it tends to work well.

[Dr. Gopi Shah]
Just a regular Yankauer, like the metal tonsil Yankauer suction?

[Dr. Kevin Huoh]
Yes. The metal one. I think [unintelligible 00:28:06] tip vascular suction, I think is the correct name. Some people hold a plastic Yankauer too, but I don't like those. I think they're too big.

[Dr. Gopi Shah]
They're kind of big. Then let's say, do you then have to go over and Coblate the whole area? You know how sometimes when you do a bovie tonsillectomy, then you're like, "Okay." You sometimes need to start-- Do you have to do that or just what's bleeding? Do you do that with vessels you may come across or what is that?

[Dr. Kevin Huoh]
I actually coagulate the whole tonsil that remains, the capsule. It doesn't take very long, but I think that might be why our regrowth rate is lower. Similar to when you're using a suction bovie on the adenoids, you just have a bed of charge sometimes, and that's what we have. You just use a Coag setting on the Coblator device and go over the whole bed.

Listen to the Full Podcast

Intracapsular Tonsillectomy in Children with Dr. Kevin Huoh on the BackTable ENT Podcast)
Ep 110 Intracapsular Tonsillectomy in Children with Dr. Kevin Huoh
00:00 / 01:04

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Transitioning to Intracapsular Tonsillectomy Surgery

The transition to intracapsular tonsillectomy from other techniques can be relatively seamless and can provide multiple benefits to patients and providers, such as reduced postoperative complications, lower bleed rates, and improved patient recovery. In Dr. Huoh’s experience, even surgeons who have been practicing with other methods for several years can adopt intracapsular tonsillectomy effectively. By witnessing the procedure in practice through in-person shadowing and guidance, as well as researching online videos of surgical technique, providers can learn how to make a successful transition in clinical practice.

[Dr. Gopi Shah]
If you're somebody that's been practicing 5 to 15 years and you've been doing, because I would say, wait, that's going to be the majority of the people that haven't transitioned over. It sounds compelling enough in terms of post-op pain and recovery, in terms of bleeding, even with the regrowth when you compare it to a potential post-op bleed and how difficult and complicated those can be. If somebody is interested, how should they start making that transition? What do you recommend for that?

[Dr. Kevin Huoh]
It's not hard to switch. I think it's never too late to switch to intracapsular tonsillectomy. Funny story is when I first came into practice at CHOC, I joined a group of three other otolaryngologists. Like I said, my partner, Nguyen Pham, had done a fellowship right before me. We started doing intracapsular together. The older partners, who were in their 50s and 60s, saw our post-op complications were much lower than theirs, lower bleed rates, didn't get the phone calls in the middle of the night. Our residents were happier, didn't have to come in to see tonsil bleeds.

Our senior partners just basically watched us do one or two in the OR and then they started doing it and they switched. Another one of my partners joined us three years ago. She had already been in practice for several years, and when she first joined us, she's like, "No, I'm just going to do bovie, that's what I've been doing," and then she had a bleed, and then she's like, "All right." Then she switched.

It's not a hard operation to learn. You're basically just ablating tissue. You can watch videos. There's a lot of videos online of intracapsular tonsillectomy. I would invite anyone. If you want to come out, visit Disneyland and watch me do some tonsils, now in this post-COVID era, we can do that again. If you want to come watch me do something, I'm happy to have anyone join me in the OR.

Podcast Contributors

Dr. Kevin Huoh discusses Intracapsular Tonsillectomy in Children on the BackTable 110 Podcast

Dr. Kevin Huoh

Dr. Kevin Huoh is a pediatric otolaryngologist and assistant professor in Southern California.

Dr. Ashley Agan discusses Intracapsular Tonsillectomy in Children on the BackTable 110 Podcast

Dr. Ashley Agan

Dr. Ashley Agan is a practicing ENT and assistant professor at UT Southwestern Medical Center in Dallas, TX.

Dr. Gopi Shah discusses Intracapsular Tonsillectomy in Children on the BackTable 110 Podcast

Dr. Gopi Shah

Dr. Gopi Shah is a practicing ENT at UT Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2023, May 16). Ep. 110 – Intracapsular Tonsillectomy in Children [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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