SIALENDOSCOPY - KARL STORZ Endoskope · SialendoScopy The endoscopic approach to Salivary Gland...

Francis MARCHAL

SIALENDOSCOPYThe Endoscopic Approach to

Salivary Gland Ductal Pathologies

SialendoScopyThe endoscopic approach to

Salivary Gland ductal pathologies

Francis MaRcHal, Md, FacS

Professor of Otorhinolaryngology, Head and Neck Surgery Department of ORL, Head and Neck Surgery

University Hospital of Geneva, Switzerland

Director of the European Sialendoscopy Training Centre, Geneva, Switzerland

Founder and General Secretary of the European and International Salivary Glands Societies

Preface

Sialendoscopy is a prime example of the shifting paradigms in surgery which have irrevocably changed the landscape of our specialty. Other minimally invasive procedures such as: transoral CO2 laser surgery of the larynx, endoscopic- assisted thyroid surgery, functional endoscopic sinus surgery, and robotic surgery have been made possible through the close co-operation between surgeons and industry. These remarkable advances in our specialty, driven by the development of innovative technology, have made minimally-invasive surgery readily available for the benefit of our patients.

The development of endoscopes, tiny enough to be inserted into salivary ducts, was pioneered by Karl Storz (1911–1996). Professor Francis Marchal, in close collaborationwithKARL STORZ,developedaseriesofminiaturizedinstrumentswhich can be inserted through the endoscope to accomplish a variety of important tasks, such as pulverizing calculi with a laser, retrieving calculi with a forceps or a basket, biopsy of lesions, removing granulation tissue, dilating stenotic ducts, and irrigating ducts clogged with mucous such as those that develop secondary to treatment.

The new paradigm in the management of sialadenitis and calculi has in large measure eliminated the need to remove salivary ductal stones or non-malignant salivary glands by open surgery. This new approach has modified our thinking about these problems and has resolved many of the complications inherent in the open approaches.

Successful application of sialendoscopy, as with all minimally invasive procedures, requires a well-organized training program. Surgeons from around the world have attended the many courses that Professor Marchal has organized in Geneva and many other countries around the world.

In these courses, didactic material is supplemented by a robust “hands-on” animal laboratory experience as well as observation of live surgery dispensed in 3D in the conference room. Such an intensive educational experience is necessary to assure a firm foundation for the surgeon wishing to perform sialendoscopy.

Research is another important element in this area of our specialty. The European Salivary Gland Society (ESGS) was formed to promote research in this area, and includes members from: Basic Sciences, Dental and Oral and Maxillofacial Surgery, Otolaryngology – Head and Neck Surgery, Pathology and Radiology all of whom have a particular interest in salivary gland disorders. The ESGS organizes courses and conferences, promotes teaching and designs consensus protocols for European Standards through multi-disciplinary efforts.

Eugene Nicholas Myers, M.D., F.A.C.S., F.R.C.S., Edin (Hon)

Distinguished Professor of Otolaryngology University of Pittsburgh School of Medicine, Pittsburg, PA, U.S.A.

Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies6

Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies

Francis Marchal, MD, FACS Professor of Otorhinolaryngology, Head and Neck Surgery Department of ORL, Head and Neck Surgery University Hospital of Geneva, SwitzerlandDirector of the European Sialendoscopy Training Centre, Geneva, SwitzerlandFounder and General Secretary of the European Salivary Gland Society and the International Salivary Gland Society Editorial Board of: ‘The Laryngoscope’ and ‘The Annals of Otology, Rhinology, and Laryngology

Correspondence address of the author: Francis Marchal, M.D., FACS 16, Cours de Rive CH-1204 Geneva, Switzerland Phone: +41 22 735 72 47 Fax: +41 22 735 70 58 E-mail: [email protected] Internet: www.sialendoscopy.com

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Sialendoscopy – The Endoscopic Approach to Salivary Gland Ductal Pathologies 7

Table of Contents

1.0 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

1.1 History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81.1.1 History of Endoscopy . . . . . . . . . . . . . . . . . . . . . . 81.1.2 History of Sialendoscopy . . . . . . . . . . . . . . . . . . . 8

1.2 Disease Process of Sialadenitis . . . . . . . . . . . . . . . . . . . 91.3 Historyand PhysicalExaminationof

Sialadenitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

2.0StandardDiagnosticApproaches . . . . . . . . . . . . . . . . . . . . 10

3.0 Diagnostic Sialendoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . 11

3.1 LSDClassificationSystem . . . . . . . . . . . . . . . . . . . . . . . 113.2 NormalAnatomyoftheSalivaryDuctSystem . . . . . . . 12

3.2.1 TheDuctalSystem . . . . . . . . . . . . . . . . . . . . . . . . 123.2.2 Submandibular Sialendoscopy . . . . . . . . . . . . . . 133.2.3 Parotid Sialendoscopy . . . . . . . . . . . . . . . . . . . . . 133.2.4 Sialendoscopy in Case of Sialadenitis . . . . . . . . 13

3.3 PathologicalFindings . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.3.1 Mucous Plugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143.3.2 Sialolithiasis–MultipleStones,Various

MorphologiesofSalivaryStones . . . . . . . . . . . . . 153.3.3 Ductal Stenosis . . . . . . . . . . . . . . . . . . . . . . . . . . . 163.3.4 Polyps and Tumors . . . . . . . . . . . . . . . . . . . . . . . . 16

3.4 ClassicalApproachtoSialadenitis . . . . . . . . . . . . . . . . 173.4.1 MedicalTreatmentandExternalSurgery . . . . . . 173.4.2 ExtracorporealLithotripsy . . . . . . . . . . . . . . . . . . 17

4.0 InterventionalSialendoscopy. . . . . . . . . . . . . . . . . . . . . . . . 18

4.1 StoneRemovalbyuseofaWireBasket . . . . . . . . . . . . 18Wharton’sDuct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18Stensen’sDuct. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

4.2 StoneRemovalbyUseofaWireBasket, precededbyLaserFragmentation . . . . . . . . . . . . . . . . . 20

4.3 Sialendoscopic Treatment of Stenosis. . . . . . . . . . . . . . 214.4CombinedTechniques . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

4.4.1 CombinedTechniquesforthe Submandibular Gland . . . . . . . . . . . . . . . . . . . . . . 22

4.4.2 CombinedTechniquesforthe Parotid Gland. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

5.0TechniqueofSialendoscopy. . . . . . . . . . . . . . . . . . . . . . . . . 23

5.1 Indications and Contraindications . . . . . . . . . . . . . . . . . 235.2 Operating Room Set-up. . . . . . . . . . . . . . . . . . . . . . . . . . 235.3 AnestheticTechnique . . . . . . . . . . . . . . . . . . . . . . . . . . . 235.4 Step-by-StepTechnique . . . . . . . . . . . . . . . . . . . . . . . . . 24

5.4.1 Parotid Sialendoscopy . . . . . . . . . . . . . . . . . . . . . 245.4.2 Submandibular Sialendoscopy . . . . . . . . . . . . . . 24

5.5 Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.5.1 SalivaryProbes . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.5.2 Conic Dilator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.5.3 HollowRigidBougies . . . . . . . . . . . . . . . . . . . . . . 255.5.4 Forceps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.5.5 Sialendoscopes . . . . . . . . . . . . . . . . . . . . . . . . . . . 255.5.6 DisposableDevices. . . . . . . . . . . . . . . . . . . . . . . . 25

5.6 InherentLimitationsofSialendoscopy . . . . . . . . . . . . . 265.6.1 SignificanceoftheTipDesign . . . . . . . . . . . . . . . 265.6.2 SignificanceoftheBevelledTip . . . . . . . . . . . . . 265.6.3 SignificanceofLateMarsupialization . . . . . . . . . 26

5.7 PostoperativeCare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

6.0Workflow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

6.1 DecisionalAlgorithms . . . . . . . . . . . . . . . . . . . . . . . . . . . 276.2 RecommendedEquipmentforBeginners:

BasicSet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 286.3 RecommendedEquipment:

AdvancedSet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28

7.0 Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

7.1 Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297.2 TheEuropeanSialendoscopyTraining

Center (ESTC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297.2.1 AimsoftheESTC. . . . . . . . . . . . . . . . . . . . . . . . . . 297.2.2 Hands-on Training . . . . . . . . . . . . . . . . . . . . . . . . 297.2.3 Conferences . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297.2.4 LiveSurgeryin3D. . . . . . . . . . . . . . . . . . . . . . . . . 307.2.5 CoursesforBeginnersandAdvancedCourses . 30

7.3 CourseEvaluation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

8.0 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

SialendoscopyBasicandAdvancedSetsforDiagnosisandTreatmentoftheParotidandSubmandibularGlandsas recommended by Prof. MARCHAL . . . . . . . . . . . . . . . . . . . . . . . . 34


1.0 Introduction

1 Hippocrates (460–370 BC).

a

1 Thomas Wharton (1614–1673).

b

1 Karl Storz (1911–1996).

e

1 Nicolaus Stenonius (1638–1686), Well come Institute Library, London.

c

1 Caspar Bartholin (1655–1738).

d

1.1.1 History of EndoscopyThe first endoscope, of a kind, wasdeveloped in 1806 by Philippe Bozzini but not introduced in a human until 1853. In 1911, a procedure termed ‘Laparo thorakoskopie’ was introduced. Its use in the abdomen was extended by Heinz Kalk in 1930. In 1953, Karl Storz (1911–1996) developed and produced the first endoscope. In January 1957,Basil Hirschowitz (*1925) invented the glass fiber for use in flexible and rigidscopes,and in thiswaypioneeredflex-ible endoscopy. The first laparoscopiccholecystectomy was performed in 1984 and further generalized in the 90’s.

1.1.2 History of SialendoscopyThefirstattemptstoperformsalivaryen-doscopy in the early 1990’s by Katz33 and Gundlach25 were not followed by wider

clinical applications, either on account ofpoor visionordue to lackof specificinstrumentation. The first blind retrievalsof salivary stones were performed by radiologists in submandibular (1990) and parotid (1994) glands. In 1994, Nahlieli et al.61 reported on endoscope-assisted retrieval of stones using a hazel-type of scope. In the following period, dedicated instruments were simultaneously devel-oped in two different centers (Marchal, Switzerland – Nahlieli, Israel). Once feasibility of the technique was demon-strated,48, 59 and particularly after start-up of regular training programs at the Euro-pean Sialendoscopy Training Center in 2002, physicians have been trained using the new method and members of ESTC began to adopt the technique, which is reflectedinanabundanceofliterature.*

in 1659. Ever since, the duct has borne his name.

The anatomy of the parotid ductal system was discovered shortly thereafter in 1660 during an animal dissection by Nicolaus Stenonius.

Van Horne of Leyden demonstrated the anatomy in public and named it after Stenon. Stenon’s main work, ‘De glandulis oris et novis earundum vasis. Observationes anatomicae in iclyta Lugdunensi Academia sub praesidio DD Johannis van Horne”76 was published in 1661, and the parotid duct also bears his name.

Casparus Bartholinus (1655–1738), professor of anatomy, first describedthe sublingual ductal system, which now bears his name.26

1.1 HistorySalivary gland diseases were firstdescribed in ancient times by Hippocrates,29 460–370 BC. More than 1000 years later, Abulcasis,75 reported on a pioneering work and instrumenta-tion for what later became known as otolaryngology, ophthalmology and neurosurgery. He described at that time the ranula and its treatment.

Further descriptions of salivary gland diseases focused on parotid tumors, although the humoral theory was devel-oped already by Paulus Aeginata64 and by Ambroise Paré,63 a French surgeon of the 16th century.

Thefirstdescriptionoftheductalsystemof a salivary gland appeared in the 17th century, with the pioneering work of Thomas Wharton, who published a monograph entitled, ‘Adenographia sive glandularum totius corporis descriptio’82

*) see References: 1–3, 5–7, 9, 12, 14, 17–21, 24, 31, 34–45,

55–57, 62, 65–67, 69–73, 78–81, 83–86


1.2 Disease Process of Sialadenitis

1.3 Historyand PhysicalExaminationofSialadenitis

2 Acute parotitis, with spontaneous abcess drainage.

3 Purulent exudate emerging from Sten sen’s parotid papilla.

4 Deeply located salivary stone necessitat-ing submandibular resection.

Salivary probe in the primary passageway of Wharton’s duct.

ba

Salivary gland pathology can be divided into two categories: tumoral and ductal diseases. The latter is the predominant group comprising mainly stones, strictures, and polyps wheras salivary gland tumors are more rarely seen.10 The etiology of sialadenitis in case of stones remains unclear and various hypothesis

have been described. Ductal strictures can be encountered mainly in juvenal re-current parotidis, in Sjögren syndrom, or, in the absence of an underlying disease process, their cause remains unclear. Strictures can be localized, thin or thick or more generalized in the ductal tree.

Stones and strictures do obstruct the salivary duct and patients present with recurrent glandular swelllings during meals, which can remain transitory or be complicated by bacterial infections. In this case, patients ocassionally have fever, complain of inappropriate taste in the mouth due to purulent discharge, often accompanied by continuous pain-

ful swelling of the gland. On physical examination, the gland is swollen and massage of the gland is painful and expresses thick saliva or pus through the papilla (Figs. 2, 3). Manual pal pation of the submandibular gland is also painful and sometimes a stone can be palpated intraorally or, more rarely, in the parotid gland by bimanual or external palpation.

Transoral removal of a palpable salivary stone located in the floor of the mouth.

*) Figs. 4a, b by courtesy of Prof Willy Lehmann, ORL Department, University of Geneva, Switzerland.


2.0 StandardDiagnosticApproachesThe classical investigation methods of salivary glands are radiography, including X-rays, ultrasound, CT scan and sialo graphy, which up to now is considered as the gold standard37 for evaluation of the ductal system.74 Ultra-sound remains an excellent primary diagnostic method for the detection of salivary stones, however calculi with a size of less than 3 mm cannot be visual-ized.74 Another non-invasive diagnostic option is nuclear magnetic resonance tomo graphy, MR-sialography,3 which provides scans of the salivary ducts by

opacificationofthenaturalsalivarypath-ways without the need for administration of contrast medium and without exert-ing the patient to ionizing irradiation. As shown in the figures below, theseprocedures aim to visualize the ductal system for the diagnosis of obstructive pathologies, typically stones or other rarer diseases. New diagnostic options like 3D-sialography using the technique ofconebeamCTwithflatpanel(CPCT)have been described recently, opening new vistas that certainly are of interest to thefield.32, 77

5 CT scan showing a 4 mm calculus (➞) located in the distal portion of Wharton’s

duct, as it enters the submandibular gland.

6 Conventional X-ray image of a 6 mm calculus (➞)attheleveloftheanteriorthirdofthefloorof the mouth (a).

Ultrasound examination (b) in the same patient as in (a) shows the cal c ulus (➞) with a characteristic acoustic shadow. The calculus is located in the anterior por tion of Wharton’s duct.

ba

8

ba

7 MR-Sialography in chronic sialadenitis, showing a significant stenosis of

Stensen’s duct (➞) as well as massive dilation of the intraglandular ductal system.

a Conventional sialography shows a 4 mm calculus (➞)locatedneartheorificeof Wharton’s duct. Note the marked dilatation of the ductal system after admini stra tion of contrast media in a retro grade fashion.

b MR-sialography of the same patient as in (a) shows the anteriorly located calculus (➞). The ductal system is visualized due to the presence of saliva inside the duct al system (shown in white on T2-weighted sequences) without the need for retro grade injection of contrast medium.

*) Figs. 5–8 by courtesy of Prof. Minerva Becker, Department of Radiology, University of Geneva, Switzerland.


3.0 Diagnostic Sialendoscopy3.1 LSDClassificationSystemIn recent years, sialendoscopy has gained in popularity, which is reflectedby the increase of related publications (Table 1).Theonlyexistingclassificationwasbasedon sialographic findings anddid not include stones or dilatations. Therefore, the author and team felt the need to develop a classification ofpathologies involving the salivary duct system. The acronym ‘LSD’ stands for

‘lithiasis’ (L), ‘stenosis’ (S) and ‘dilata-tion’ (D). The LSD classification systemwas approved by all members of the ESTC and further ackowledged by other sialendo scopists.12,58* The classificationsystemisbasedonendoscopicfindings,which is why it can be applied for assessment purposes only after diag-nostic sialendoscopy (see Tables 2–4).

* (Consensus Meeting on Salivary Gland Diseases, Paris, 2007)

Table 1Number of sialendoscopy-relatedpublications in the past 18 years.


3.2 NormalAnatomyoftheSalivaryDuctSystem

9

a

d

f

b

e

g

c

aFirst centimeters of the Wharton’s duct.

bEndoscopic view as seen in Wharton’s duct when reaching the sublingual duct junction.

cMain duct.

dPrimary branches.

eSecondary branches.

fTertiary branches.

gTerminal branches (same endoscopic aspect in both the submandibular and the parotid gland).

The new endoscopic techniques described47, 49 and the specific instru-ment set designed and developed by the author in close collaboration with KARL STORZ allow almost completeexploration of the ductal system of both the submandibular and parotid glands. The main duct of both glands, as well as secondary, tertiary, quaternary and even quinary branches, can be explored in a vast majority of cases. Rare limita-

tions include convoluted sections that are impassable with a rigid endoscope. Mobility of the endoscope is also limited at the distal end of the gland due to the mouth opening. Sialendoscopy provides direct, reliable information about most pathologies and reduces the need for radiological investigations. In the author’s opinion, the bevelled-tip multi-purpose endoscope is extremely impor-tant as it facilitates exploration of smaller

branches by smooth dilatation. The op-tion of customizing the semi-rigid multi-purpose endoscope (at the risk of the user!) is a key feature, that has shown to be very helpful in exploring wide-angled ramifications.Thisisthereasonwhythe‘all-in-one scopes’ at our institution are of semi-rigid type.

3.2.1TheDuctalSystem


3.2.2 Submandibular Sialendoscopy

3.2.3 Parotid Sialendoscopy

3.2.4 Sialendoscopy in Case of Sialadenitis

10 Salivary duct probe in the papilla.

13 The tip of the sialendoscope can be visualized in Stensen’s duct due to transillumination.

a

11 Salivary dilator inserted in the papilla.

b

12 Dilated papilla ( ) of the left Wharton’s duct.

c

14 Endoscopic view of an inflammed ductal system suring removal of a sialolith (which should be avoided, if possible).

a b c


3.3 PathologicalFindings

3.3.1 Mucous Plugs gressively grows by deposition of layers of inorganic and organic substances.

Another hypothesis for the formation of sialolithiasis is that aliments, substances or bacteria within the oral cavity might migrate to the salivary ducts and stimu-latefurthercalcification.

Mucous plugs are found in cases of sialolithiasis, but also in cases of Sjögren syndrome and in several cases of chronic parotitis in children.

Unlike with urolithiasis and cholelithia-sis, the etiology of sialolithiasis is unknown. Various hypotheses have beenproposed.Thefirstisbasedonthe existence of intracellular micro-calculi, which when excreted in the canal, be-comeanidusforfurthercalcification28, 50.

The second theory supposes that ‘mucous plugs’ in the ductal system may represent the nidus. Both hypo theses suggest an initial organic nidus that pro-

Thickmucousplugfloatinginthemainduct.Blurred image due to mucosal plug.

a

15

The mucosal plug is mechanically detach ed by gently tapping on the stone with the laser fibertip.

d

Extraction of this plug using a wire basket.

b

Mucous plug is detached from the stone ...

e

A mucous plug is attached to the stone which impairs intraductal vision

– sialolith mp – mucous plug

c

... and ensuingly removed.

f

mp


3.3.2Sialolithiasis–MultipleStones,VariousMorphologiesofSalivaryStones

According to past autopsy studies60 sialo lithiasis is supposed to affect 1 % of salivary glands. However, its frequency is most probably underestimated due to the poor sensitivity of outdated detec-tion methods and absence of treatment options for intraglandular stones, leading to more conservative approaches.

According to most published data, salivary stones are localized in the submandibular gland in 80 % to 90 % of cases. In our experience, parotid glands are affected more frequently (30 % to 40 %), a difference possibly explained by the sensitivity of the new detection methods.

Sialoliths are composed of organic and inorganic substances, in varying ratios. The organic substances are glyco-proteins, muco-polysaccharides and cellular debris. The inorganic substances are mainly calcium carbonates and cal-cium phosphates.47 Salivary stones can be either solitary or multiple, particularly in the parotid gland. As seen before, their location can be proximal, distal or intra-

glandular. They vary in shape, being ei-ther round or irregular. The annual growth rate of established salivary stones has been estimated at 1 mm per year.68

Depending on the size of the stones, they can either float (Fig. 16a) in the lumen, become partially fixed due toirregular shapes or even attach to the

ductal wall. In some cases, they are trapped behind a bifurcation (Fig. 16c).

Stone shapes vary between the parotid and submandibular glands; stones found in the parotid (Fig. 18a) are often smaller, longer and smoother than the more cal-cified submandibular stones (Fig. 18b).

Floating stones.

a

16

Floating stones.

a

17

Various morphologies depending on the site of the stone(s).Oval-shaped parotid stone (a). Ball-shaped submandibular stone (b).

a

18

Multiple stones.

b

Stone trapped behind a bifurcation.

c

Multiple stones.

b

Multiple stones.

c

b


3.3.3 Ductal Stenosis

According to the LSD classification,strictures can either be localized and thin, large or diffuse. These can be encountered in juvenile recurrent parotidis,17, 19, 21 34, 57, 67 Sjögren syndrom, radiation-induced sialadenitis65 (either

after external radiation therapy or as a sequela of radioactive iodine treatment for thyroid carcinoma and precipitating further salivary symptoms and strictures of one or multiple salivary glands).

3.3.4 Polyps and Tumors

Polyps and tumors of the ductal tree are of very rare occurrence. They can be be-nign or malignant. In case of malignant tumors,22 the prognosis is relatively poor and any suspicious sign on endoscopy eliciting doubts about the nature of the lesion should prompt the sialendo scopist to have histologic analysis be made of the collected specimen.54

Endoscopic view of a concentric stenos is in the sec ond branch of Stensen’s duct.

a

19

a

20

Close-up view of the same site as in (a).

b

b

Stenosis of a third generation Wharton’s duct.

c


3.4 ClassicalApproachtoSialadenitis

3.4.1MedicalTreatmentandExternalSurgeryProximal stones close to the papilla are extracted, whereas glandular resection46 is indicated for deeply located stones (Fig. 4b).

In submandibular glands, sialolithiasis still represents 70 % to 90 % of all actual indications13, 23 for glandular resection. Although resection of the submandibular gland is a frequent operation, several reports27 demonstrate a rather high rate of complications – up to 37 %. In rare cases, this may include neurological damage.

Parotidectomy is rarely performed for in-flammatoryconditionsinparotidglands,because it remains a tedious procedure and is associated with a higher incidence of postoperative paresis.8, 11, 16 Because of this operation’s higher morbidity, surgeons and, more often, patients are reluctant to proceed with surgery.

In case of strictures, usually no other treatments are applied than the medical therapy employed prior to sialendoscopy which consisted of anti-inflammatory

medication, massages and administra-tion of sialagogues.

One possible reason behind the high rate of submandibular resections may be the common opinion that submandibular glands with sialolithiasis (chronic infec-tions) should be removed because they are non-functional.

In a clinical-histological study47 on 48 pa-tients with sialolithiasis who were treated by resection of the submandibular gland, the clinical history was correlated with the histological alteration of the gland.

The authors found out that up to one-half of the patients had subnormal histology patterns, and that there was no correla-tion between the number of infectious episodes and the alteration of the gland. Therefore, numerous infectious episodes or a long duration of symptoms cannot be used to predict the degree of glan-dular alteration, and thus a conservative attitude toward sialolithiasis appears justified.

3.4.2ExtracorporealLithotripsy

In search of conservative approaches toward the treatment of sialolithiasis, a new technique was developed in the 1990s, namely extracorporeal shock wave lithotripsy30 (e.g., by use of the extracorporal lithotriptor MINILITH® SL; STORZ MEDICAL AG, Kreuzlingen, Switzerland). Success rates vary from 40 % to 75 % for the submandibular (Fig. 22) and parotid glands, respec-

22

tively. Performed on an outpatient basis, this technique is now widely practiced but often requires multiple sessions. The main problem remains the clearance of fragments, which, if incomplete, can become the cause of recurrent sialo-lithiasis.

Interventional sialendoscopy allows to avoid these problems, as described hereafter.

With its precise focus zone (0.2 x 2 cm) and an in-line ultrasound scanner the MINILITH®SL1 lithotriptor is specifically designed for extracor poreal shock wave litho tripsy (ESWL) of salivary stones.The optimum stone size for effective treatment varies between 2–8 mm in diameter. Even though disintegration of calculi larger than 8 mmindiametercanbeaccomplished,the

gland may reach the limits of its excretion capacity if the amount of residual fragments is too large to be washed out spontaneously by salivation induced by medication. In this case, stone clearance can be protracted and may require repetitive treatment sessions and/or adjunctive minimally invasive sialendoscopic stone removal.

a

21

Normal histological appearance of a sub mandibular gland specimen (a).Histologicallyconfirmedalterationofglandulartissue (b).

b


4.0 InterventionalSialendoscopy4.1 StoneRemovalbyuseofaWireBasketFollowing diagnostic sialendoscopy and exposure of the sialolith, the adopted strategy is the same for the submandi-bular53 and parotid glands,54 although the diameter of the ductal system is smaller in the parotid duct.87

For small stones, less than 4 mm in dia-meter in submandibular cases and less than3 mminparotidcases,extractionis

performed with wire baskets of various sizes. The basket is advanced through the working channel of the scope and opened behind the stone. It is then closed over the stone and basket and endoscope are removed altogether in one movement. Papillotomy is per-formed at the end of the procedure, and it should be kept as minimal as possible.

Wharton’sDuct

a

23

d

b c

e


Stensen’sDuct

g hf

i

Stone extraction in Stensen’s duct (a–c).

a

24

b c

23


4.2 StoneRemovalbyUseofaWireBasket, precededbyLaserFragmentation

a

25

d

g

b

e

h

c

f

In cases of bigger stones, prior fragmen-tation is necessary using a laser system. The first successful endoscopic-guidedlaser lithotripsy of salivary stones was reported by Gundlach in Germany,26 who, until now, uses two types of lasers for stone fragmentation with a success rate of above 90% for L2 stones of less

than 10 mm. Limitations are stones that are only partially visible, or calculi too large in size.

Various types of laser systems are suited for laser lithotripsy of sialoliths: The Dye Laser at 350 nm is very useful, as well as the Holmium-YAG Laser at 2104 nm. Laser irradiation may inadvertently cause

damage to ductal walls and hidden structures. Therefore, it is mandatory that the laser be operated only under clear vision, continuous flow irrigationand in close contact with the stone while carefully sparing the ductal walls.

a–h Laser fragmentation and extraction of stone debris by use of a wire basket through a minimal incision made in Wharton’s papilla, followed by complete clearance of the duct.NB:Stone removal should only be performed after complete fragmentation of the sialolith. Attempting to retrieve large stone fragments poses the risk of wire basket entrapment, a situation that cannot be resolved by applying firmtractiontotheinstrument,which–underany circumstances – must be avoided!


4.3 Sialendoscopic Treatment of StenosisStrictures are more common in the parotid than in the submandibular gland. The main issue with stricture treatment is the overall diameter of the duct, which is generally less than 1.5 mm. The best way to dilate the stricture is to choose the multi-purpose sialoscope. Following diagnostic sialendoscopy, a guide wire is first introduced through the channelof the scope. The shaft is then removed leaving the guide wire in the duct. The interventional sialendoscope is then passed over the guide wire allowing the scope to be securely advanced. Dilata-

tion is accomplished by the beveled type of the scope without causing any trauma. In principle, the same technique can be applied via the guide wire when using the all-in-one scope, however, in order to achieve adequate dilatation, the surgeon needs to have available several scopes of increasing diameter. In clinical practice, we were frequently faced with difficulties to achieve dilatation, thoughusing scopes of increasing diameter (because the all-in-one scope does not have a beveled tip).

Endoscopic view of the stenosis before …

a

26

Endoscopic view of the stenosis before …

d

… and after dilatation.

b

… and after dilatation.

e

Close-upviewofthecompletelyfilledballoon-tip at the catheter’s distal end.

c

Bougies of various sizes for dilation of stenoses.

f


4.4CombinedTechniquesLarge salivary stones or impassably dense strictures have always posed a therapeutic challenge that could not be solved by sialendoscopy alone. The advent of external lithotripsy in the early 1990’s opened up the prospects that all stones may become amenable to conservative treatment, however the relatively poor success rates in case of large stones were disappointing. The use of intraductal laser fragmentation had also its limitations in case of large stones.

In all these cases, removal of the gland was the last-resort option, which as we allknow, isassociatedwithasignificantrate of morbidity. Therefore, we proposed a new combined approach using both sialendoscopy and external surgery45 as described below. In close collaboration withKARLSTORZTuttlingen,Germany,the author hasdesigned specific instru-ments for use in combined approaches. This set of instruments is currently in production and will be available soon.

4.4.1CombinedTechniquesfortheSubmandibularGlandThe sialendoscope is positioned in front of the stricture / stone, which owing to the diaphanoscopic effect provides adequate orienation for the combined external-intraoral approach. First, an accurate mucosal incision is made with meticulous care, followed by a ductal incision, which enables careful dissec-tion of the duct following visualization

of the lingual nerve to remove the stone. Concurrent sialendoscopy of the distal part of the gland is extremely important and has proven useful in removing more distally located stones. At the end of the procedure, the duct is approximated by placing one or two nylon sutures. A stent may be introduced in the papilla in order to avoid improper scaring.

4.4.2CombinedTechniquesfortheParotidGlandAt the author’s insitution, sialendoscopy is also performed with the 1.3-mm all-in-one sialendoscope or the diagnostic multi-purpose scope. The sialendoscope is inserted in the duct, stabilized in a position proximal to the lesion, which may be a stricture or a stone. Through-out the next steps of the procedure, the scopemaybefixed to theangleof themouth. The patient is then prepared for a classical parotid approach. We commonly use a facelift approach assisted by intraoperative facial nerve monitoring15, 45 but as an alternative option, a ‘lazy-S’-shaped incision may also be used. The skin is then elevated and a SMAS*flapraisedandtheU-orT-

* SuperficialMuscular Aponeurotic System

shapedSMASflapisthencreatedalongtheareadefinedbytransillumination.Thesalivary tissue is then very carefully dis-sected free with the help of a binocular loup or a microscope in order to expose Stensen’s duct. Constant awareness of proximity to the facial nerve branches is extremely important and particular care must be paid while cutting over the duct avoiding under any circumstances to cause iatrogenic damage to the nerve. Once the incision in the duct has been made, the stone may be removed and/or the stricture be treated by use of a venus patch. Constant irrigation of the ductiscrucialtoconfirmpatencyoftheductal sutures. Following wound closure, a pressure dressing is applied.


5.0 TechniqueofSialendoscopy5.1 Indications and ContraindicationsThe indications for sialendoscopy are all salivary gland swellings of unclear origin.51, 60 There are no specific contra-indications, mostly because sialendo-scopy is a minimally invasive outpatient procedure performed under local anes-thesia. Even elderly or unstable patients unable to undergo general anesthesia canbenefitfromthistechnique.

Despite its apparent simplicity, inter-ventional sialendoscopy is a technically challenging procedure. Maneuvering the rigid sialendoscope is delicate, requires extensive experience and involves certain hazards due to the

potential risks of causing perforation and vascular or neural damage. The sialen-doscope should only be advanced under adequate vision. Perforations of iatro-genic origin can lead to diffuse swellings of the floor of the mouth. Meticulousattention has to be given to this anatomi-cal area because of the potential risk of a life-threatening increase of the swellings.

The main technical limitations of inter-ventional sialendoscopy at the present time are salivary stones in an extreme posterior location, or a fibrosed canalwall with a reduced diameter, which im-pedes advancement of the endoscope.

5.2 Operating Room Set-upSialendoscopy can be done as an outpatient procedure in the clinic with the patient sitting in a chair or partial ly recumbent.52 The author prefers the patient sitting in a chair or lying, which allows for better surgeon mobility. The disadvantage of a fully upright sitting position is that it is associated with an increased risk of vaso-vagal syncope. To be readily prepared for sensitive patients or the incidenceofdifficulties,ananes-

thesia unit should be kept available with the anesthetist on standby throughout the entire procedure. A mobile cart with connections for a video camera, video monitor, digital video recorder (DVR) and printer are on the opposite side of the patient, allowing for direct observation of the surgical procedure. An assistant (physician, nurse or technician) is located on that side and is responsible for per-forming the perioperative procedures.

5.3 AnestheticTechniqueSialendoscopy generally requires local anesthesia of the papilla and the ductal system. A topical anesthetic paste or spray (10 or 20%) is applied to either Stensen’s or Wharton’s papilla at the beginning of the procedure. After intro-duction of the sialendoscope, anesthesia of the ductal system is induced with an irrigation solution of Xylocain, Lidocain or Carbostesin 0,5 %. Depending on age and weight of the patient, the total

amount infiltrated should not exceed40 cc,becauseofabsorptionrisks.

As a rule, diagnostic sialendoscopy can be performed under local anesthesia. Taking into account that interventional sial endoscopy is usually performed in the same setting, sedation or even general anaesthesia can be applied by the anaesthesiologist. This largely dependson the levelofdifficultyof theindividual case.

27 The patient can rest in a comfortable upright position during the whole course of treatment.

a b


5.4 Step-by-StepTechnique

1 Local anesthesia of the papilla with an anesthetic paste or spray (10 or 20%).

2 Introduction of salivary probes of increasing diameter.

3 Introduction of the dilator.4 Placement of dental tampons in the

posterior aspect of the vesti bule and gingivo-buccal sulcus. These will later be replaced with new dry ones during sialendoscopy.

5 Introduction of the sialendoscope.6 Introduction of a guidewire in the

working channel (this step is optional, depending on the experience of the surgeon. It facilitates reintroduction of the scope in the duct).

7 Interventional sialendoscopy invol-ves the use of laser fibers, stonebaskets or balloon dilators. The guidewire may be left in place in the duct throughout the procedure. By removing the endoscope and reinsert-ing the sialendo scope parallel to the guidewire the working channel can be kept open for the use of additional instruments. In view of the numerous ramifications, and the difficulty ofinspecting sharply angulated distal parts of the gland, initial advancement of the guide wire in the branch that is difficult to access usually allows theendoscope to slip on the wire and explore the duct.

5.4.2 Submandibular Sialendoscopy5.4.1 Parotid Sialendoscopy1 Local anesthesia of the papilla with an

anesthetic paste or spray (10 or 20%).2Superficial infiltration of the papilla

with a local anesthetic solution and adrenalin / epine phrine.

3 Introduction of salivary probes of increasing diameter.

4 Introduction of the dilator.5 Placement of dental tampons in both

sides of the lateral aspects of the floorofthemouth.Thesewilllaterbereplaced with new dry ones during sialendoscopy.

6 Introduction of the sialendoscope.7 Introduction of a guidewire in the

working channel. This step is optional – depending on the experience of the surgeon – and facilitates reintroduc-tion of the scope in the duct.

8 Interventional sialendoscopy in-volves theuseof laser fibers, stonebaskets or balloon dilators. The guide wire may be left in place in the duct throughout the procedure. By removing the endoscope and reinsert-ing the sialendoscope parallel to the guidewire the working channel can be kept open for the use of additional instruments. In view of the numerous ramifications, and the difficulty ofinspecting sharply angulated distal parts of the gland, initial advancement of the guide wire in the branch that is difficult to access usually allows theendoscope to slip on the wire and explore the duct.


5.5 Equipment

The second generation sialendoscopes could be called ‘all-in-one endoscopes’ because they have an integrated irriga-tion channel that may also be used for introducing small-sized operating instru-ments.

Multi-Purpose SialendoscopesDiagnostic sialendoscopy requires that the miniature endoscope be available in two sizes, 0.75 mm and 1 mm in dia-meter, for pediatric or stenosed ducts, and adult / nonstenotic ducts, respec-tively. The irrigation channel is formed by the tiny gap between the scope and the lumen of the examination sheath (11576 KA and 11577 KA with outer diameters of 1 mm and 1.3 mm).

Interventional sialendoscopy re qui res that the examination sheath be replaced by a special operating sheath with irriga-tion channel and one integrated working channel. Operating sheaths are available in three sizes, with inner diameters of 0.65 mm, 0.9 mm, and 1.15 mm.

All-in-one SialendoscopesThese endoscopes may be used for both diagnostic and interventional procedures eliminating the need for changing the in-strument. They are available in 4 different diameters.

# the 0.89 mm-sialendoscope allows for exploration of small pediatric ducts, or fibrous / stenoticducts. In thehandsof the author the device is also used to perform dacryocystorhinosto mies.

# the 1.1 mm-sialendoscope is suited for both diagnostic and interventional procedures with a working channel of 0.4 mm.

# the 1.3-mm sialendoscope is the‘universal’ sialendoscope, as its outer diameter is sized to allow for diagnos-tic and interventional sialendoscopy of the subman dibular and parotid ducts. Its working channel of 0.6 mm allows thepassageofbasketsorlaserfibers.However, the size of the working chan-nel does not permit the use of balloon dilators or forceps.

5.5.1SalivaryProbesAccess via the papilla may either involve initial marsupialization60 or by use of a non–traumatic approach. In order to systematically catheterize the papilla without causing any trauma, we devel-oped a complete set of salivary probes which are made of various types of alloys with different levels of rigidity (the smallerdiametersaremoreflexibleandhave a lower elastic modulus in order to prevent perforations).

5.5.2 Conic DilatorThis specially designed dilator should be used instead of a salivary probe for gentle dilation of the papilla without any hemorrhage or trauma.

5.5.3HollowRigidBougiesThese bougies allow a blind dilatation of gross stenosis of the main duct, parotid or submandibular duct. The guidewire is inserted first under endoscopic control,traversing the stenotic process, and the sialendoscope removed after having marked the distance to the stenosis. The metallic bougie is then gently inserted, using increasing diameters.

5.5.4ForcepsCustom-made forceps measuring 0.8 mm may also be used to retrievesmall salivary stones (11538TJ) or fortaking biopsies in the salivary duct system. Care has to be taken when handling and maneuvering these instru-ments since they are small and fragile. Thus, very little pressure should be ex-erted when grasping the sialolith to avoid damage to the instrument.

5.5.5 SialendoscopesTwo types of miniature endoscopes were developed for sialendoscopy. The firstgeneration multi-purpose sialendo scopes comprised two scopes of different size, and various sheaths allowing for diag-nostic and interventional sialendoscopy.

# the 1.6 mm-sialendoscope allows the use of forceps. Its outer diameter is designed to allow for endoscopic in-spection and treatment of the parotid and submandibular ducts. It is impor-tant to note that the lumen of affected ducts is often narrowed owing to inflammatory conditions, making theuse of small-diameter sialendoscopes necessary. Therefore, the 1.6 mm-sialendoscope may not always be suitable in parotid cases due to the narrow lumen of Stensen’s duct.

5.5.6DisposableDevices

Balloon DilatorsDisposable dilators allow for endo-scopic-controlled dilatation of localized stenosis, mainly encountered in the parotid ductal system but also in the submandibular gland. In addition, we de-veloped high-pressure balloon catheters designed to treat particularly dense strictures that are not amenable to dila-tation when using low-pressure balloons. Great caution should be exercised while insufflatingtheballoontopreventunduedistension of the duct.

Stone Retrieval BasketsThe initial trials to remove salivary calculi were performed with dormia baskets designed foruse in thefieldof urology, however this was fraught with the drawback that they did not fit intoour scopes, which is why we decided to develop baskets of very thin diameter. Today, a wide range of special baskets are available in different sizes and with various numbers of strands. The latest model that has been developed is the tipless basket including a special handle that can be adapted to the ‘all-in-one’ sialendoscope.


5.6 InherentLimitationsofSialendoscopy

The writhing course of the canal puts certain limitations on semi-rigid sialendoscopy, especially if sharply bent curvatures of the duct prevent the scope from being advanced. The main previously described limitation being the size of the sialendoscope has drastically changed since the development of the last generation ‘all-in-one’ sialendo-scopes. The variety in sizes now allows for exploration of almost all salivary ducts.

Maneuvering within the narrow salivary ducts has to be absolutely atraumatic because of the risk of ductal perforation and unpredictable secondary conse-quences.Significanttraumatotheductalwall may result in latter stenosis.

5.6.1SignificanceoftheTipDesignThe small angulation, a distinguis hing design feature of the tips of all Marchal sialendoscopes facilitates targeted cath-eterization of branches, whereas with a standard on-axis tip, difficulties mayoccur when advancing to the branch ahead. Aminor deflectionmay also begiven to the sheaths of sialendoscopes 11576 and 11577. After inserting the obturator, the tip may be bent very cautiously, providing the optimal curve. Theendoscopemustneverbedeflected.

It usually follow the curve of the sheath and reverts to its former state after completion of the procedure.

5.6.2SignificanceoftheBevelledTipCatheterization of the papilla is a challenging step of the procedure involv-ing a relatively long learning curve. Once adequate dilatation has been achieved by use of bougies of varying sizes, intro-duction of the opera ting sialendoscope is considerably facilitated by the bevelled tip of the sheath since this design feature allows the tip to be used as a dilation probe.

5.6.3SignificanceofLate Marsupialization

Marsupialization should be completely avoided, particularly at the beginning of the procedure. The irrigation liquid has a dilating effect that provides excel-lent vision of all ductal branches. Early marsupialization leads to poor visual conditions and makes the technique moredifficult tomaster,becauseof theirrigation liquid escaping from the ductal system at its opening. Apart from that, marsu pializa tion of the ductal papillae should either be completely avoided, or kept as small as possible to prevent retrograde passage of air and aliments.

5.7 PostoperativeCare

28 The minor deflection of the tip – a distinguishing design feature of all MARCHAL sialendo-scopes – facilitates targeted catheterization of ductal branches (b, c), because an on-axis

tip is more susceptible to become jammed (a) while attempting to advance the scope.

a b c

Interventional sialendoscopic procedures are usually conducted under prophylac-tic antibiotic medication administered 48 hoursorearlierpriortotheprocedure,depending on the individual case. Frequent self-massages of the gland are re commended. Clinical controls are performed directly after the intervention.

Patients with ruptures of Wharton’s duct, or in cases of deliberately extended marsupialization of the latter, have to be subjected to careful clinical monitoring because of the risk of edema diffusion and/orinfectionofthefloorofthemouthwhich poses the risk of developing into a life-threatening emergency.


6.0 Workflow6.1 DecisionalAlgorithms

Diagram 2Technical algorithms for selecting the appropriate sialendoscopic instrumentation.

Diagram 1Decisional algorithm of diagnostic and interventional sial endo scopy.

Recurrent glandular swelling during meals Diffusesalivaryglandswelling

Unilateral Bilateral

Diagnostic Sialendoscopy MRSialography

SmallSialolith submandibular < 4 mm

parotid < 3 mm

LargeSialolith submandibular > 4 mm

parotid > 3 mmStenosis

InterventionalSialendoscopy

WireBasketExtraction LaserLithotripsy WireBasketExtraction Dilatation

SalivaryStone

ParotidSubmandibular

Diagnostic Sialendoscopy InterventionalSialendoscopy Diagnostic Sialendoscopy InterventionalSialendoscopy

� 0.75 mm Sialendoscope 11576 � 1 mm Sialendoscope 11577 � All MARCHAL Sialendoscopes 11581, 11582, 11583, 11575, 11576, 11577

� 0.75 mm Sialendoscope 11576 and OperatingSheaths 11576 KF/KG

� 1 mm Sialendoscope 11577 and OperatingSheaths 11577 KD/KE

� All MARCHAL Sialendoscopes 11581, 11582, 11583, 11575, 11576, 11577

� 0.75 mm Sialendoscope 11576 and ExaminationSheath 11576 KA

� 1 mm Sialendoscope 11577 and ExaminationSheath 11577 KA

� All MARCHAL Sialendoscopes from 0.89 mm to 1.3 mm: 11581, 11582, (11583 in limited cases), 11575, 11576, 11577

� 0.75 mm Sialendoscope 11576 and OperatingSheath 11576 KG (11576 KF, if possible)

� 1 mm Sialendoscope 11577 and OperatingSheath 11577 KD

� All MARCHAL Sialendoscopes except for 11583 (may be traumatic under specific circumstances )

SmallSialolith ≤3mm

WireBasketorForceps

LargeSialolith> 3 mm

LaserLithotripsyandRetrievalofFragmentswithBasket/Forceps

SmallSialolith ≤4mm

WireBasketorForceps

LargeSialolith> 4 mm

LaserLithotripsyandRetrievalofFragmentswithBasket/Forceps


6.2 RecommendedEquipmentforBeginners:BasicSet

The 1.3-mm MARCHAL Sialendoscope is the universal scope that may be used for diagnosis and treatment in the major-ity of patients undergoing outpatient sialendoscopy as well as for minor inter-ventional procedures.

The Basic Set consists of a conic dilator, bougies of various sizes, and the univer-sal 1.3 mm MARCHAL Sialendoscope.

(Basic Set: see page 34)

29 Compact and functional in design, the MARCHAL Sial endoscope 11575 meets the demands of the practitioner and may also be used for minor interventional proced ures that

requiretheuseofawirebasketorlaserfiber.

30 Another option is to use the small lateral channel (I.D.: 0.9 mm) of operating sheath 11576 KF for introducing the Miniature Endo scope 11576, wheras the biopsy forceps

(11570 ZJ)isinsertedthroughthecentralchannel(I.D.:1.15mm).

31 The central channel (I.D.: 1.15 mm) of operating sheath 11576 KF may also be used for introducing a balloon-tipped cathet er, while the Miniature Endo scope 11576 is inserted

through the lateral channel (I.D.: 0.90 mm).

6.3 RecommendedEquipment: AdvancedSet

The 0.75-mm sialendoscope in conjunc-tion with various sheaths extends the technical options and may be applied in the entire field of interventional sialen-doscopy:

# Optional custom-made bending of the scope at the risk of the user.

# Sialendoscopy under pediatric or stenotic conditions.

# Application of baskets, laser fibers,forceps and balloon-tipped dilators.

(Advanced Set: see page 35)


7.0 Training

7.1 IntroductionSince the initial development stage of sialendoscopy we have been convinced that the best way to popularize the tech-nique is teaching. Since 2002, more than 600 physicians from 65 countries have been trained in the European Sialendo-scopy Training Center (ESTC) in Geneva, Switzerland.

7.2 TheEuropeanSialendoscopyTrainingCenter(ESTC)

7.2.1AimsoftheESTCThe aims of the ESTC are:

# to train clinicians in the indications and procedures associated with diagnostic and therapeutic sialendoscopy,

32 Sialendoscopy in the operating theatre.

33 Hands-on training on an animal model.

# to organise and disseminate experi-encegainedbyclinicians in thisfield,and

# to conduct international courses and conferences as appropriate, to facilitate exchange of knowledge, experiences and advances gained by leading clinical physicians who focus on diseases and conditions of the salivary glands.

7.2.2 Hands-on TrainingIn Geneva, a specific training anddemonstration model for sialendoscopy has been validated. The use of fresh pig heads has proven to be ideal, after extensive trials conducted with other animal models and human cadaveric specimen.

During each course, participants are paired and work on one fresh pig head. The lectures held during the hands-on course are divided into two sessions, one focusing on diagnostic and the other on interventional sialendoscopy.

7.2.3 ConferencesThe international faculty addresses clinic al, radiological, medical and surgical approaches to salivary gland pathologies. They explain and describe their techniques of sialendoscopy in a step-by-step fashion using a variety of videos and interactive presentations that allow for open discussion and com-ments.

Recent developments in new ma-terials and designs combined with advances in instrumentation tech-nology are presented during such conferences. Abstract sessions are an outstanding way to disseminate the results of clinical research or to pres-ent and discuss case histories. Round table format and informal discussions facilitate reporting on advances and prospects of research that address the management of salivary gland duct pathologies.


7.2.4LiveSurgeryin3DOwing to the availability of an excellent video-conference system linking the opera ting room to the conference room, live surgeries can be viewed on a large central video screen. Participants are encouraged to ask questions and discuss with the surgeon during the operation. Through this real-time approach, the steps of the procedure, but also the risks and advantages are made tangible to the course participants. At the subsequent hands-on sessions surgical tricks and tips are demonstrated, expanded upon and taught. For a few years now, the courses are recorded with a 3D camera and transmitted to the auditorium.

7.2.5CoursesforBeginnersandAdvancedCourses

At the request of hundreds of par-ticipants, we started a few years ago to offer a beginners’ course and an advanced course in order to better cope with the individual needs at each level.

34 A video-conference system links the operating room to the conference room and allows live surgeries to be viewed on a large central video screen

7.3 CourseEvaluationFor retrospective evaluation of the courses held at the ESTC, question-naires are distributed on a regular basis among the participants. As a result, 95% are satisfied with the theoreticalpart and 98% with the practical part of the course, under lining the importance of hands-on training with fresh pig heads. All participants agreed that the trickiest part of the procedure is the practical handling of the papilla in order to utilize the technique by ways of a truly minimally invasive approach. Based on the conclusions from this evaluation, we found out that the majority of par-ticipants (60%) requested an advanced course, so we decided to install both a beginners’ course and an advanced course, held annually in Geneva (www.sialendoscopy.com).

8.0 ConclusionTaking into consideration differences in instrumentation and video-endoscopic equipment, as well as complexity, dura-tion, and potential compli cations of the procedures, a distinction has to be made between diagnostic and interventional sialendoscopy.

Diagnostic sialendo scopy is a low-morbidity minimally invasive technique, which may become the investigational procedure of choice for salivary duct pathologies.

Interventional sialendoscopy allows for extraction and/or fragmentation in the majority of cases of sialolithiasis, and can therefore prevent salivary gland ex-cisions.


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51. MARCHAL F, DULGUEROV P, BECKER M et al. Interventional Sialendoscopy. In: WACKYM P, RICE DH, SCHAEFER SD eds, Minimally Invasive Surgery of the Head, Neck, and Cranial Base. Philadelphia: Lippincott Williams & Wilkins; 2002: 416–426

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53. MARCHAL F, BECKER M, DULGUEROV P et al. Sialolithiasis: ultrasound versus conventional sialography. Eur Radiol Accepted for publication 2002:

54. MARCHAL F, DULGUEROV P, BECKER M et al. Specificity of parotid sialendoscopy. Laryngoscope 2001; 111: 264–271

55. MARCHAL F, CHOSSEGROS C, FAURE F et al. Salivary stones and stenosis. A comprehensive classification. Rev Stomatol Chir Maxillofac 2008; 109: 233–236

56. MARCHAL F, CHOSSEGROS C, FAURE F et al. [Salivary stones and stenosis. A comprehensive classification]. Rev Stomatol Chir Maxillofac 2009; 110: e1–4

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SialendoscopyBasicandAdvancedSets forDiagnosisandTreatmentofthe Parotid and Submandibular Glandsas recommended by Prof. MARCHAL


11575 A Miniature Straight Forward Telescope 0°, O.D. 1.3 mm, semirigid, autoclavable, 5° distal angulation, working channel I.D. 0.65 mm, irrigation channel I.D. 0.25 mm, working length 12 cm, length 100 cm, remote eyepiece, fiber optic light transmission incorporated, including protection cover 11570 P

11580 B Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11575 A, 11581 A – 11583 A, perforated, lid with silicone bridges, external dimensions (w x d x h): 275 x 178 x 35 mm

11575 K Stone Extractor, O.D. 0.6 mm, basket with 3 wires, sterile, for single use11575 L Stone Extractor, O.D. 0.6 mm, basket with 6 wires, sterile, for single use745847 Salivary Duct Probe, size 0000745848 Salivary Duct Probe, size 000745849 Salivary Duct Probe, size 00745850 Salivary Duct Probe, size 0745851 Salivary Duct Probe, size 1745852 Salivary Duct Probe, size 2745853 Salivary Duct Probe, size 3745854 Salivary Duct Probe, size 4745855 Salivary Duct Probe, size 5745856 Salivary Duct Probe, size 6745857 Salivary Duct Probe, size 7745858 Salivary Duct Probe, size 811580 A Metal Tray, for sterilizing Salivary Duct Probes 745847 – 745858 and Dilator 745910, perforated,

lid with silicone bridges, external dimensions (w x d x h): 178 x 178 x 35 mm745910 Dilator for salivary duct, length 14 cm745720 Guide Wire, O.D. 0,6 mm, sterile, for single use, package of 10, for use with Bougies 745710 – 745713745715 Forceps, angled, serrated, length 15 cm745716 Forceps, angled, with 1x 2 teeth, length 15 cm745717 Angled Scissors for Salivary Gland, with bulb, length 14 cm27651 K2 Cleaning Brush, for working channel diameter 0.6 – 0.8 mm, length 40 cm,

for single use, package of 1027651 K5 Cleaning Brush, for working channel diameter 0.25 – 0.4 mm, length 40 cm,

for single use, package of 10

Sialendoscopy Basic Setfor Diagnosis and Treatment of the Parotid and Submandibular Glands as recommended by Prof. MARCHAL

It is recommended to check the suitability of the product for the intended procedure prior to use.



11580 B Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11575 A, 11581 A – 11583 A, perforated, lid with silicone bridges, external dimensions (w x d x h): 275 x 178 x 35 mm

11576 A Miniature Straight Forward Telescope 0°, diameter 0.75 mm, working length 16 cm, semirigid, autoclavable, length 145 cm, with remote eyepiece and light connection, LUER-Lock adaptor, fiber optic light transmission incorporated, including Protective Tube 11576 P

11580 C Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11576 / 11577, perforated, lid with silicone bridges, external dimensions (w x d x h): 373 x 178 x 35 mm

11576 KA Examination Sheath, O.D. 1.1 mm, working length 16 cm, with blunt obturator, with lateral LUER-Lock adaptor for irrigation, for use with miniature telescope 11576

11576 KF Operation Sheath, oval, O.D. 1.1 mm and 1.3 mm, working length 16 cm, telescope channel O.D. 0.9 mm, working channel O.D. 1.15 mm with 2 obturators, with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11576

11576 KG Operation Sheath, oval, O.D. 1.1 mm and 0.8 mm, working length 16 cm, telescope channel O.D. 0.9 mm, working channel 0.65 mm, with 2 obturators, with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11576

11576 TJ Foreign Body Forceps, double action jaws, flexible, O.D.1 mm, working length 19 cm11576 ZJ Biopsy Forceps, double action jaws, flexible, O.D. 1 mm, working length 19 cm11577 BP Balloon Catheter, diameter 0.9 mm, sterile, single use, package of 1011575 K Stone Extractor, O.D. 0.6 mm, basket with 3 wires, sterile, for single use11575 L Stone Extractor, O.D. 0.6 mm, basket with 6 wires, sterile, for single use745847 Salivary Duct Probe, size 0000745848 Salivary Duct Probe, size 000745849 Salivary Duct Probe, size 00745850 Salivary Duct Probe, size 0745851 Salivary Duct Probe, size 1745852 Salivary Duct Probe, size 2745853 Salivary Duct Probe, size 3745854 Salivary Duct Probe, size 4745855 Salivary Duct Probe, size 5745856 Salivary Duct Probe, size 6745857 Salivary Duct Probe, size 7745858 Salivary Duct Probe, size 811580 A Metal Tray, for sterilizing Salivary Duct Probes 745847 – 745858 and Dilator 745910, perforated,

lid with silicone bridges, external dimensions (w x d x h): 178 x 178 x 35 mm745910 Dilator for salivary duct, length 14 cm745720 Guide Wire, O.D. 0,6 mm, sterile, for single use, package of 10, for use with Bougies 745710 – 745713745715 Forceps, angled, serrated, length 15 cm745716 Forceps, angled, with 1x 2 teeth, length 15 cm745717 Angled Scissors for Salivary Gland, with bulb, length 14 cm27651 K2 Cleaning Brush, for working channel diameter 0.6 – 0.8 mm, length 40 cm,

for single use, package of 1027651 K5 Cleaning Brush, for working channel diameter 0.25 – 0.4 mm, length 40 cm,

for single use, package of 10

Sialendoscopy Advanced Setfor Diagnosis and Treatment of the Parotid and Submandibular Glands as recommended by Prof. MARCHAL


MARCHAL All-In-One Miniature Endoscopesfor Diagnostic and Interventional Sialendoscopy

11581 A Miniature Straight Forward Telescope 0°, O.D. 0.89 mm, semirigid, autoclavable, 5° distal angulation, irrigation channel I.D. 0.25 mm, working length 12 cm, length 100 cm, remote eyepiece, fiber optic light transmission incorporated, including protection cover 11520 P


for use with: – Stone Extractor 11582 M – Guide Wire 745725 – Laser Probe

11575 A Miniature Straight Forward Telescope 0°, O.D. 1.3 mm, semirigid, autoclavable, 5° distal angulation, working channel I.D. 0.65 mm, irrigation channel I.D. 0.25 mm, working length 12 cm, length 100 cm, remote eyepiece, fiber optic light transmission incorporated including protection cover 11570 P

for use with: – Stone Extractor 11575 K / L – Guide Wire 745720 – Laser Probe

11583 A Miniature Straight Forward Telescope 0°, O.D. 1.6 mm, semirigid, autoclavable, 5° distal angulation, working channel I.D. 0.8 mm, irrigation channel I.D. 0.2 mm, working length 12 cm, length 100 cm remote eyepiece, fiber optic light transmission incorporated including protection cover 11520 P,

for use with: – Stone Extractor 11575 K / L – Micro Burr 11574 MB – Foreign Body Forceps 11583 TJ – Biopsy Forceps 11583 ZJ – Guide Wire 745720 – Laser Probe

11581 A


11576 A Miniature Straight Forward Telescope 0°, diameter 0.75 mm, working length 16 cm, semirigid, autoclavable, length 145 cm, with remote eyepiece and light connection, LUER-Lock adaptor, fiber optic light transmission incorporated, including Protective Tube 11576 P

11576 A

Small-Size Miniature Endoscope for Diagnostic and Interventional Sialendoscopyas recommended by Prof. MARCHALIdeal for assessment of stenotic ducts (juvenile recurrent parotitis, Sjögren, radio-iodine sialadenitis etc.)

Sheath for Diagnostic Sialendoscopy


11576 KA


Sheath for Interventional Sialendoscopy

11576 KF/KG

11576 KF Operation Sheath, oval, O.D. 1.1 mm and 1.3 mm, working length 16 cm, telescope channel O.D. 0.9 mm, working channel O.D. 1.15 mm with 2 obturators, with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11576

Operating instruments for use through the working channel of 11576 KF

– Stone Extractor 11575 K – Stone Extractor 11575 L – Guide Wire 745720 – Ballon Catheter 11577 BP – Grasping Forceps 11576 TJ – Biopsy Forceps 11576 ZJ – Laser Probe

11576 KG Operation Sheath, oval, O.D. 1.1 mm and 0.8 mm, working length 16 cm, telescope channel O.D. 0.9 mm, working channel 0.65 mm, with 2 obturators, with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11576

Operating instruments for use through the working channel of 11576 KG

– Stone Extractor 11575 K – Stone Extractor 11575 L – Guide Wire 745720 – Laser Probe

11576 KF

11576 KG


11577 A Miniature Straight Forward Telescope 0°, diameter 1 mm, working length 16 cm, semirigid, autoclavable, length 145 cm, with remote eyepiece and light connection, LUER-Lock adaptor, fiber optic light transmission incorporated, including Protective Tube 11576 P

11577 A

Miniature Endoscopes for Diagnostic and Interventional Sialendoscopyas recommended by Prof. MARCHAL

Sheath for Diagnostic Sialendoscopy


11577 KA


11577 KE

Sheaths for Interventional Sialendoscopy

11577 KE Operation Sheath, oval, O.D. 1.3 mm and 1.3 mm, working length 16 cm, telescope channel O.D. 1.15 mm, working channel 1.15 mm, with 2 obturators, with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11577

Operating instruments for use through the working channel of 11577 KE

– Stone Extractor 11575 K – Stone Extractor 11575 L – Guide Wire 745720 – Ballon Catheter 11577 BP – Grasping Forceps 11576 TJ – Biopsy Forceps 11576 ZJ – Laser Probe

11577 KD Operation Sheath, oval, O.D. 1.3 mm and 0.8 mm, working length 16 cm, telescope channel O.D. 1.15 mm, working channel 0.65 mm, with 2 obturators, with lateral LUER-Lock adaptor for irrigation for use with miniature telescope 11577

Operating instruments for use through the working channel of 11577 KD

– Stone Extractor 11575 K – Stone Extractor 11575 L – Guide Wire 745720 – Laser Probe

11577 KD/KE

11577 KD


745910 Dilator, for salivary duct, length 14 cm

Dilator

Additional Instrumentsas recommended by Prof. MARCHAL

745708 MARCHAL Bougie diameter 1 mm, for use with guide wire 745725

745709 Same, diameter 1.5 mm, for use with guide wire 745725745710 Same, diameter 2.0 mm, for use with guide wire 745725745711 Same, diameter 2.5 mm, for use with guide wire 745725745712 Same, diameter 3.0 mm, for use with guide wire 745725745713 Same, diameter 3.5 mm, for use with guide wire 745725

Bougiesfor Elimination of Stenosis

745710

Set of Salivary Duct Probesfor Dilation of the Salivary Ducts

Set of MARCHAL Salivary Duct Probes, 745847 size 0000 745848 size 000 745849 size 00 745850 size 0 745851 size 1 745852 size 2

745853 size 3 745854 size 4 745855 size 5 745856 size 6 745857 size 7 745858 size 8


Stone Extractors, Ballon Catheter and Guide Wires

11582 M Stone Extractor, O.D. 0.4 mm, basket with 4 wires, sterile, for single use

11573 T Stone Extractor, diameter 0.6 mm, basket with 4 wires, tipless, handle for fixation to endoscope

11573 M Stone Extractor, diameter 0.4 mm, basket with 4 wires, handle for fixation to endoscope

11575 K Stone Extractor, O.D. 0.6 mm, basket with 3 wires, sterile, for single use

11575 L Stone Extractor, O.D. 0.6 mm, basket with 6 wires, sterile, for single use

11577 BP Balloon Catheter, diameter 0.9 mm, sterile, single use, package of 10

11583 BP Balloon Catheter, diameter 0.7 mm, sterile, for single use, package of 10, for use with Telescopes 11574 A and 11583 A

745720 Guide Wire, O.D. 0,6 mm, sterile, for single use, package of 10, for use with Bougies 745710 – 745713

745725 Guide Wire, O.D. 0.4 mm, sterile, for single use, package of 10, for use with Bougies 745708 – 745713

n

n

n


745715 Forceps, angled, serrated, length 15 cm

745716 Forceps, angled, with 1x 2 teeth, length 15 cm

Dissecting and Tissue Forceps, ScissorsGrasping and Biopsy Forceps

745715

745716

745715

745717 Angled Scissors for Salivary Gland, with bulb, length 14 cm

11576 TJ Foreign Body Forceps, double action jaws, flexible, O.D.1 mm, working length 19 cm

11576 ZJ Biopsy Forceps, double action jaws, flexible, O.D. 1 mm, working length 19 cm

11583 TJ Foreign Body Forceps, double action jaws, flexible, O.D. 0.8 mm, working length 26.5 cm

11583 ZJ Biopsy Forceps, double action jaws, flexible, O.D. 0.8 mm, working length 26.5 cm


Sterilizing and Storage Trays

11580 A

11580 A Metal Tray, for sterilizing Salivary Duct Probes 745847 – 745858 and Dilator 745910, perforated, lid with silicone bridges, external dimensions (w x d x h): 178 x 178 x 35 mm

11580 B Metal Tray, for sterilization and storage of one Miniature Straight Forward Telescope 11575 A, 11581 A, 11582 A, 11583 A, 11578 A or 5800, perforated, lid with silicone bridges, with port for irrigation connector, external dimensions (w x d x h): 275 x 178 x 35 mm

11580 B


Sterilizing and Storage Trays

11580 C Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11576 / 11577, perforated, lid with silicone bridges, external dimensions (w x d x h): 373 x 178 x 35 mm

11580 C

11580 D Metal Tray, for Sterilization and Storage of a Miniature Straight Forward Telescope 11572 A – 11574 A, perforated, lid with silicone bridges, external dimensions (w x d x h): 275 x 175 x 37 mm

Cleaning

27651 K1 Cleaning Brush, round, flexible, for working channel diameter 0.4 – 0.6 mm, length 40 cm, for single use, package of 10

27651 K2 Same, for working channel diameter 0.6 – 0.8 mm27651 K3 Same, for working channel diameter 0.8 – 1.4 mm

27651 K5 Cleaning Brush, round, flexible, for working channel diameter 0.25 – 0.4 mm, length 40 cm, for single use, package of 10

27651 K4 Cleaning Brush, for working channel diameter 0.2 – 0.25 mm, length 30 cm, for single use, package of 10


Flexible storage possibilities## SD card-slot allows high storage capacity

## USB-slot for external HDDs and flash drives

## Picture gallery for records

## Playback of saved videos

## Print-ready patient report documentation

Crystal clear image## 15" LCD monitor

## Rotatable image display

## 24 Bit color intensity for natural color rendition

## DVI video input for pristine picture quality

## DVI video output for connecting HD monitors

Additional information## Sturdy, portable casing

## Ergonomic design allows comfortable transport ## Universal power supply unit: 100 – 240 VAC, 50/60 Hz

## Measurement (H x W x D): 450 mm x 350 mm x 150 mm

## Weight: 7 kg

Unique benefits of the KARL STORZ TELE PACK X at a Glance

20 2120 40 / 20 2121 40

20 2120 40 PAL TELECAM 20 2121 40 NTSC One-Chip Camera Head

color system PAL, autoclavable, soakable, gas-sterilizable, with integrated Parfocal Zoom Lens, f = 14 – 28 mm (2x), 2 freely programmable camera head buttons, including plastic container 39301 ACT for sterilization

Natural illumination## LED high-performance light source

## Natural colour rendition close to sunlight with a colour temperature of 6400 K

## Up to 30,000 hours lamp operating time

Ordering InformationTP100 EN TELE PACK X LED, endoscopic video

unit for use with all KARL STORZ TELECAM one-chip camera heads and video endoscopes, incl. LED-light source on a similar niveau as the Power LED 175, with integrated digital Image Processing Module, 15" LCD monitor with LED backlight, USB/SD memory module, color systems PAL/NTSC, power supply 100 – 240 VAC, 50/60 Hz,

including: USB Silicone Keyboard

with Touchpad, with US character set

Easy control combined with highest safety## Membrane keyboard approved for wipe disinfection

## Hot-Keys assuring fast and direct adjustment

## Arrow keys for intuitive control

## Pedal control available


IMAGE1 S™ – A System for all Requirements

Connects alltechnologies

IMAGE1 SCONNECT™

3DendoscopyIMAGE1 SD3-LINK™

e.g.,4K/UHD

Open tofuture

technologies

2DendoscopyIMAGE1 S™

H3-LINK

2DendoscopyIMAGE1 S™

X-LINK

VITOM® 3D10 mm 3D

video laparoscope

4 mm 3Dvideo endoscope

Flexible video endoscopes

1-chipcamera heads

PDD camera heads

Microscopycamera head

Near Infrared(NIR/ICG) 3-chipcamera head FI

3-chip camera heads


IMAGE1 S™

As individual as your requirements

Brilliant imaging

• Versatile visualization options for diagnosis and therapy

• Innovative S-Technologies for easy differentiation of tissue structures

• Clear and razor-sharp imaging

• Natural color rendition

• Automatic light source control

CLARA + CHROMA: Homogeneous illumination + contrast enhancement

Standard Image CLARA + CHROMA

CLARA: Homogeneous illumination *SPECTRA A: Color hue shift and exchange (filtering reds)

Standard Image CLARA Standard Image *SPECTRA A

CHROMA: Contrast enhancement *SPECTRA B: Spectral color shift (intensification of greens and blues)

Standard Image CHROMA Standard Image *SPECTRA B

With the IMAGE1 S™ camera platform, KARL STORZ once again sets a new milestone in endoscopic imaging, consolidating their reputation as an innovative leader in minimally invasive surgery.

The IMAGE1 S™ camera platform offers surgeons a single system for all applications. As a modular camera platform, IMAGE1 S™ combines various technologies (e.g., rigid, flexible and 3D endoscopy) in one system and can therefore be adapted to individual customer needs. Furthermore, near infrared (NIR/ICG) for fluorescence imaging, the integration of operating microscopes and the use of VITOM® 3D exoscopes is possible via the camera platform.

* SPECTRA A: Not for sale in the U.S. * SPECTRA B: Not for sale in the U.S.


IMAGE1 S™


Side-by-side View: Parallel display of standard image and *SPECTRA B

Innovative Design

• Side-by-side View: Parallel display of standard image and visualization mode possible

• Multiple source management: Simultaneous control, display and documentation of two image sources possible (e.g., hybrid procedures)

• Intuitive user guidance (dashboard, live menu and setup menu)

• Intelligent icons display settings and status

• Individual presets possible

• 50 patient data records can be archived

Status indication icons

Dashboard

Economical and futureproof

• Modular platform: Rigid, flexible and 3D technology can be selected according to individual preferences

• Easy integration of new technologies

• Forward and backward compatibility

• No additional equipment (e.g., special light sources) required for S-Technologies

* SPECTRA A: Not for sale in the U.S. * SPECTRA B: Not for sale in the U.S.


IMAGE1 S™


IMAGE1 S™ 3D

IMAGE1 S™ 3D is a further component in the IMAGE1 S™ camera platform. The 3D system provides surgeons with excellent depth perception. Furthermore, the 3D stereoscopic imaging system is particularly valuable for activities that demand a high degree of spatial perception. The 3D camera platform from KARL STORZ impresses with its wide range of applications – from laparoscopy, gynecology, ENT to microsurgical interventions.

Benefits of IMAGE1 S™ 3D

• Brilliant and razor-sharp imaging in 2D and 3D

• Switchover from 3D to 2D at the touch of a button

• Easy integration into the IMAGE1 S™ platform

• CLARA, CHROMA, SPECTRA* in 2D and 3D

• 3D system with video endoscopes with diameters of 10 mm and 4 mm as well as VITOM® 3D

Benefits of 3D integration into the IMAGE1 S™ camera platform

• Communication between all units

• One system for multiple applications

• Reduced space requirements

• One user interface for all applications

• Synergy effects between the OR workflow and financing

Available in 0°/30°

Lightweight and ergonomic design

Easy documentation in 2D via USB flash drive

Programmable camera head buttons

Optimal sharpness in the working area

* SPECTRA: Not for sale in the U.S.

AutoclavableEasy switchover

from 3D to 2D

CLARA, CHROMA,

SPECTRA* in 2D and 3D


TC 200EN* IMAGE1 S CONNECT™, connect module, for use with up to 3 link modules, resolution 1920 x 1080 pixels, with integrated KARL STORZ-SCB and digital Image Processing Module, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz

including: Mains Cord, length 300 cm DVI-D Connecting Cable, length 300 cm SCB Connecting Cable, length 100 cm USB Flash Drive, 32 GB, USB silicone keyboard, with touchpad, US

* Available in the following languages: DE, ES, FR, IT, PT, RU

Specifications:

HD video outputs

Format signal outputs

LINK video inputs

USB interface SCB interface

- 2x DVI-D - 1x 3G-SDI

1920 x 1080p, 50/60 Hz

3x

4x USB, (2x front, 2x rear) 2x 6-pin mini-DIN

100 – 120 VAC/200 – 240 VAC

50/60 Hz

I, CF-Defib

305 x 54 x 320 mm

2.1 kg

Power supply

Power frequency

Protection class

Dimensions w x h x d

Weight

TC 300 IMAGE1 S™ H3-LINK, link module, for use with IMAGE1 FULL HD three-chip camera heads, power supply 100 – 120 VAC/200 – 240 VAC, 50/60 Hz, for use with IMAGE1 S CONNECT™ TC 200ENincluding:Mains Cord, length 300 cm

Link Cable, length 20 cm

For use with IMAGE1 S CONNECT™ Module TC 200EN

IMAGE1 S™ Camera System

TC 300 (H3-Link)

TH 100, TH 101, TH 102, TH 103, TH 104, TH 106 (fully compatible with IMAGE1 S™) 22 2200 55-3, 22 2200 56-3, 22 2200 53-3, 22 2200 60-3, 22 2200 61-3, 22 2200 54-3, 22 2200 85-3 (compatible without IMAGE1 S™ technologies CLARA, CHROMA, SPECTRA*)

1x

100 – 120 VAC/200 – 240 VAC

50/60 Hz

I, CF-Defib

305 x 54 x 320 mm

1.86 kg

Camera System

Supported camera heads/video endoscopes

LINK video outputs

Power supply

Power frequency

Protection class


Weight

Specifications:

* SPECTRA A : Not for sale in the U.S.** SPECTRA B : Not for sale in the U.S.


TH 104

TH 104 IMAGE1 S H3-ZA Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, autoclavable, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

IMAGE1 FULL HD Camera Heads

Product no.

Image sensor


Weight

Optical interface

Min. sensitivity

Grip mechanism

Cable

Cable length

IMAGE1 S H3-ZA

TH 104

3x 1/3" CCD chip

39 x 49 x 100 mm

299 g

integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x)

F 1.4/1.17 Lux

standard eyepiece adaptor

non-detachable

300 cm

Specifications:

TH 100 IMAGE1 S H3-Z Three-Chip FULL HD Camera Head, 50/60 Hz, IMAGE1 S compatible, progressive scan, soakable, gas- and plasma-sterilizable, with integrated Parfocal Zoom Lens, focal length f = 15 – 31 mm (2x), 2 freely programmable camera head buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

IMAGE1 FULL HD Camera Heads

Product no.

Image sensor


Weight

Optical interface

Min. sensitivity

Grip mechanism

Cable

Cable length

IMAGE1 S H3-Z

TH 100

3x 1/3" CCD chip

39 x 49 x 114 mm

270 g

integrated Parfocal Zoom Lens, f = 15 – 31 mm (2x)

F 1.4/1.17 Lux

standard eyepiece adaptor

non-detachable

300 cm

Specifications:

For use with IMAGE1 S Camera System IMAGE1 S CONNECT Module TC 200EN, IMAGE1 S H3-LINK Module TC 300 and with all IMAGE 1 HUB™ HD Camera Control Units

IMAGE1 S Camera Heads n

TH 100


9826 NB

9826 NB 26" FULL HD Monitor, wall-mounted with VESA 100 adaption, color systems PAL/NTSC, max. screen resolution 1920 x 1080, image format 16:9, power supply 100 – 240 VAC, 50/60 Hzincluding:External 24 VDC Power SupplyMains Cord

9619 NB

9619 NB 19" HD Monitor, color systems PAL/NTSC, max. screen resolution 1280 x 1024, image format 4:3, power supply 100 – 240 VAC, 50/60 Hz, wall-mounted with VESA 100 adaption,including:

External 24 VDC Power SupplyMains Cord

Monitors


Monitors

Optional accessories:9826 SF Pedestal, for monitor 9826 NB9626 SF Pedestal, for monitor 9619 NB

26"

9826 NB

l

–

l

l

l

l

l

–

l

–

l

l

l

l

l

l

19"

9619 NB

l

–

–

l

l

l

l

l

l

l

–

l

l

l

l

l

KARL STORZ HD and FULL HD Monitors

Wall-mounted with VESA 100 adaption

Inputs:

DVI-D

Fibre Optic

3G-SDI

RGBS (VGA)

S-Video

Composite/FBAS

Outputs:

DVI-D

S-Video

Composite/FBAS

RGBS (VGA)

3G-SDI

Signal Format Display:

4:3

5:4

16:9

Picture-in-Picture

PAL/NTSC compatible

19"

optional

9619 NB

200 cd/m2 (typ)

178° vertical

0.29 mm

5 ms

700:1

100 mm VESA

7.6 kg

28 W

0 – 40°C

-20 – 60°C

max. 85%

469.5 x 416 x 75.5 mm

100 – 240 VAC

EN 60601-1, protection class IPX0

Specifications:

KARL STORZ HD and FULL HD Monitors

Desktop with pedestal

Product no.

Brightness

Max. viewing angle

Pixel distance

Reaction time

Contrast ratio

Mount

Weight

Rated power

Operating conditions

Storage

Rel. humidity


Power supply

Certified to

26"

optional

9826 NB

500 cd/m2 (typ)

178° vertical

0.3 mm

8 ms

1400:1

100 mm VESA

7.7 kg

72 W

5 – 35°C

-20 – 60°C

max. 85%

643 x 396 x 87 mm

100 – 240 VAC

EN 60601-1, UL 60601-1, MDD93/42/EEC, protection class IPX2


Cold Light Fountain XENON 300 SCB

20 133101-1 Cold Light Fountain XENON 300 SCB

with built-in antifog air-pump, and integrated KARL STORZ Communication Bus System SCB power supply: 100 – 125 VAC/220 – 240 VAC, 50/60 Hz

including: Mains Cord SCB Connecting Cord, length 100 cm20133027 Spare Lamp Module XENON

with heat sink, 300 watt, 15 volt20133028 XENON Spare Lamp, only,

300 watt, 15 volt

Cold Light Fountains and Accessories

495 NT Fiber Optic Light Cable, with straight connector, diameter 2.5 mm, length 180 cm

495 NTW Fiber Optic Light Cable, diameter 2.5 mm, length 180 cm with 90° deflection to the light source

495 NTX Same, length 230 cm

20 1133 20 Cold Light Fountain HALOGEN 250 twin, power supply: 100 – 240 VAC, 50/60 Hz

including: Mains Cord

105 HALOGEN Spare Lamp, 250 watt, 24 volt

Cold Light Fountain HALOGEN 250 twin

20134001 Cold Light Fountain XENON NOVA® 175, power supply: 100 – 125 VAC/220 – 240 VAC, 50/60 Hz

including: Mains Cord

20132026 XENON Spare Lamp, only, 175 watt, 15 volt

Cold Light Fountain XENON NOVA® 175


UG 540 Monitor Swifel Arm, height and side adjustable, can be turned to the left or the right side, swivel range 180°, overhang 780 mm, overhang from centre 1170 mm, load capacity max. 15 kg, with monitor fixation VESA 5/100, for usage with equipment carts UG xxx

UG 540

Equipment Cart

UG 220

UG 220 Equipment Cart wide, high, rides on 4 antistatic dual wheels equipped with locking brakes 3 shelves, mains switch on top cover, central beam with integrated electrical subdistributors with 12 sockets, holder for power supplies, potential earth connectors and cable winding on the outside,

Dimensions: Equipment cart: 830 x 1474 x 730 mm (w x h x d), shelf: 630 x 510 mm (w x d), caster diameter: 150 mm

including: Base module equipment cart, wide Cover equipment, equipment cart wide Beam package equipment, equipment cart high 3x Shelf, wide Drawer unit with lock, wide 2x Equipment rail, long Camera holder


Recommended Accessories for Equipment Cart

UG 310 Isolation Transformer, 200 V – 240 V; 2000 VA with 3 special mains socket, expulsion fuses, 3 grounding plugs, dimensions: 330 x 90 x 495 mm (w x h x d), for usage with equipment carts UG xxx

UG 310

UG 410 Earth Leakage Monitor, 200 V – 240 V, for mounting at equipment cart, control panel dimensions: 44 x 80 x 29 mm (w x h x d), for usage with isolation transformer UG 310

UG 410

UG 510 Monitor Holding Arm, height adjustable, inclinable, mountable on left or right, turning radius approx. 320°, overhang 530 mm, load capacity max. 15 kg, monitor fixation VESA 75/100, for usage with equipment carts UG xxx

UG 510


Headlight KS60with Cold Light Illumination

Special features:## Luminous field can be focused – adjustable from 20 to 80 mm at a working distance of 40 cm – resulting in brightness of over 175,000 lux

## Double lens system provides outstanding illumination in the depths of the operating field

## Precise delineation and no luminous field color margins## Homogeneous illumination of the luminous field without shadows

## Newly designed, lightweight headband provides improved comfort, also suitable for a small head size, can be adjusted both horizontally and vertically

## Sterilizable handle allows adjustment under sterile conditions, moveable and height adjustable

## Light cable is divided in the head area, ensuring even distribution of weight

## Extremely robust and flexible light cable due to special protective casing

## Convenient light cable length of 290 cm provides greater freedom of movement

310060 Headlight KS60, with double lens system and Y-fiber optic light cable, >175,000 lux, illuminated area adjustable from 20 – 80 mm with 40 cm working distance,

including: Headlight KS60, with removable and sterilizable Focus Handle 310065 Headband, fully adjustable, with Forehead Cushion 078511,

with cross band, including holder for Headlight 310063 Y-Fiber Optic Light Cable, with special protective casing for Headlight 310063,

length 290 cm Clip with Band, for attaching the fiber optic light cable to OR clothing

310060/310061

310061 Same, including: Headlight KS60, with removeable and sterilizable Focus Handle 310065 Headband, fully adjustable, with Forehead Cushion 078511, with cross band,

including holder for Headlight 310063 Y-Fiber Optic Light Cable, with special protective casing for Headlight 310063,

with 90° deflection to the light source, length 290 cm Clip with Band, for attaching the fiber optic light cable to OR clothing

with the compliments of

KARL STORZ — ENDOSKOPE

SIALENDOSCOPY - KARL STORZ Endoskope · SialendoScopy The endoscopic approach to Salivary Gland...

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Transcript of SIALENDOSCOPY - KARL STORZ Endoskope · SialendoScopy The endoscopic approach to Salivary Gland...