This article was first published at SinusDoctor by Dr.G V K Chaitanya Rao, a member of American Rhinologic Society (ARS) and European Rhinologic Society (ERS), and has 10+ years of experience in the field of ENT.
If there is one thing all surgeons are afraid of while performing surgery it is sudden and uncontrollable bleeding. Any kind of bleeding, actually. Among them (particularly for ENT surgeons!), one of the parameters of individual skill and technique is the amount of blood a patient loses during surgery. Of course, things are not that simple, there are a lot more factors that define a surgeon’s skill, but a tendency to trigger massive bleeding is definitely something any surgeon wouldn’t be proud of.
Blood is essential for life. The problem is, it supports all kinds of life – it is an exceptional breeding ground for several microorganisms. This is important because infections are more likely to develop as a complication of surgery if there is a significant amount of blood in the operating field. Also, it blocks the view – paints the operating field in plain red making quite difficult for the surgeon to differentiate between tiny anatomical structures in the area.
The idea of bloodless cuts occupied doctors’ minds for decades before it became a reality – Laser and Coblation surgery made it possible.
Before jumping into details, let’s just say that these two techniques made cutting of soft tissues such as nasal polyps or tonsils, and reduction of turbinates a lot easier, safer and quicker.
What’s the difference between those two, you might ask? Well, for now, let’s just say they achieve the same result by different means.
Coblation
The term Coblation comes from two words – controlled and ablation. Those two root words perfectly describe what happens during the procedure – by generating plasma field in highly controlled conditions with extreme precision, the surgeon treats the target tissue and peels it layer by layer. Plasma field causes denaturation of proteins in the tissue.
Denaturation is a biochemical process in which an organic molecule loses its properties and solidifies or dissolves. An excellent example of protein denaturation is boiled eggs –in high temperatures, egg white hardens and what used to be a colorless liquid turns into white condensed matter.
In the case of Coblation, to the naked eye, it looks as if the tissue melts, dissolves and simply disappears under the beam of plasma. This comes particularly handy in cases when the target tissue is small, so small it’s hard just to cut it off. For example, nasal polyps can grow in large numbers and be very small in size, therefore proving to be difficult to remove by cutting.
A significant advantage of Coblation is it’s a cold technique, meaning it does not use thermal energy to achieve the denaturation of the proteins in tissue. This comes particularly handy in situations when it’s crucial to spare as much of the deeper and surrounding tissues as possible, which is the case with the nasal cavity. Deeper tissue damage may lead to complications such as scarring or obstructions of the communication canals between the nasal sinus cavity and Coblation significantly reduces the risk of such complications.
Another advantage of Coblation over Laser surgery is the absence of smoke and vapor (which in some cases cause the spread of an infection).
However, it’s not a perfect technique. Low temperature and limited field of denaturation come with a price – compared to laser surgery, bleeding episodes are more likely. This is not a big issue when the target tissue has poor circulation, but in cases of large polyps with rich blood flow and other soft tissue changes that have a tendency to bleed a lot, Laser might be a better solution.
In the end, it’s the surgeon’s decision which technique to pick, the choice depends on many factors.
Laser Surgery
Laser surgery has been around for a long time. CO2 laser system is the most commonly used one in ENT surgeries, but other technologies are in use as well. Unlike Coblation that dissolves the tissue, laser cuts through it with high precision by using pulses of light energy that heat up and almost instantaneously vaporize water in the target tissue, which causes the above mentioned denaturation of proteins.
The laser pulse is so small, the surgeon can navigate it with the precision of a fraction of a millimeter. Since it acts like a knife, the laser is ideal for cutting off large pieces of soft tissues. ENT surgeons extensively use laser technology for different pathologies in their operating field. Removal of nasal polyps, turbinate reduction, resection of carcinomas are just some of the conditions treated with this technology.
Before the blood leaks, tiny blood vessels are closed by the process of protein denaturation. This comes particularly handy when a surgeon needs to cut through the tissue with rich circulation. Also, due to the precision of the laser beam, the technique is suitable whenever pinpoint precision is a must.
Instant vaporization comes with a price. Compared to Coblation, thermal penetration is significantly higher, so deeper tissue damage is inevitable. Sometimes this is unacceptable because of the close anatomical relation between the target tissue and essential blood vessels or nerves. To clear the air a bit, deeper tissue means about a fraction of a millimeter! However, the lining of the nasal cavity is exceptionally important for proper sinus drainage, and sparing it as much as possible is one of the core principles of Sinus surgery.
Modern ENT surgery has advanced so much and so rapidly in the last 50 years that we can now fight for every layer of cells in the lining. So when discussing the advantages and disadvantages of different techniques, we are essentially talking about fractions of a millimeter or single-digit percentages in outcome improvement.
Recovery Time
Minimally invasive surgery, and particularly Laser and Coblation techniques, have shortened recovery time drastically. Hospital stay almost exclusively nowadays depends of the type of anesthesia. Both procedures can be carried out under local anesthesia when the patients return home the same day. Sometimes, general anesthesia is chosen, and in such cases, the patient stays at the hospital overnight.
Mild local irritation as a result of surgery of the tissues can cause temporary swelling, stiffness, and mild pain in some patients. But it typically resolves in 2-3 days. Some patients (severe cases) require a bit longer recovery time that lasts up to a week at the most.
Of course, the recovery period also depends on how extensive the procedure was. Removal of big polyps that covered a large surface of the nasal lining requires longer recovery than the removal of one big polyp with a narrow attachment to the lining.
Which one is better?
These two techniques do not compete with each other, but rather complement each other. The choice of the treatment method is on the surgeon and depends on several factors such as severity of the condition, its clinical presentation, patient’s age, anatomical relations in the area, co-morbidities and many more.
Generally speaking, Laser surgery is the preferred option in cases of extensive soft tissue lesions such as a single nasal polyp that needs to be cut off, while Coblation is recommended for smaller multiple surface lesions such as nasal polyposis.
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