Tonsillectomy - Step-by-Step Surgical Guide with Instruments

Pre-operative Setup

Instruments List (Cold Steel Tonsillectomy)

Step-by-Step Operative Technique (Cold Steel Dissection)

Step 1 - Position and Exposure

• The patient is placed supine with a shoulder roll under the shoulders.
• The surgeon sits at the patient's head.
• A Crowe-Davis or McIvor mouth gag is gently inserted, fitting the endotracheal tube into the groove of the blade. The gag is opened to expose the oropharynx and suspended from a rack or held by an assistant.
• A Wieder tongue depressor depresses the tongue base further if needed.
• Bilateral tonsils are inspected and the procedure is usually started on the right side.

Figure: Dissection tonsillectomy showing grasping of the tonsil and snare placement (Bailey & Love's Surgery, 28th ed.)

Step 2 - Grasping and Medialization of the Tonsil

• The Allis clamp (or White tonsil clamp) is applied to the superior pole of the tonsil.
• The tonsil is pulled medially (toward the midline), which stretches and tautens the overlying mucosa, making the anterior pillar and tonsillar capsule border visible.

Step 3 - Mucosal Incision

• Using a No. 7 knife handle fitted with a No. 12 blade, an incision is made through the mucosa of the anterior faucial pillar at the medial edge of the tonsil, running from the superior pole downward.
• The incision stays just outside the tonsillar capsule to avoid entering tonsillar tissue and causing bleeding.

Step 4 - Identifying the Capsule Plane

• The Hurd dissector is used to retract the anterior pillar laterally and begin blunt dissection.
• The Fisher tonsil knife/dissector or curved Metzenbaum scissors is then used to identify the avascular plane of loose areolar tissue between the tonsillar capsule and the underlying superior constrictor and palatoglossus muscles.
• Dissection proceeds in this plane - staying outside the capsule avoids inadvertent entry into tonsillar tissue and minimizes bleeding.

Step 5 - Dissection from Superior to Inferior Pole

• Using the Fisher tonsil dissector (and supplemented by gauze-on-forceps blunt dissection), the tonsil is progressively freed from its bed:
  • Start at the superior pole
  • Work around the lateral surface
  • Continue to the inferior pole (where the attachment to the lingual tonsil remains)
• The Hurd dissector retracts the posterior pillar and helps expose deeper tissue planes.
• A small inferior pedicle remains at the end of this dissection.

Step 6 - Removal of the Tonsil (Snaring)

• The Tyding tonsil wire snare is passed around the inferior pedicle of the tonsil.
• The wire is tightened and the tonsil is amputated at the inferior pole, severing its attachment to the lingual tonsil.
• The snare wire must pass freely through the shaft - any resistance can cause tearing and bleeding.
• The tonsil is removed and sent for histopathology if indicated.

Step 7 - Haemostasis

• A tonsil sponge (held in Foerster-Ballenger sponge forceps) is packed into the tonsillar fossa and firm pressure is applied for 2-3 minutes.
• The sponge is removed and the fossa inspected for bleeding.
• Bleeding vessels are controlled by:
  • Ligature (suture ties) using the Baum tonsil needle holder and absorbable suture (e.g., Vicryl or silk)
  • Negus artery forceps to clamp vessels before tying
  • Bipolar diathermy forceps for coagulation of small bleeding points
• The same procedure is then performed on the contralateral (left) tonsil.

Step 8 - Final Check and Closure

• Both tonsillar fossae are inspected thoroughly for residual bleeding.
• The mouth gag is carefully released and removed.
• The pharynx is suctioned with a Yankauer sucker.
• The patient is turned to the lateral (recovery) position before extubation to prevent aspiration of blood.

Hot/Diathermy Technique (Most Common in the US)

• The Allis clamp grasps and medializes the superior pole.
• The lateral tonsil edge is identified submucosal.
• The cautery incises the superior pole, and the avascular plane is developed using the cautery tip.
• The entire tonsil is removed from superior to inferior pole.
• Haemostasis is maintained continuously with the cautery throughout the dissection.

Coblation Technique

• Uses an Arthrocare Evac plasma wand (Coblation device) with saline irrigation.
• Creates a plasma field of ionized particles that dissociates tissue at low temperature (40-70°C), minimizing heat damage to surrounding tissue.
• Two variants: extracapsular (total removal) or intracapsular (partial - leaves a thin capsule layer).
• Particularly popular for paediatric cases given lower post-operative pain.

Post-operative Care

• Patient placed in the lateral/tonsil position on recovery to allow blood/secretions to drain from the mouth.
• Closely observed for reactionary (primary) haemorrhage in the first few hours.
• Oral fluids encouraged early; a normal diet is resumed as soon as tolerated.
• Secondary haemorrhage (5-10 days post-op, due to sloughing of membrane) is the main late complication.

Summary Table of Key Instruments and Their Role