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 Table of Contents  
IDEA AND INNOVATION
Year : 2017  |  Volume : 4  |  Issue : 3  |  Page : 192-194

Double-angled palatal needle holder: An innovative instrument for cleft surgeries


1 Department of Plastic, Aesthetic and Microvascular Surgery, ASTER MIMS Hospital, Calicut, Kerala, India
2 Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

Date of Web Publication21-Nov-2017

Correspondence Address:
B S Bibilash
Department of Plastic, Aesthetic and Microvascular Surgery, ASTER MIMS Hospital, Calicut - 673 016, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jclpca.jclpca_69_17

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  Abstract 

Introduction: The devices used for cleft surgeries are different from the routine plastic surgical ones. The currently available needle holders for palatal surgeries do not address many issues like poor visibility and excessive strain for the surgeon's dominant hand. We present an innovative needle holder which could alleviate these problems. Materials and Methods: The new needle holder was inspired from the design of a Magill forceps. It was modified to a needle holder and later on the angles were adjusted for using in palatoplasty surgery. Results: The final device had following advantages: Surgeon's hands are outside the target visual field and no blind spots or shadows in the field, surgeon's wrists, elbows and shoulders were in a more comfortable position while operating from the head end. Conclusion: The double angle needle holder was really useful for oral surgeries especially palatoplasty. The position of the surgeon's hands was more comfortable; they had better visibility and was easier to maneuver.

Keywords: Needle holder, Palatoplasty, Cleft palate


How to cite this article:
Bibilash B S, Kumar S D, Chittoria RK, Mohapatra DP, Friji M T, Krishnakumar K S. Double-angled palatal needle holder: An innovative instrument for cleft surgeries. J Cleft Lip Palate Craniofac Anomal 2017;4, Suppl S1:192-4

How to cite this URL:
Bibilash B S, Kumar S D, Chittoria RK, Mohapatra DP, Friji M T, Krishnakumar K S. Double-angled palatal needle holder: An innovative instrument for cleft surgeries. J Cleft Lip Palate Craniofac Anomal [serial online] 2017 [cited 2022 Jan 27];4, Suppl S1:192-4. Available from: https://www.jclpca.org/text.asp?2017/4/3/192/218886


  Introduction Top


Cleft palate surgery is unique, by its long history of evolution and the variety of procedures described by pioneer cleft surgeons to the present innovators. The devices used for cleft surgeries are different from the routine plastic surgical ones.[1] The primary instruments used for a cleft palate surgery have undergone various modifications during the timeline but still awaiting the ideal ones.[2],[3] Moreover, the surgeon has to keep his shoulder abducted and wrist flexed during the surgery, which is an uncomfortable position for longer durations. We present an innovative needle holder which could alleviate these problems.


  Materials and Methods Top


We are introducing a new needle holder by combining the design of a Magill forceps and a straight needle holder.[4] The author himself has tried various available needle holders during cleft surgeries and on simulators. The disadvantages noticed were mainly poor visualization of the operative field and uncomfortable position of the wrist, elbow, and shoulder.

The idea of the new instrument was inspired from the Magill forceps. To the pediatric Magill forceps, we added a needle holder jaws with adequate length and ratchets near the ring. The screw joint of the Magill forceps was replaced with a box joint which suits a needle holder. We have made it a needle holder using moldable metal (copper), and the angles were adjusted for the new use. The instrument was made lighter so that surgeon can use it for longer durations with less physical strain.

The angles were adjusted in such way that the needle faces the suturing surface at right angles when the surgeon's elbows are flexed and forearm in a prone position. Later, the length of the jaws reduced to attain more precision [Figure 1].[5] A mirror image instrument was made for left-handed and ambidextrous surgeons.[6] The proximal angle was made more obtuse and twisted the plane between the closing surfaces little more for a better needle position and backhand bites.
Figure 1: Double-angled palatal needle holder with its convex side up

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The instrument can be used for any kind of oral surgeries, especially when the surgeon is operating from the headend such as palatal, alveolar, and pharyngeal surgeries [Figure 2]. It can be used for other surgeries too when the surgeon needs to operate in a deeper plane through a small opening.
Figure 2: Cleft surgeon using the needle holder for a palatoplasty

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  Results Top


The final device was manufactured and used for the cleft surgeries by four different surgeons. Till date, we have used it for >25 cases. The advantages noticed were: surgeon's hands are outside the target visual field and no blind spots or shadows in the field, surgeon's wrists, elbows, and shoulders were in a more comfortable position while operating from the headend [Figure 3]. All four surgeons found that the forehand suturing is easier compared to the backhand sutures using this instrument.
Figure 3: Mirror image comparison of the same surgeon using the double-angled needle holder (left) and the normal straight Ryder needle holder (left). The more comfortable position of the wrist and elbow in the left figure is noticeable

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  Discussion Top


Proper instruments always make the surgeon's job easy. Surgeons were always hunting to find proper instruments which can reduce their effort. Cleft surgeries are unique because of the demand for higher esthetic and reconstructive skills. A proper three-dimensional orientation and fine hand skills are the fundamental need for a cleft surgeon. Stability of the hand and proper visualization becomes very important then.

Magill introduced a new forceps in 1920 for intratracheal anesthesia.[4] Nowadays, it is being used by anesthesiologists and laryngeal surgeons for different purposes. It is a distinct instrument by its peculiar curves. It is an essential component of an anesthesia workstation. The potential of it being used as a needle holder was noticed by the author. The grip, length, angles, and weight of the device were adjusted to make it a needle holder.

Edlich et al. described the principles of designing a needle holder.[5] The length proportions of an ideal needle holder are mentioned with the effective force available for the needle gripping.

Boo-Chai described three new instruments for cleft lip and palate repair.[1] The needle holders are better used for cleft lip surgeries than palate, but the scissors are useful for the palatal dissection.

Ameer et al. have mentioned the evolution of palatal gags and its time frame.[2] The gags have undergone extensive modifications for the fine use such as the Agarwal modification.[3] Even though there are different types of needle holders used by cleft surgeons, there is no consensus which is the better, and they have not really evolved with time.

Todd, in 1912, designed a palatal needle holder.[7] It had the advantage of better visualization at an expense of easiness of handling. The angles were more acute, the screw joint was too distal, and the bows needed to be abducted more. These technical issues made this instrument to lose its popularity. There is an extra angulation for our new needle holder. The joints are box joints, and the fulcrum is placed more proximally for improving the maneuverability. Furthermore, with the double angles, the tip is more in line with the shanks giving it a better control.

Other historical palatal needle holders worth mentioning here are the Mehendale's needle holder and Arbuthnot Lane's needle holder.[8],[9] Mehendale's needle holder is an ergonomically designed instrument with a pencil grip and spring action for the easiness of handling and better visibility. The problems were the strain for small muscles of the hand, and the surgeon's hands were not completely out of the field. Arbuthnot Lane's needle holder which was published in 1902 was a long linear device with a proximal handle and a switch for opening the needle holder tip. It did not become much popular because of the steep learning curve and fine handling difficulties.

The author first made a prototype instrument using a moldable metal. It has undergone modifications on simulators, and the final instrument was made using surgical-grade stainless steel. After being used for multiple cleft palate surgeries, the instrument has undergone fine-tuning to be an ideal one for a palatoplasty. The existing issues are the learning curve and handedness.


  Conclusion Top


The double-angle needle holder was found to have been really useful for oral surgeries, especially palatoplasty. All four surgeons reported that the position of the hands was more comfortable; they had better visibility and were easier to maneuver. The new instrument has a shallow learning curve and was well appreciated by senior cleft surgeons.

Acknowledgment

We would like to extend our sincere thanks to Mr. SudhakaranPfor his help in making the final instrument in the present form by providing his technical support and JIPMER Smile Train Cleft Project for the scientific and clinical support.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Boo-Chai K. Three surgical instruments for cleft lip-palate repair. Br J Plast Surg 1971;24:216-7.  Back to cited text no. 1
[PUBMED]    
2.
Ameer F, Singh AK, Kumar S. The story of mouth gags. J Cleft Lip Palate Craniofacial Anomalies 2014;1:70-7.  Back to cited text no. 2
    
3.
Agrawal K, Panda KN. Modified palate mouth gag tongue blade to prevent endotracheal tube compression. Plast Reconstr Surg 2005;116:857-9.  Back to cited text no. 3
[PUBMED]    
4.
Magill IW. Forceps for intratracheal anaesthesia. Br Med J 1920;2:670.  Back to cited text no. 4
    
5.
Edlich RF, Towler MA, Rodeheaver GT, Becker DG, Lombardi SA, Thacker JG, et al. Scientific basis for selecting surgical needles and needle holders for wound closure. Clin Plast Surg 1990;17:583-602.  Back to cited text no. 5
    
6.
Adusumilli PS, Kell C, Chang JH, Tuorto S, Leitman IM. Left-handed surgeons: Are they left out? Curr Surg 2004;61:587-91.  Back to cited text no. 6
[PUBMED]    
7.
Todd GM. Cleft palate needle-holder. JAMA 1912;LIX: 2127.  Back to cited text no. 7
    
8.
Kirkup J. Arbuthnot lane's cleft-palate needle-holder. J Med Biogr 2005;13:72.  Back to cited text no. 8
[PUBMED]    
9.
Shrotriya R, Agrawal K, Puri V. Revisiting mehendale's needle holder for cleft palate surgery: A gift from the bygone era. Indian J Plast Surg 2016;49:293-4.  Back to cited text no. 9
[PUBMED]  [Full text]  


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Materials and Me...
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