Quantifying the utility of a ‘second look’ for detecting occult bleeding in pediatric tonsillectomy

Objective

Quantify the intraoperative utility of a standardized ‘second look’ assessment following initial hemostasis in pediatric tonsillectomy procedures.

Design

Retrospective observational study.

Setting

Single tertiary care children's hospital between February and August 2023.

Participants

Children aged 2–18 years who underwent tonsillectomy with or without adenoidectomy.

Outcome measures

Following completion of surgery and initial hemostasis, the mouth gag was relaxed for 1 min, after which a standardized ‘second look’ examination of the tonsillar fossae was performed. The primary outcome was the need for additional cautery during the ‘second look’ phase.

Results

A total of 126 children were included with a mean age of 5.8 ± 0.5 years. Obstructive symptoms were the primary surgical indication (n = 107, 84.9 %). Procedures were performed by otolaryngology attendings (n = 64, 50.8 %), otolaryngology residents (n = 57, 45.2 %), or collaboratively (n = 5, 4.0 %). Suction cautery was the predominant hemostasis method (n = 115, 91.3 %), with alternative methods used in the remaining cases (n = 11, 8.7 %). Cautery was required during the ‘second look’ phase in 92 cases (73.0 %). No significant associations were found between additional cautery usage and procedure type, patient age, surgical indication, surgeon training level, or hemostasis method.

Conclusion

The high frequency of additional cautery during the ‘second look’ phase demonstrates that occult intraoperative bleeding is common and may otherwise go undetected, supporting the utility of incorporating this brief reassessment step prior to case completion.