Alternative surgical technique of secondary puncture
Sometimes the introduction of a rigid esophagoscope can be difficult, making the standard secondary puncture technique too cumbersome, for instance in case of trismus or severe scarring of the neck. A good option then is the alternative procedure, described here. This procedure can also quite easily be performed under local anesthesia. Besides the instruments, used in the standard technique, a bendable uterine probe (Simm’s Uterine Probe EO 12, 330 mm (13 inch), with a 4 mm blunt tip, Aesculap, Tuttlingen, Germany) is needed. The curvature of this probe can be adjusted easily. Figure above shows the bent probe and the trocar and cannula, from which the cannula part is used in this procedure.
The probe is passed gently by feel through the mouth, pharynx and cervical esophagus towards the stoma. If needed, the curvature of the probe is adjusted according to the anatomical situation. The tip can be easily seen protruding (figure right top left) and palpated in the posterior tracheal wall. With the disposable scalpel of the original Provox package or any other scalpel with a sharp curved tip, the TE fistula is created by puncturing towards the tip of the probe at a distance of 5 mm from the mucocutaneous juncture (figure right top right).
The tip of the probe then can slide outwards through the fistula (next figure right). Next, the cannula is placed on top of the tip and with gentile pressure onto the probe passed into the esophagus (next figure right).
After removal of the probe, the remainder of the procedure is identical the standard secondary puncture technique, described earlier. The guide wire is passed through the cannula out of the mouth and the Provox prosthesis is attached (figure right bottom left). The guide wire is pulled back into the TE fistula and the prosthesis is rotated into the fistula tract by pulling onto the tracheal flange with two non-toothed hemostats. The last figure to the right shows the prosthesis in its proper place, high up in the stoma.