Centripetal endoscopic sinus surgery

Introduction:

Endoscopic sinus surgery has its own attendent complications. Intraoperative complications include bleeding, CSF leak, and periorbital damage. There are also short term complications which include infections, synechiae formation and lateralization of middle turbinate. Intraoperative complications can largely be avoided by scrupulously following meticulous surgical technique and precise anatomical knowledge.

Centripetal FESS technique:

Vertical incision is made in the nasal mucosa close to the anterior margin of the uncinate process. If the uncinate process is not clearly visible due to the presence of polypoidal changes the incision can be sited close to the posterior margin of agger nasi. The medial wall of the orbit is identified at the earliest and the dissection proceeds in the postero superior direction to the floor of the anterior cranial fossa (roof of the ethmoid) which should be identified in all cases. Dissection always proceeds in a direction parallel to the lamina papyracea. The bulla ethmoidalis is sectioned away from its attachment to the lamina papyracea using a scissors. It should be sectioned in a plane parallel to lamina papyracea. This dissection proceeds till the anterior wall of sphenoid sinus is reached. If need be the anterior wall of sphenoid sinus can be opened. The surgical plane formed by the junction of lamina papyracea as it joins the lateral wall of sphenoid sinus. If this plane is adhered to then damage to vital structures can be avoided.

If surgery is not contemplated in the frontal outflow tract then the superior portion of the uncinate process is left undisturbed.

This centripetal technique of ethmoidectomy begins at the periphery and progresses towards the centre.

Advantages of centripetal resection:

1. It provides wide exposure
2. It provides excellent hemostasis
3. This provides adequate lateral margins
4. Since the plane is dissection proceeds along the floor of anterior cranial fossa keeping medial to the medial wall of orbit, the surgeon need not bother about the variations in the ethmoidal lamella.