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LASER Assisted Stapedotomy
Surgery - David Gatland, UK
Capture, Editing, and Script - S Meghji, UK
Narration (Pending) - S Meghji, UK
An instructional video on the surgical technique of a LASER assisted stapedotomy for otosclerosis.
I always make an endaural incision to harvest the preauricular vein. You make your endaural incision in line with the top of the helix. Dissect around the vein.
Cut and clip both ends of the vein and tie.
Take the vein patch and place on the side with a bit of saline. Haemostase the surrounding tissue.
The endaural incision gives greater access than a canal incision.
Use a Hughes elevator or a spade elevator to lift the flap.
Never put the sucker on the flap.
Place the sucker behind the elevator.
As you raise the flap you will first see the annulus tympanicus, keep lifting the flap in a gentle semicircular manner.
The incus soon comes into view.
Do a scutotomy and identify the chorda tympani.
To perform the scutotomy you take the scutum down with a small curette in a slow measured movements.
Use the sucker to remove the pieces of bone.
You can slowly see the facial nerve canal coming into view.
You want to take the scutum back to see the pyramid where the tendon arises.
You may use a needle to assess the movement of the footplate.
The stapes footplates is rigid.
Take the time to fully mobilise the chorda tympani so that you don’t have a problem placing the prosthesis later.
Take a hook an separate the incustapedial junction.
Go back to the vein graft, get a fine elevator and place it in the middle of the vein graft.
Tease off the adventitia with a scalpel.
Then cut the vein open with a pair of micro-scissors.
Keep this to the side until it is needed, place a drop of saline on the patch.
Now is the time to make sure the theatre is laser safe.
Make sure all the doors are locked, all who are in the theatres have appropriate laser protective glasses and there are signs to alert that laser is in use in theatre.
Use 1 watt, 0.5 second single duration pulse.
Laser the posterior crura of the stapes and the superior stapes.
You then get a hook to disarticulate the stapes superstructure.
The anterior crus is very difficult to get at with a laser.
Some people use a mirror but if you laser the superior stapes and the posterior crura.
You can disarticulate the anterior crus with a hook.
A titanium smart prosthesis is used.
You can measure this by placing the prosthesis in to see where it sits. The footplate is very thickened, so by the time you make the hole in the footplate the prosthesis usually sits in the right position.
You need to make a hole in the footplate.
Place the laser at a setting of 0.5 watts, 0.5 seconds single pulse to make an initial hole in the footplate.
Laser carefully until you are through the footplate.
Do not suction on the actual hole you have made, suction around it. Then use a drill to make the hole uniform.
Place the vein graft over the hike in the footplate.
Slowly advance the prosthesis, use a hook to place the end of the prosthesis onto the incus.
Put the laser on a minimum setting 0.5 watts, 0.1 seconds single pulse. Two single laser pulses will soldier the hook of the prosthesis onto the incus.
You can see if you move the incuse the prosthesis moves and if you move the prosthesis it sits well in the footplate.
Finally you lay your tympanomeatal flap back carefully.
You can see now why you have to make your initial flap large so that it
can cover the scutotomy that you have made.
Use gelfoam to cover the flap you can then suture up your end aural incision with 4-0 vicryl rapid.
Clear the ear and then place a head bandage.

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