Transcription
Hello, I'm Marcus Hess from the Medical Voice Center in Hamburg, Germany, and this is my colleague Susannah Fleischer. We will show you how we perform endoscopy.
There are several ways to hold the handle. One way is ruling this lever of the endoscope with a thumb, so that the tip of the endoscope moves according to my thumb's movement. This is the way how the gastroenterologists handled endoscopes. There's a second way how to handle this. This is when the endoscope is held like this, and then the tip of the endoscope is again ruled with the thumb. But as you can see, I'm directing this handle towards the patient's nose. Some colleagues prefer this. I think that it sometimes is a little bit awkward because you need this thumb for opposing.
There's a third way how to hold this endoscope. You just rotate it 180 degrees and hold the endoscope with your finger here. Your thumb is opposing, and then with your index finger you can also move the tip. As you see, I like this position because here the handle is directed towards the patient, and even with the other fingers you can stabilize the handle. And then you have the index finger to do the movements. We will see later that this also is advantageous for the four-way and the scope.
There are different ways how to hold an endoscope. So first, let me show you how the gastroenterologists hold an endoscope. Here you have two levers, 1 and 2, and they are handled with a thumb, as you can see here. If you want a special position, so let me show you the tip of the endoscope like this or like that, you can lock one position by putting this little button up and down this little lever. So this is the locked mode, as you can see. This stays here, and if I release it, then it levels again to the normal position. The same is true for the longer one, the bigger one, and then I can go up and down like this, and I can also fix it or lock it in any position that I want to, this position or in this position.
However, if you want to do endoscopy in the larynx where the target is moving, I think you need two fingers to control these two levers. That's why I prefer the index finger and the middle finger to control these two levers. This means that you have to hold the endoscope in a way that you control with your fingers the levers, and then you have to, of course, hold the endoscope. And I'm doing that with my thumb here, and with these fingers I'm holding this cable, which means it is a stable position. The stable position is even given if I do not touch the two levers. The advantage is that one finger controls the left right, and the other one the up and down. We will see that in a video shortly.
There are some colleagues who also like to drive the levers with their thumb, but again in this position here you have only one finger, the thumb, to control for two levers, and then you would have to take your other hand and then control the lock unlock switch. That's why I would recommend to hold the endoscope like this, so that the two levers are controlled like here. And then if you're right-handed, you can also hold the endoscope. Even if you miss and do not control very well, you can always catch your endoscope. It does not slide off.
I want to demonstrate to you how a flexible endoscope with an inside channel functions, and there are a couple of devices that you should know of. Now the flexible endoscope that is channeled has actually two inlets, one here and one there. These form a Y, and they come together here and follow one channel all the way to the end here. Of course, the endoscope also has an illumination source and has a little lens so that we can see what's happening inside. If you have these two channels, the question arises which channel is used for what. Now this channel here, the lower one, is used for instruments like biopsy forceps or glass fibers for lasers, or it's used for injections. We need an airtight seal here because if we want to in parallel suction air or secretions out of this inlet, then the air will be sucked out of here. That means we have to seal this one with a snap-on device. This is single use, as you can see. When you want to snap it on, you have to apply some force, and now it snaps on. You cannot detach that from now on unless you really break it. I will do that afterwards and show you. For up here you can see this is all metal, and inside there's a smaller inlet, and this is basically meant for inserting this little device here where you can put your suction tube on, and this has to have an airtight seal, and it comes with this little rubber here, and this little rubber is inserted as well here. So I will snap it on, and now it has a fit. This one can be detached and put on again. The tubing for the suction goes over here and functions like this. When you close this, then it sucks out. If you do not press on this button, the air comes through here and does not suck on your tip of the endoscope. So this is how you go inside via two inlets down here for instrumentation, glass fiber, biopsy forceps, and injection tube. This is for suction with this little device.
We also have some other little buttons on here. This endoscope has four buttons, one, two, three, four, and you can control these buttons, and you can I individually put different kinds of tasks on these buttons, for instance, photo or start and stop the video stills, etc. We also have two levers, as you can see here. This is a small lever, and it controls this endoscope like here, and the other lever goes exactly in the 90 degrees different direction, as you can see here. That means with these two levers you can go all four ways with the tip of your endoscope. There are two more little levers here, as you can see. This is the F, and it means lock and unlock. Let's see what happens when I put this lever up here and down here. You can see I can control or free it, unlock it. The lever is easily moved and goes to a neat neutral position, whereas when I put it in this position and I want it fixed here, then I put it in this position and it stays. Unlock again, and then it goes to neutral. The same is true with this one over here.
Now in laryngology we want to do a couple of things in the larynx, which means we want some instrumentation. The instrument that is easily used and makes sense for biopsies or when you manipulate inside of the larynx, you want to put in a biopsy forceps. They're different biopsy forceps, and I want to talk about these forceps. So they come in as single use, and as you can see they are controlled with this handle over here and this little opening here. I hope you can see that, and this is open, closed, and sometimes you want it halfway open. And if you have a nicely training, you can see that you can open it all the way, half the way, closed. The different devices here is like in this one, they have a little some teeth, so they will bite into the tissue. You can also have that without the teeth, but that's whatever you want and need. If you want to insert that into the endoscope, of course you have to straighten out this cable so that it comes straight, and you want to close the forceps while you insert it like this. So in the closed position you can go in, and you want to go through this airtight sealed little cap, and then you push it through because there's a tiny little hole. And when you insert it, you can do that before you insert the endoscope into the patient's nose and all the way to the larynx, or you can do it while the endoscope is outside.
Now to easily advance this instrument, best is to keep it straight and then advance. For demonstration purposes I will bend it here so that you can see the tip. When it comes out, it is very important for the surgeon to have a feeling how easily does that move inside, and you will see when you do operations that it's always advisable to have a contact to the handle and then advance your instrument. As you can see here with two fingers, don't do it like this, because as you can see it shakes the handle of the endoscope. So you always want to have a fixed contact, and sometimes these little movements make a big difference. We will talk about the advancement and retraction later. I want to show you now that if this little part is sticking out only a little bit, it will not open. Now let me try to open and close it. You can see it tries to move but cannot. So you need at least a minimal distance, so that you need a minimal distance so that this head can move and open and close like this. I advise that you try out where is the minimum that you have to advance your instrument so that you can do an operation within the larynx. Sometimes it is also very helpful when you keep a long distance to your target and advance your instrument, but keep in mind the further it is away the target from the lens, the less you see, the less you have control what is happening, you do not have the resolution of the image. So most times it is good to have a distance something like that. When you do an operation you can see, oh this is now a fixed opening angulation, maybe you want to have that turned like 90 degrees in another direction. Let's see what happens if I try to turn it here. You will see that it's not easy, even if I apply some force here, I cannot move that. What is more easy is when you have the endoscope in a straight position, so you have less resistance inside, and then let's open, close, keep it open just for demonstration purposes, and as you can see now I can turn it. I bend it again, and it has too much resistance. This can also happen when I fix my lever. I will do that right now, and if I now try to turn it, you see it's almost impossible. So for turning of this biopsy forceps, it is advisable to first close it and then turn it. Sometimes it's easier, let's say you are in the larynx and you cannot straighten the tip, then you retract it, then you turn it inside, and then you push it out again, and then it has a different turn.
For inserting the adapter for suction, you have a single-use adapter that snaps into here, and it has a tight airtight seal. When you press this button, when you press this button, a suction tube can suction out the air and the secretion that is in here. It will not suck anything from here because this is, although it has a little pinhole, a very airtight ceiling. So this is the way out of secretions, and everything you want to put into the endoscope comes from this inlet. How does this function? As you saw right here, there's a spring in here where you can suck, not suck, and you can take this out very easily. It has a little rubber part here for the ceiling inside. So what happens if you have the endoscope inside the nose, in the hypopharynx or larynx, and you want to anesthetize? Then you take a normal syringe filled, let's say with lidocaine, and we want it in here, so it comes in through this little rubber part adapter, and then you can squeeze in your anesthesia. If you need another one, you take it out again, refill, insert, and put in like this.