Application of natural orifice transluminal endoscopic surgery (NOTES) instrumentation to the endolarynx

Objectives: RealHand instruments are high-dexterity instruments that have been designed for natural orifice transluminal endoscopic surgery applications. They provide dexterity by offering a full range of motion to endoscopic instruments. We hypothesize that RealHand instruments will resolve some of the limitations encountered in traditional endolaryngeal surgery. They have the potential to do so in the following ways: 1) they negate the limitation of mobility of traditional laryngoscopy instrumentation, which is rigid and fixed; 2) they maintain the ability of direct visualization through a telescope while precluding the need for an operating microscope; 3) they provide the dexterity to perform tasks that are otherwise not possible with traditional instrumentation; and 4) they provide flexibility that can be advantageous in difficult foreign body retrieval from distal airways. Methods: To test this hypothesis, we developed and optimized a cadaveric lamb larynx model for endolaryngeal microsurgery. To evaluate the feasibility of the RealHand instruments in their application to laryngeal surgery, we had 2 otolaryngology senior residents and 2 laryngology fellows-in-training perform 5 different endoscopic tasks: 1) foreign body removal; 2) arytenoidectomy; 3) microflap elevation; 4) cricopharyngeal myotomy; and 5) endoknot suture tying. Results: Experience with RealHand instruments demonstrated that although they are limited in application to phonosurgery, they have the potential for more facile tissue manipulation in the supraglottic and hypopharyngeal structures. Endoscopic suturing ability is enhanced. Conclusions: RealHand high-dexterity instrumentation allows for full range-of-motion instrumentation and, with modification, has potential for wider application in endoscopic laryngeal surgery.