®

F.E.S.S.
“UNCAPPING THE EGG”
The Endoscopic Approach to Frontal Recess and Sinuses

A Surgical Technique of the Graz University Medical School

by use of the KARL STORZ HOPKINS® 45° Telescopes

Heinz STAMMBERGER
 ®

F.E.S.S.
“UNCAPPING THE EGG”
The Endoscopic Approach to
Frontal Recess and Sinuses
A Surgical Technique of the Graz University Medical School
by use of the KARL STORZ HOPKINS® 45° Telescopes

Prof. Heinz STAMMBERGER, M.D.

HonFRCS(Ed), HonFRCS(Engl), HonFACS

Endoscopic Sinus & Skull Base Surgery

Consultant, Interdisciplinary Skull Base Group
Medical University Graz, Austria
 FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

All anatomical sketches and schematic

drawings were made by
Ms. Astrid Hambrosch,
Anatomical Institute of the
Karl-Franzens-University, Graz, Austria
(Head: Prof. F. Anderhuber, M.D.)

Important notes: FESS – “Uncapping the Egg” –

Medical knowledge is ever changing. As new The Endoscopic Approach to Frontal Recess and Sinuses
research and clinical experience broaden our A Surgical Technique of the Graz University Medical School
knowledge, changes in treat ment and therapy by use of the KARL STORZ HOPKINS® 45° Telescopes
may be required. The authors and editors of the Prof. Heinz Stammberger, M.D.
material herein have consulted sources believed to
HonFRCS(Ed), HonFRCS(Engl), HonFACS
be reliable in their efforts to provide information that
is complete and in accord with the standards accepted Endoscopic Sinus & Skull Base Surgery,
at the time of publication. However, in view of the Consultant, Interdisciplinary Skull Base Group
possibility of human error by the authors, editors, or Medical University Graz, Austria
publisher, or changes in medical knowledge, neither
the authors, editors, publisher, nor any other party who Correspondence address of the author:
has been involved in the preparation of this booklet,
warrants that the information contained herein is in Prof. Heinz Stammberger, M.D.
every respect accurate or complete, and they are Sonnleitenweg 51
not responsible for any errors or omissions or for the A - 8034 Graz, Austria
results obtained from use of such information. The E-mail: [email protected]
information contained within this booklet is intended for
use by doctors and other health care professionals. This All rights reserved.
material is not intended for use as a basis for treatment 1st edition 2005
decisions, and is not a substitute for professional ®
consultation and/or use of peer-reviewed medical
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FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

Contents

Introduction.................................................................................................... 7

Anatomy and Pathophysiology of

Frontal Recess and Frontal Sinus ............................................................... 9

Variants of the Uncinate Process ................................................................ 10

“Uncapping the Egg” .................................................................................... 14

Postoperative Care ....................................................................................... 17

Telescopes and Instruments ........................................................................ 18

Surgical Steps (Anatomical Specimen) ....................................................... 21

Case 1 ............................................................................................................. 23

Case 2 ............................................................................................................. 25

Case 3 ............................................................................................................. 27

Case 4 ............................................................................................................. 29

The KARL STORZ HOPKINS® 45° Telescopes

Telescopes, Instruments, Units,
Video Cameras and Accessories ........................................................... 31–49

Extracts from the following Catalogs:

ENDOSCOPES AND INSTRUMENTS FOR ENT
TELEPRESENCE, IMAGING SYSTEMS, DOCUMENTATION – ILLUMINATION
FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

Introduction
The endonasal approach to the frontal sinus undoubtedly requires sound
anatomical knowledge, highest surgical skills and dexterity. The frontal recess
is an anatomically very complex structure and can be seen as the ethmoidal
”pre-chamber” to the frontal sinus proper. Its configuration depends on a variety
of cells and lamellae with a high degree of individual variation. Almost always
disease in the frontal sinus results from underlying disease processes in the clefts
of the frontal recess. Rarely ever will inflammatory processes originate in the frontal
sinus cavity itself. These findings consequently resulted in diagnosis, conservative
and surgical therapeutic measures to focus on these ”pre-chambers” to the frontal
sinus. Especially in surgery, the delicate bony structures and the mucosa in the Fig. 1
frontal recess region require a very careful, minimally traumatic approach: Overly Original drawing from Halle’s publication
forceful handling of instruments, traumatising the mucosa or its removal willrapidly from 1906: Drilling away the entire superior
nasal spine. Provided Halle already had had
lead to granulations, scar and stenosis formation. In these cases postoperative telescopes of different angulations, he most
healing will be significantly delayed, local postoperative care must be intensified likely would have chosen the more
and patients frequently be seen for follow-up. It is not a rare finding, that following physiologic approach dorso-laterally to the
traumatic manipulations in this region patients show frontal sinus problems which nasal spine (dotted line).
were not present before. These frontal sinus problems therefore must in part be
seen as iatrogenic.

Fig. 2 Fig. 3
Massive opacification of the frontal sinus …resulting from blockage of the frontal
bilaterally… recess.
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A Surgical Technique of the Graz University Medical School

In recent years many surgical schools have recommended to routinely create as

large a communication between the frontal recess and the frontal sinus as possible,
to avoid the well know tendencies for scarring and stenosis. In our view this has
resulted in too frequently used, too radical, too traumatic approaches. These
are usually performed with a drill (or curved blades of powered instruments) as
so-called “drill-out procedures”. According to our experience, these are required
for a very small number of special indications only. In this brochure we would like
to illustrate how to succeed in the vast majority of cases with significantly less
traumatic procedures, “simply” following the anatomy. This surgical approach has
been applied by us for almost 3 decades now and has been constantly improved.
According to our experiences, atraumatic functional surgery in the vicinity of
the frontal sinus ostium can only be performed using endoscopes of different
angulations. This fact is sort of self-explanatory if one studies the topographical
anatomy of the region. There is no need to drill away the “nasal beak” (the inner
superior nasal spine) if one uses telescopes of different angulations and follows
the anatomical route predesigned by nature. In doing so, only thin and delicate
bony lamella have to be removed, though in a “delicate surrounding”. If one
wants to engage in this kind of frontal sinus surgery, it is mandatory that the
same principles of care (and I dare to say: of dexterity) are applied as in stapes
surgery (D.W. Kennedy).

Following our recommendations KARL STORZ Tuttlingen designed two

45° endoscopes, which allow for an excellent view into the frontal recess,
especially if the middle turbinate is preserved.

Fig. 4
Mucus transport through frontal sinus and recess. There can be an active transport into the
frontal sinus from out of the frontal recess medially.
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A Surgical Technique of the Graz University Medical School

Anatomy and Pathophysiology

of Frontal Recess and Frontal Sinus
The frontal sinus develops from the most anterior and superior parts of the anterior
ethmoid: The frontal bone is pneumatised from the frontal recess (Killian). We
discourage the use of the term “ductus nasofrontalis, nasofrontal duct”, as a true
tubular structure connecting frontal sinus and anterior ethmoid does not exist. In a
somewhat simplified way, the frontal sinus is nothing else but a cell of the anterior
ethmoid, pneumatising the frontal bone. Not surprisingly therefore the frontal
sinus depends on its “origin” in the anterior ethmoid with respect to its normal and
pathophysiology.
On a sagittal section (Fig. 5) the transition of frontal sinus to frontal recess has
an hour-glass shape: The floor of the frontal sinus (sf) narrows downward like
a funnel towards the frontal sinus ostium (osf). From here, the frontal recess
widenes like an inverted funnel (rf). So both structures together can be seen as an
hour-glass, with the “waist” at the level of the frontal sinus ostium.
The frontal recess can be significantly influenced and narrowed by a number
of structures (Fig. 6): 1.) the uncinate process, 2.) agger nasi cell(s), 3.) the
ethmoidal bulla, 4.) other cells of the anterior ethmoid, located in the frontal recess.
Frequently, combinations of the variants to be discussed below are encountered
in patients suffering from acute or recurrent inflammations of the frontal sinus. In a
very schematised and simplified way, all these structures narrow the inferior part of
the “hour-glass”, i.e. the frontal recess and thus predispose to recurring problems.

Fig. 5 Fig. 6
Sagittal CT demonstrating the basal Schematic drawing of narrowing of frontal
lamellae: recess by agger nasi-cells (blue), uncinate
1 = basal lamella of the uncinate process (red) and ethmoidal bulla and
2 = b. l. of the bulla other anterior ethmoidal cells (green),
3 = b. l. of the middle turbinate respectively.
4 = b. l. of the superior turbinate
Note the hourglass configuration of the
transition from frontal sinus to frontal
recess.
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A Surgical Technique of the Graz University Medical School

Variants of the Uncinate Process

There are three basic configurations of the uncinate process (Fig. 7):
a) In a coronal cut, the uncinate process can extend superiorly, bend laterally
and insert at the lamina papyracea (orbitalis). Thus a superior blind
(recessus terminalis) of the ethmoidal infundibulum is formed, separating the
latter to some degree from the frontal recess.
b) The uncinate process can extend straight superiorly and reach the skull
base.
c) It can curve medially and fuse with the insertion of the middle turbinate.
Transitions between these three extremes occur.
If there is a pronounced terminal recess (Fig. 8b) reaching extremely far
superiorly, the uncinate process with this “cap” can almost fill the frontal recess,
even contact the skull base and medially the lateral lamella of the cribriform
plate. The clinically significant effect of such a configuration can be impairment or
even blockage of ventilation and drainage of the frontal sinus proper.
If the agger nasi region is pneumatised, i.e. agger nasi cells exist, these can expand
towards superiorly and posteriorly and thus more or less fill the entire frontal recess
with their thin “cap” of bone in an analogous fashion.

a b c a b c

Fig. 7 Fig. 8
Anatomical variations of the uncinate process. Narrowing of frontal recess by combinations of variants of uncinate,
bulla and agger nasi cells.
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A Surgical Technique of the Graz University Medical School

The ethmoidal bulla (or other cells of the anterior ethmoid, for instance so-called
infundibular cells) may expand into the frontal recess from posterior-inferiorly,
i.e. they pneumatise upward and forward and thus with their cranial “cap” of
bone may fill the frontal recess. This too, may lead to impairment/stenosis. Not
only may combinations of these three basic variants prevail, but cells may
develop into the frontal sinus (bulla frontalis, intrafrontal cells) presenting a true
challenge for diagnosis and even more, surgical therapy (Figs. 5–9).
Figs. 8 and 9 demonstrate some of the possibilities in a schematic fashion and in
CT: One can clearly see, that in all cases access to the frontal sinus is blocked by a
paper-thin cap of bone with its two mucosal layers.
It is of utmost importance to understand, that access to the frontal sinus ostium is
not blocked by the allegedly important “nasal beak”. This massive bony structure is
only of relevance in patients with extremely narrow dorsum of the nose. Even then,
access to the frontal sinus is only impeded medially, next to the nasal septum.
Approaching from dorso-laterally, the internal nasal spine very rarely presents an Fig. 10 a
obstacle or a pathophysiologically relevant structure.
Very clearly this situation can be recognised in Fig. 1 taken from Halle’s publication
from 1906: It must be assumed that Halle would not have chosen this approach,
if at that time endoscopes for “looking around the corner” had been available
to him. The removal of the very thin bony septations posterolateral to the “nasal
beak” would have resulted in a wide and natural passage, via a far less traumatic
approach, avoiding unwarranted removal of bone and mucosa.

Fig. 10 b
Figs. 10 a + b: Schematic drawing of
frontal recess narrowed by agger nasi and
infundibular cells (a), as well as by a
terminal recess and infundibular cells (b).

Fig. 9a Fig. 9 b
Figs. 9a + b: Several cells may be superimposed and narrow the frontal recess, sometimes even reach into the sinus lumen itself as
“intrafrontal cells”.
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A Surgical Technique of the Graz University Medical School

If uncinate, bulla and agger nasi cells were resected during endonasal surgery
and the frontal sinus ostium is not visible, this almost always can be traced
back to a typical anatomical situation: A thin curved bony “shell” has remained,
which may be in contact with the skull base or the lateral lamella of the middle
turbinate. This thin bone layer blocks access to the frontal sinus proper, towards its
ostium. The technical challenge is to identify and carefully remove this cap of bone.
In the vast majority of cases this manoeuvre will expose the level of the frontal sinus
ostium. Rarely there is need then to enlarge the latter let alone to drill away the
“nasal beak”.
For these manipulations simple but delicate instruments are required (Figs.
12, 13). With specially curved curettes (according to F. Kuhn) or Giraffe forceps
these structures can be removed. All these manoeuvres must be performed
under good direct vision and optimal hemostasis. Only in this way true
atraumatic surgery is possible. The new KARL STORZ 45° endoscopes were
especially developed for this purpose. They offer a crucial “extra”of retrograde
upward viewing allowing for a complete inspection of the frontal recess.

Fig. 12 Fig. 13
Removal of an “cap of the egg” with giraffe Remnants of an “egg cap” are identified and
forceps. carefully removed.

Fig. 11 a Fig. 11 b Fig. 11 c

Figs. 11 a–c: Remnants of thin “bone caps” of a terminal recess (a), an agger nasi-cell (b) and an ethmoidal bulla (c),
all narrowing access to the frontal sinus.
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A Surgical Technique of the Graz University Medical School

In the past it was not always possible to achieve this with the well proven 30°
telescopes. On the other hand the 45° telescopes are constructed in a way
that they still allow for a straight forward view. This is important when inserting
the instruments, as at 6.00 o’clock of the visual field the view is almost parallel
to the longitudinal axis of the endoscope. This is an advantage over the
well proven 70° endoscopes, which do not offer any optical information in the
direction of the shaft itself.
One of our favourite instruments for surgery in the frontal recess, especially
when removing thin bone caps, is the upbent circular cutting punch (Fig.14).
With this instrument one can well avoid to expose bare bone which in turn will
help to avoid scaring and restenosis. If performed well, this approach leaves
behind a wide frontal recess and an open frontal sinus ostium. All walls are
covered by mucosa with only minimal areas of bone exposed at the cutting edges
of the very thin bony lamella. This considerably shortens the postoperative healing
phase.

Fig. 14 a Fig. 14 b
Schematic drawing demonstrating the use of the upcurved circular cutting punch.
 FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

“Uncapping the Egg”

For many years we have been teaching this technique in our endoscopy
courses at Graz and have presented the concept of “uncapping the egg”
for the first time internationally during the “3rd International Symposium on
Advanced FESS” at Cairns/Australia in 1995. “Uncapping the Egg” represents a
mnemonic only; the diagrams are very schematic, over-simplified, not to scale –
but do point out the main principle.
In a sagittal section, the transition from frontal sinus down to the frontal recess
has an hour-glass shape (see page 9), one might as well say: The shape of an
egg-holder. The waist corresponds to the level of the frontal sinus ostium. If one
now puts a breakfast-egg into the egg-holder, opens and empties it, the lower
portion of the “cap of the egg” remains in the egg-holder. If this now is turned
upside down, the situation is analoguous to the frontal recess: The superior
“empty” part of the egg-holder represents the frontal sinus infundibulum, i.e. the
Fig. 15
“The Egg” in an egg holder. floor of the frontal sinus narrowing towards the ostium. The inferior part of the egg-
holder with the cap of the egg represents the frontal recess. The task now is, to
remove the eggshell sitting tightly in the “frontal recess”. If one succeeds, the walls
of the frontal recess are not traumatised, but the passage through frontal recess via
frontal sinus ostium into frontal sinus is free (Figs. 15–18).
“Uncapping the Egg” has proven an excellent mnemonic to think of and look
for the “eggshells” which usually block the frontal recess in difficult situations.
Following these principles and using the new KARL STORZ 45° telescopes,
drill-out procedures have remained an absolute rarity amongst thousands of
cases we have operated over the years.
Especially the circular cutting punch in its upbent version (Fig. 18) allows to
enlarge the frontal sinus ostium itself – if required – following the same principles of
minimal trauma.
Fig. 16
The egg is uncapped, the contents
removed and the egg holder turned
upside down.

Fig. 17
Fig. 17 Superimposing the “inverted” egg
Superimposing the “inverted” egg holder over the frontal sinus
holder over the frontal sinus infun- infundibulum and frontal recess, …
dibulum and frontal recess, …

Fig. 18
…the challenge is to remove the remaining “cap of the egg” from the frontal recess to reach the frontal sinus ostium and, finally,
the frontal sinus proper.
FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

In Figs. 19 and 20 postoperative CT-findings demonstrate why these patients

suffer from recurring frontal sinus problems: In all cases the surgeons failed
to remove (or to identify) the cranial cap of the individual cells or the uncinate
process. Looking back at our own learning curve, it is not rare to mistake a
pronounced terminal recess or supraorbital ethmoid cell for the frontal sinus
proper. The pictures clearly identify the thin bony caps remaining and the
resulting narrowing and stenosis which must be taken care of during revision
surgery. These pictures furthermore stress the need for exact endoscopic and
radiologic diagnosis (axial CT-scans would not show these changes!) in avoiding
unwarranted radical surgery using drills.

Fig. 19
Typical postoperative finding: On the left
side (of the patient) the bony cap of an
agger nasi-cell was not removed, resulting
in recurrent frontal sinusitis.

Fig. 20
As before, agger nasi-cells on both sides
were not removed sufficiently, resulting in
recurrent frontal sinus problems.
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A Surgical Technique of the Graz University Medical School

The main prerequisite for the success of this surgical approach is an atraumatic
technique.
Particular care must be taken to avoid any damage to the parietal mucosa, i.e.
ideally the walls of the frontal recess should be completely covered with mucosa
or at least the basal layers thereof. Areas of denuded bone must be reduced to
a minimum. In no case the frontal sinus ostium should be traumatised circularly,
let alone mucosa be removed in this region. Inevitably this will lead to scar and
stenosis formation. This problem is illustrated in Figs. 21–24. Fracturing of the
middle turbinate should be avoided by all means, to prevent lateralisation, scaring
and stenosis of the frontal recess. The mucosa at the insertion of the middle
turbinate should not be traumatised, especially no opposing raw surfaces be
created. If a middle turbinate has been destabilised accidentally, the technique
illustrated in Fig. 25 can be used to avoid lateralisation. Stents and drains are not
helpful if mucosa has been removed. The process of reepitheliasation and scarring
continues for many months!

Fig. 21
Schematic drawing of a seriously affected
frontal recess.

Fig. 22 Fig. 23 Fig. 24

Ideal postoperative situation: The arrows A situation like this must be avoided by Fractures of the middle turbinate should
indicate the resection margins of uncinate all means: Significant areas of bone are strictly be avoided, to prevent lateralisation
process and anterior ethmoidal cells. denuded and no longer covered by and ensuing formation of scars and
Only here has bone been minimally mucosa. stenosis.
exposed, all other walls of the surgical
cavity are covered by mucosa.
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A Surgical Technique of the Graz University Medical School

Postoperative Care
In patients who underwent frontal recess/sinus revisions, careful endoscopic
postoperative care is of utmost importance. Usually 8–12 days postoperatively
we start to aspirate wound secretions and instrumentally remove crust under
direct endoscopic vision, using 45° telescopes for these manipulations. No new
trauma should be produced during this procedure. The duration of follow-up
varies depending on the findings and the underlying disease. Usually this first
endoscopic control gives a good impression on whether or not a problem
case is at hands requiring frequent follow-ups at short intervals, or whether the
patient needs to be followed up at intervals of 4–5 weeks only. Depending on
initial underlying pathology, normalisation/stabilisation can be expected after
6 weeks to 6 months.

Fig. 25
If a middle turbinate insertion is fractured by accident, it can be stabilised as follows:
Small areas of opposing mucosal surfaces are scarified, inducing circumscribed adhesions.
These scars can – but do not have to – be separated again several weeks later
(following W. Bolger).
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A Surgical Technique of the Graz University Medical School

Telescopes and Instruments

Fig. 27 demonstrates the features and advantages of the KARL STORZ 45°
telescopes: Despite the significant angulation a straight forward view along the
shaft axis is yet possible.
This allows to avoid contact with and lesions of mucosa of the septum, the turbinate
and other structures and is a definite advantage over the 70° lenses. Compared to
the 30° lenses, the new 45° endoscopes significantly enhance the capability for
“looking around the corner”. This is a prerequisite for surgical procedures in the
difficult topography of the frontal recess and sinus. The surgeon not only has to
Fig. 26 look “around the corner”, but the instruments have to reach “around the corner”
Schematic drawing of the endonasal
endoscopic route “around the corner” as well. Endoscope and instrument are inserted almost parallel to the nasal dorsum
(yellow broken line) to the frontal sinus, under (i. e. lateral to) the middle turbinate. From here, the working and viewing
modifying Halle’s depiction from 1906. direction changes towards superiorly and anteriorly, i.e. in a retrograde fashion
when approaching the frontal sinus through the frontal recess. In patients with
pronounced supraorbital bulging, this angulation can be almost 90°. Instruments
developed for endoscopic surgery of the frontal recess and sinus are designed
for this respect. Inserting them through the nostrils requires some training and
dexterity, as the tips of the instruments must be guided in an arch to be inserted
under the middle turbinate and then retrogradely up and anteriorly. It is especially
during these moves that the less experienced (and sometimes: less patient)
surgeon finds it difficult to proceed without occasional lesions of the mucosa.
Consequent training is mandatory therefore.
Like the 30° telescopes, the 45° telescopes from KARL STORZ are available in
two versions: A standard version and one with lateral light cable connection (Fig.
27). This latter version offers the following additional advantage: Sometimes the
eyepiece of the endoscope must be significantly lowered to allow view towards
the frontal sinus ostium. In these cases, the light cable may interfere with the chin
of the patient and/or the intubation gear. This interference is largely avoided when
using the endoscope with lateral light cable connection. Thus the eyepiece can
be lowered an additional 10 centimetres, resulting in an important gain of view
towards far anteriorly located frontal sinus ostia.

Fig. 27
The two KARL STORZ HOPKINS® 45° telescopes.
FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

For the same reason upbiting Blakesley forceps have been designed with a
horizontal handle (Fig. 28). This results in a better angulation during the initial work
in the frontal recess.
The delicate “giraffe” forceps are used to remove the delicate bony lamellae
(“cap of the egg”) from the frontal recess: Frontally oriented segments are
grasped with the forward-backward opening forceps, longitudinally oriented bone
segments with the laterally (left-right) opening one. If there is need to remove
thicker bony segments, through-cutting forceps (Figs. 29) are used. Of all the
instruments mentioned, we only use the smaller size (size 1) to avoid trauma to the
mucosa by trying to insert large instrument tips.
Several years ago we developed the circular cutting punch to resect horizontally
oriented thin bony lamellae if required. If we have to enlarge the frontal sinus
ostium proper, we almost exlusively do this with circular cutting forceps.
The advantage is evident: Cutting and thus removal of bone is possible in all
directions (360°), without any need to rotate the shaft or handle of the instrument. Fig. 29 a
Interference with the endoscope thus is minimised. “Giraffe Neck” Forceps.

Fig. 29 b
Through-cutting BLAKESLEY Nasal
Forceps.

Fig. 28 Fig. 30
45° upturned BLAKESLEY-STAMMBERGER Nasal Forceps with handle in right horizontal Detail of upturned Circular Cutting
position. Punches.
 FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6

Fig. 7 Fig. 8 Fig. 9

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Sequential Digital Photographs

Demonstrating some of the Surgical
Steps on an Anatomical Specimen with
Simple Topography (right side).
Fig. 1: View on the right middle nasal meatus with a 30° telescope. An anterior
and posterior ethmoidectomy have been performed, whereas all of the
parietal mucosa was preserved (!). Superior remnants of the bulla lamella have
remained, the frontal sinus ostium cannot be visualised.
Fig. 2: The same situation seen through the 45° telescope: Clearly, anterior
to the bulla lamella the frontal recess can be visualised, narrowing upwards
towards the frontal sinus ostium. The 45° telescope is advanced into the
middle nasal meatus right under the bulla lamella (Fig. 3). Clearly, the skull base Fig. 10
posterior to the bulla lamella and, at the same time, the frontal sinus ostium
high up in the frontal recess become visible. With a curved curette (Fig. 4) the
remaining parts of the bulla lamella are carefully pushed anteriorly and the skull
base behind the lamella becomes visible (Fig. 5). Here, the oblique course of the
anterior ethmoidal artery can be identified. With an upbiting Blakesley, remnants of
the bulla lamella are removed without resection of the parietal mucosal lining (Fig.
6). Now, the frontal sinus ostium can be better visualised (Fig. 7) and it becomes
evident that it was narrowed from dorsally by the bulla lamella. When the latter is
removed further, the frontal sinus ostium can be enlarged posteriorly without any
problems (Fig. 8). lf required, in a “real” patient the frontal sinus ostium proper
can be enlarged now with an upcurved circular cutting punch without any need
to remove thicker bone areas (Figs. 9–11). A wide access to the frontal sinus
ostium results, with the mucosal layer more or less completely intact. There is no
region in the frontal recess, where bone is not covered by mucosa. With the 45°
telescope not only the roof of the frontal sinus with its small subseptations can
be identified, but even the anterior wall (!) be visualised. This demonstrates that
a type-II-drainage can be performed endoscopically, without any interference by
the “nasal beak/internal superior nasal spine”. lf required, manipulations inside the
frontal sinus proper can be performed through such enlarged access.
The endoscopic technique reaches its limitations however, when attempting Fig. 11
to remove ethmoidal cells which have encroached extremely far into the frontal
sinus, or when trying to approach extremly far laterally located processes.
The intraoperative sequences documented on the following pages are not
intended to represent “ideal cases” but rather everyday unselected situations with
all their smaller and larger problems, including diffuse intraoperative bleeding, and
difficulty of anatomical orientation.

Fig. 12
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A Surgical Technique of the Graz University Medical School

Fig. 1

Fig. 2 Fig. 3 Fig. 4

Fig. 5 Fig. 6 Fig. 7

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A Surgical Technique of the Graz University Medical School

Case 1
Fig. 1: Typical intraoperative situation: Only the surgeon and the scrub nurse
are required for endonasal endoscopic procedures (including tumors and other
operations at the anterior skull base). No assistant is necessary. The surgeon can
control the position of his endoscopic picture via the smaller monitor, the larger
monitor providing information for the scrub nurse, the anesthetists and residents/
registrars and/or visitors.

Fig. 2: Intraoperative situation on the left side: The 45° telescope has been
introduced into the middle meatus lateral to the middle turbinate. View is up
into the frontal recess. The uncinate process and bulla have been resected. The
patient is suffering from massive chronic rhinosinusitis with polyposis (type IV). The
frontal sinus ostium cannot be visualised yet. Looking for the “cap of the egg”, a
curved curette is introduced and the medial free margin of the bony cap carefully
palpated. After identification, the thin bony shell is carefully elevated off the middle
turbinate (Figs. 3, 4). Clearly one can see now that all which needs to be removed
is an eggshell thin bone cap with its bilateral mucosal layer, indeed. This “cap of
the egg” is carefully pushed laterally now (Fig. 5) and removed with a thin giraffe
forceps. This results in a first free view of the frontal sinus ostium (Fig. 6), and after
aspiration of retained mucus a more or less normal mucosa inside the frontal sinus
can be visualised.
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A Surgical Technique of the Graz University Medical School

Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6

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A Surgical Technique of the Graz University Medical School

Case 2
Right side of a patient: The 45° telescope has been introduced under the
middle turbinate into the middle meatus behind the suspected “cap of the egg”,
blocking access to the frontal sinus ostium. The posterior portion of this bone
cap has been identified and is gently elevated towards anteriorly (Fig. 2). This
results in identification of the frontal sinus ostium proper. The latter now is
enlarged with the upturned circular cutting forceps (Fig. 3), removing further
fragments of the “eggshell” of this high reaching agger nasi cell. In Fig. 4 the
precision can be seen resulting from the use of the upcurved circular cutting
punch. Now view into the frontal sinus proper is possible (Fig. 5). Some minor
bony edges are carefully removed out of the frontal recess (Fig. 6), leaving the
parietal mucosa to cover all of the bony walls. No packing is used in this region
nor are stents applied. Fig. 7 demonstrates the situation encountered at the first
endoscopic control 10 days postoperatively, after removal of minor crusts and
aspiration of wound secretions. lt is time and again surprising to see the rapid
recovery and healing following these atraumatic approaches to the frontal sinus.
We believe, that preservation of the parietal mucosa and the avoidance of bone
exposure contribute significantly to this phenomenon.

Fig. 7
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A Surgical Technique of the Graz University Medical School

Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6

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A Surgical Technique of the Graz University Medical School

Case 3
View into the frontal recess, left side, with the 45° endoscope. Clearly one can
see the somewhat oblique course of the anterior ethmoidal artery, suspended
in an approximately 5 mm long bony mesentery from the skull base. Anterior to
the artery a small supraorbital cell can be identified. Anterior to that, a delicate
bony “cap” blocks view and access to the frontal sinus. In Fig. 2, a curved
spoon is carefully introduced between the supraorbital cell and the “bone cap”
and the thin bony intersection removed. This does not yet open access to the
frontal sinus, but one can recognise the small bony edge of the “cap of the egg”
(Fig. 3). Further approach is between the latter and the middle turbinate, and the
bony wall of this (agger nasi) cell is carefully pushed laterally, thus identifying
the way to the frontal sinus ostium proper (Fig. 4). In Fig. 5 one can see how
prior to removal of the “egg cap” a malleable suction tube is introduced into the
frontal sinus and the retained mucus is aspirated. Now the lumen of the frontal
sinus can clearly be identified (Fig. 6). Thin remnants of the “egg cap” which had
reached significantly into the lumen of the frontal sinus, are removed with a
curved circular cutting punch (Fig. 7). This results in a free and well epithelialised
passage between frontal sinus and recess (Fig. 8).

Fig. 7 Fig. 8
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A Surgical Technique of the Graz University Medical School

Fig. 1 Fig. 2 Fig. 3

Fig. 4 Fig. 5 Fig. 6

Fig. 7 Fig. 8 Fig. 9

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A Surgical Technique of the Graz University Medical School

Case 4
Same patient, right side: The anterior ethmoid has been cleared already, the
middle turbinate is in situ and unharmed (Fig.1). When a 45° telescope is
inserted lateral to the middle turbinate, view is possible into the frontal recess
(Fig. 2) and onto the anterior skull base. The frontal sinus ostium itself cannot
be identified however. At 12.00 o’clock clearly the dome-like roof of an anterior
ethmoidal cell can be recognised, apparently reaching into the frontal sinus
proper (Figs. 2 and 3). With a malleable suction tube the posterior circumference
of this cell cap is further delineated (Figs. 4 and 5). In Fig. 6 the curved curette
points towards the cell cap which needs to be removed. Clearly, the posterior and
medial margin of the latter can be identified. The cell cap together with its mucosa
is carefully removed progressing from the back to the front (Figs. 7 and 8), and the
frontal sinus ostium proper can now clearly be identified (Figs. 9 and 10). Remnants
of the “cap of the egg” are carefully removed with the upcurved circular cutting
punch (Fig. 11), resulting in a wide access to the frontal sinus proper (Fig.12). Fig. 10

It should be noted that the total opacification of this frontal sinus in the CT-scans
was due to the retained mucus only, whereas the mucosa itself does not present
with significant pathology. Findings like these further support our use of this
surgical technique with its relative atraumatic approach.

Fig. 11

Fig. 12
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A Surgical Technique of the Graz University Medical School

Conclusion
The endoscopic techniques illustrated in this brochure have been used by us since
many years. With these, we have managed to avoid radical endonasal surgery
(as well as routine external procedures) by and large. With an average of 400 – 600
patients operated on per year at our department we had to use drill-out techniques
in less than 2 per cent. This figure has remained constant over many years and
includes revision cases as well. With this, we do not want to dispute the value of
“drill-out” procedures. We strongly feel however, that they are required for special,
well selected indications only. In the majority of cases one can (re-)establish the
natural ventilation and drainage with significantly less radical approaches, following
the anatomical “pathways”.
If surgery is performed using the microscope or 0° endoscopes only however,
“view around the corner” and exposure of the frontal sinus ostium in many cases
is not possible at all: Then, the “nasal beak” has to be drilled away – the natural
anatomical access simply is not a straight one!
We feel that the KARL STORZ 45° telescopes are a significant development to
further improve and enhance our possibilities of less traumatic, functional surgery
of frontal sinus diseases, following the natural anatomical routes.
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A Surgical Technique of the Graz University Medical School

The KARL STORZ HOPKINS® 45° Telescopes

– Telescopes, Instruments, Units, Video Cameras and Accessories –

Extracts from the following Catalogs:

ENDOSCOPES AND INSTRUMENTS FOR ENT
TELEPRESENCE, IMAGING SYSTEMS,
DOCUMENTATION – ILLUMINATION
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A Surgical Technique of the Graz University Medical School

HOPKINS® Telescopes, 45° – autoclavable

diameter 4 mm and 2.7 mm

7230 FA/7229 FA

7230 FLA

7230 FA HOPKINS® Forward-Oblique Telescope 45°,

enlarged view, diameter 4 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: black
7230 FLA HOPKINS® Forward-Oblique Telescope 45°,
enlarged view, diameter 4 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
connection for fiber optic light cable on left side,
color code: black
7229 FA HOPKINS® Forward-Oblique Telescope 45°,
enlarged view, diameter 2.7 mm, length 18 cm,
autoclavable,
fiber optic light transmission incorporated,
color code: black

It is recommended to check the suitability of the product for the intended procedure prior to use.
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A Surgical Technique of the Graz University Medical School

Accessories
for use with HOPKINS® Telescopes

723772 STAMMBERGER Telescope Handle,

round, standard model, length 11 cm,
for use with HOPKINS® Telescopes
30° – 120° with diameter 4 mm
and length 18 cm
723750 B Protection Tube, working length 19.7 cm,
for use with HOPKINS® Telescopes
with length 18 cm

39501 A1 Wire Tray for Cleaning, Sterilization

and Storage of one rigid endoscope,
­including holder for light post adaptors,
silicone telescope holders and lid,
­external dimensions (w x d x h):
290 x 80 x 52 mm, for rigid endoscopes
39501 A1 with up to 10 mm diameter and
20 cm working length

39501 A2 Wire Tray for Cleaning, Sterilization and

Storage of two rigid endoscopes and one
light cable, including holder for adaptors,
silicone telescope holders and lid, external
dimensions (w x d x h): 352 x 125 x 54 mm,
for rigid endoscopes with up to
­diameter 10 mm and working length 20 cm

39501 A2
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A Surgical Technique of the Graz University Medical School

Sickle Knife, Frontal Sinus Curettes and Antrum Cannulas

628001 Sickle Knife, pointed, length 19 cm

628712 KUHN-BOLGER Frontal Sinus Curette,
/1
1
55° curved, oval, forward cutting,
/1
1

628712 length 19 cm
628001
628714 KUHN-BOLGER Frontal Sinus Curette,
90° curved, oval, forward cutting,
length 19 cm
586125 v. EICKEN Antrum Cannula,
LUER-Lock, long curved, malleable,
/1
1
serrated grip plate, outer diameter 2.5 mm,
628714 length 12.5 cm
586130 v. EICKEN Antrum Cannula,
LUER-Lock, long curved, malleable,
serrated grip plate, outer diameter 3.0 mm,
length 12.5 cm

628001 628712 586125

586130

Circular Cutting STAMMBERGER Punches

651055/651060 651060

651055

651050/651065 651065

651050 STAMMBERGER Punch, circular cutting, 651060 STAMMBERGER Punch, circular cutting,
for sphenoid, ethmoid and choanal atresia, 65° upturned, for frontal sinus recess,
diameter 4.5 mm, with cleaning connector, diameter 3.5 mm, with cleaning connector,
working length 18 cm working length 17 cm
651055 Same, diameter 3.5 mm 651065 Same, diameter 4.5 mm
FESS – “Uncapping the Egg” – The Endoscopic Approach to Frontal Recess and Sinuses
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A Surgical Technique of the Graz University Medical School

Circular Cutting STAMMBERGER Punches

651057

651057 STAMMBERGER Punch, egg-shaped tip,

circular cut, 60° cutting direction from distal
above to proximal below, tip diameter 3.5 mm,
straight sheath, for sphenoid, ethmoid and
choanal atresia, with cleaning connector,
working length 18 cm
651058 Same, circular cut 120°

651052 STAMMBERGER Punch, egg-shaped tip,

circular cut, 60° cutting direction from distal
above to proximal below, tip diameter 4.5 mm,
straight sheath, for sphenoid, ethmoid and
choanal atresia, with cleaning connector,
working length 18 cm
651053 Same, circular cut, 120° cutting direction
from distal below to proximal above,
tip diameter 4.5 mm

651061 STAMMBERGER Punch, egg-shaped tip,

circular cut, 90° cutting direction,
tip diameter 3.5 mm, sheath 65° upturned,
for frontal sinus recess, with cleaning connector,
working length 17 cm
651066 Same, tip diameter 4.5 mm

651050 R

651050 R Cleaning Tool, for circular cutting punches type 651050 /

651055 / 60 / 65, double-ended, length 14 cm
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A Surgical Technique of the Graz University Medical School

STAMMBERGER RHINOFORCE® II “Giraffe Neck” Forceps

651010 STAMMBERGER RHINOFORCE® II

Forceps, cupped jaws,
651010 vertical opening, 65° upturned,
cupped jaws diameter 3 mm,
with cleaning connector,
working length 12 cm
651020 Same, horizontal opening
651020

45° upturned BLAKESLEY-WILDE RHINOFORCE® II Nasal Forceps

456601 B BLAKESLEY-WILDE RHINOFORCE® II

Nasal Forceps, 45° curved to right,
size 1, with cleaning connector,
working length 13 cm
456601 B

Through-cutting GRÜNWALD-HENKE RHINOFORCE® II Nasal Forceps

451000 B GRÜNWALD-HENKE RHINOFORCE® II

451000 B Nasal Forceps, straight,
through-cutting, tissue-sparing,
BLAKESLEY shape, size 0,
width 3 mm, with cleaning connector,
working length 13 cm
451500 B 451500 B Same, 45° upturned
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A Surgical Technique of the Graz University Medical School

STAMMBERGER Bipolar Suction Forceps

bipolar

Indications/Applications:
## Arterial bleeding (ethmoidal, sphenopalatine and ## Rendu-Osler-Weber disease
maxillary arteries, turbinate and septum vessels) ## Secondary hemorrhage, e.g., from the
## Skull base surgery nasopharynx following adenotomy
## Oozing hemorrhage from the mucosa edges ## Edema prevention, shrinkage of mucosa
## Pituitary gland surgery (for example, posterior end of the turbinate)
## Vascular processes, i.e. nasopharyngeal fibroma ## Turbinate cauterization

## Epistaxis

461010

461010 STAMMBERGER Bipolar Suction Forceps,

15° upturned, with suction channel,
for bipolar coagulation in paranasal areas,
working length 12.5 cm,
for use with Bipolar High Frequency Cord
847002 E or 847002 A/M/V/U

461015

461015 STAMMBERGER Bipolar Suction Forceps,

45° upturned, with suction channel,
for bipolar coagulation in paranasal areas,
working length 12.5 cm,
for use with Bipolar High Frequency Cord
847002 E or 847002 A/M/V/U
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A Surgical Technique of the Graz University Medical School

High Frequency Cords

for use with STAMMBERGER Bipolar Suction Forceps
Accessories bipolar

Bipolar High Frequency Cords

KARL STORZ High Frequency

Instruments Electrosurgery Units

847002 E Bipolar High Frequency Cord, for KARL STORZ

Coagulator 26021 B/C/D, 860021 B/C/D, 27810 B/C/D,
28810 B/C/D, AUTOCON® system (50, 200, 350),
AUTOCON® II 400 system (111, 113, 115) and Erbe
coagulator, T and ICC series, with two 2 mm cable
sockets for KARL STORZ Bipolar Suction Forceps
461010, 461015, length 450 cm

847002 M Bipolar High Frequency Cord, for Martin and

Berchtold coagulator, with two 2 mm cable
sockets for KARL STORZ Bipolar ­Suction Forceps
461010, 461015, length 450 cm

847002 A Bipolar High Frequency Cord, with 2x 4 mm banana

plug for KARL STORZ coagulator 26020 XA/XB,
with two 2 mm cable sockets for KARL STORZ
Bipolar Suction Forceps 461010, 461015,
length 450 cm

847002 V Bipolar High Frequency Cord, for KARL STORZ

AUTOCON® II system (112, 114, 116), Valleylab
coagulator, with two 2 mm cable sockets for
KARL STORZ Bipolar Suction Forceps 461010,
461015, length 450 cm

KARL STORZ Standard Forceps

Instruments Bipolar Cords

847002 U Bipolar Universal High Frequency Cord, one side

with two 2 mm cable sockets for KARL STORZ
Bipolar Suction Forceps 461010, 461015,
other side with standard pin for connection to all
current bipolar cables, length 40 cm
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A Surgical Technique of the Graz University Medical School

IMAGE1 S Camera System n

Economical and future-proof
## Modular concept for flexible, rigid and ## Sustainable investment
3D endoscopy as well as new technologies ## Compatible with all light sources
## Forward and backward compatibility with video
endoscopes and FULL HD camera heads

Innovative Design
## Dashboard: Complete overview with intuitive ## Automatic light source control
menu guidance ## Side-by-side view: Parallel display of standard
## Live menu: User-friendly and customizable ­image and the Visualization mode
## Intelligent icons: Graphic representation changes ## Multiple source control: IMAGE1 S a ­ llows
when settings of connected devices or the entire the simultaneous display, processing and
system are adjusted ­documentation of image information from
two c ­ onnected image sources, e.g., for hybrid
operations

Dashboard Live menu

Intelligent icons Side-by-side view: Parallel display of standard image and

Visualization mode
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A Surgical Technique of the Graz University Medical School

IMAGE1 S Camera System n

Brillant Imaging
## Clear and razor-sharp endoscopic images in ## Reflection is minimized
FULL HD ## Multiple IMAGE1 S technologies for homogeneous
## Natural color rendition illumination, ­contrast enhancement and color
­shifting

FULL HD image CLARA

FULL HD image CHROMA

FULL HD image SPECTRA A *

FULL HD image SPECTRA B **

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

** SPECTRA B : Not for sale in the U.S.
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A Surgical Technique of the Graz University Medical School

IMAGE1 S Camera System n

TC 200EN

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 - 2x DVI-D Power supply 100 – 120 VAC/200 – 240 VAC
- 1x 3G-SDI Power frequency 50/60 Hz
Format signal outputs 1920 x 1080p, 50/60 Hz Protection class I, CF-Defib
LINK video inputs 3x Dimensions w x h x d 305 x 54 x 320 mm
USB interface 4x USB, (2x front, 2x rear) Weight 2.1 kg
SCB interface 2x 6-pin mini-DIN

For use with IMAGE1 S

IMAGE1 S CONNECT Module TC 200EN

TC 300

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 200EN
including:
Mains Cord, length 300 cm
Link Cable, length 20 cm

Specifications:
Camera System TC 300 (H3-Link)
Supported camera heads/video endoscopes 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*)
LINK video outputs 1x
Power supply 100 – 120 VAC/200 – 240 VAC
Power frequency 50/60 Hz
Protection class I, CF-Defib
Dimensions w x h x d 305 x 54 x 320 mm
Weight 1.86 kg

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

** SPECTRA B : Not for sale in the U.S.
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A Surgical Technique of the Graz University Medical School

IMAGE1 S Camera Heads n

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

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,
TH 100 for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-Z
Product no. TH 100
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 114 mm
Weight 270 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm

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
TH 104 buttons, for use with IMAGE1 S and IMAGE 1 HUB™ HD/HD

Specifications:
IMAGE1 FULL HD Camera Heads IMAGE1 S H3-ZA
Product no. TH 104
Image sensor 3x 1/3" CCD chip
Dimensions w x h x d 39 x 49 x 100 mm
Weight 299 g
Optical interface integrated Parfocal Zoom Lens,
f = 15 – 31 mm (2x)
Min. sensitivity F 1.4/1.17 Lux
Grip mechanism standard eyepiece adaptor
Cable non-detachable
Cable length 300 cm
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A Surgical Technique of the Graz University Medical School

Monitors
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 Supply
Mains Cord
9619 NB

9826 NB 26" FULL HD Monitor,

wall-mounted with VESA 100 adaption,
color systems PAL/NTSC,
max. screen resolution 1920 x 1080,
image fomat 16:9,
power supply 100 – 240 VAC, 50/60 Hz
including:
External 24 VDC Power Supply
Mains Cord

9826 NB
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A Surgical Technique of the Graz University Medical School

Monitors

KARL STORZ HD and FULL HD Monitors 19" 26"

Wall-mounted with VESA 100 adaption 9619 NB 9826 NB
Inputs:
DVI-D l l
Fibre Optic – –
3G-SDI – l
RGBS (VGA) l l
S-Video l l
Composite/FBAS l l
Outputs:
DVI-D l l
S-Video l –
Composite/FBAS l l
RGBS (VGA) l –
3G-SDI – l
Signal Format Display:
4:3 l l
5:4 l l
16:9 l l
Picture-in-Picture l l
PAL/NTSC compatible l l

Optional accessories:
9826 SF Pedestal, for monitor 9826 NB
9626 SF Pedestal, for monitor 9619 NB

Specifications:
KARL STORZ HD and FULL HD Monitors 19" 26"
Desktop with pedestal optional optional
Product no. 9619 NB 9826 NB
Brightness 200 cd/m2 (typ) 500 cd/m2 (typ)
Max. viewing angle 178° vertical 178° vertical
Pixel distance 0.29 mm 0.3 mm
Reaction time 5 ms 8 ms
Contrast ratio 700:1 1400:1
Mount 100 mm VESA 100 mm VESA
Weight 7.6 kg 7.7 kg
Rated power 28 W 72 W
Operating conditions 0 – 40°C 5 – 35°C
Storage -20 – 60°C -20 – 60°C
Rel. humidity max. 85% max. 85%
Dimensions w x h x d 469.5 x 416 x 75.5 mm 643 x 396 x 87 mm
Power supply 100 – 240 VAC 100 – 240 VAC
Certified to EN 60601-1, EN 60601-1, UL 60601-1,
protection class IPX0 MDD93/42/EEC,
protection class IPX2
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A Surgical Technique of the Graz University Medical School

Fiber Optic Light Cables

for Cold Light Fountains

495 NA Fiber Optic Light Cable,

with straight connector,
diameter 3.5 mm, length 230 cm
495 NL Same, size 3.5 mm, length 180 cm

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 cm
20133027 Spare Lamp Module XENON
with heat sink, 300 watt, 15 volt
20133028 XENON Spare Lamp, only,
300 watt, 15 volt

Cold Light Fountain XENON NOVA® 300

20 1340 01 Cold Light Fountain XENON NOVA® 300,

power supply:
100–125 VCA/220–240 VAC, 50/60 Hz
including:
Mains Cord
20133028 XENON Spare Lamp, only,
300 watt, 15 volt

20200032 KARL STORZ Special Beamsplitter,

for use with Endovision TRICAM® and
TELECAM®, for simultaneous viewing
by endoscope and monitor screen
The camera head connector is 120° deflected
and can instantly be swiveled to the desired
­position.
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A Surgical Technique of the Graz University Medical School

Data Management and Documentation

KARL STORZ AIDA® – Exceptional documentation

The name AIDA stands for the comprehensive implementation

of all documentation requirements arising in surgical procedures:
A tailored solution that flexibly adapts to the needs of every
specialty and thereby allows for the greatest degree of
customization.
This customization is achieved in accordance with existing
clinical standards to guarantee a reliable and safe solution.
Proven functionalities merge with the latest trends and
developments in medicine to create a fully new documentation
experience – AIDA.
AIDA seamlessly integrates into existing infrastructures and
exchanges data with other systems using common standard
interfaces.

WD 200-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL HD, 2D/3D,
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

WD 250-XX* AIDA Documentation System,

for recording still images and videos,
dual channel up to FULL HD, 2D/3D,
including SMARTSCREEN® (touch screen),
power supply 100-240 VAC, 50/60 Hz
including:
USB Silicone Keyboard, with touchpad
ACC Connecting Cable
DVI Connecting Cable, length 200 cm
HDMI-DVI Cable, length 200 cm
Mains Cord, length 300 cm

*XX Please indicate the relevant country code

(DE, EN, ES, FR, IT, PT, RU) when placing your order.
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Workflow-oriented use

Patient
Entering patient data has never been this easy. AIDA seamlessly
integrates into the existing infrastructure such as HIS and PACS.
Data can be entered manually or via a DICOM worklist.
ll important patient information is just a click away.

Checklist
Central administration and documentation of time-out. The checklist
simplifies the documentation of all critical steps in accordance with
clinical standards. All checklists can be adapted to individual needs
for sustainably increasing patient safety.

Record
High-quality documentation, with still images and videos being
recorded in FULL HD and 3D. The Dual Capture function allows for
the parallel (synchronous or independent) recording of two sources.
All recorded media can be marked for further processing with just
one click.

Edit
With the Edit module, simple adjustments to recorded still images
and videos can be very rapidly completed. Recordings can be quickly
optimized and then directly placed in the report.
In addition, freeze frames can be cut out of videos and edited and
saved. Existing markings from the Record module can be used for
quick selection.

Complete
Completing a procedure has never been easier. AIDA offers a large
selection of storage locations. The data exported to each storage
location can be defined. The Intelligent Export Manager (IEM) then
carries out the export in the background. To prevent data loss,
the system keeps the data until they have been successfully exported.

Reference
All important patient information is always available and easy to access.
Completed procedures including all information, still images, videos,
and the checklist report can be easily retrieved from the Reference module.
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Equipment Cart

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
inluding:
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
UG 220

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
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A Surgical Technique of the Graz University Medical School

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
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A Surgical Technique of the Graz University Medical School

Notes:
 with the compliments of
KARL STORZ — ENDOSKOPE