Assessment of intraoperative safety in transoral robotic surgery

INTRODUCTION: Robotic technology has been safely integrated into thoracic and abdominopelvic surgery, and the early experience has been very promising with very rare complications related to robotic device failure. Recently, several reports have documented the technical feasibility of transoral robotic surgery (TORS) with the daVinci Surgical System. Proposed pharyngeal and laryngeal applications include radical tonsillectomy, base-of-tongue resection, supraglottic laryngectomy, and phonomicrosurgery. The safety of transoral placement of the robotic endoscope and instruments has not been established. Potential risks specific to the transoral use of the surgical robot include facial skin laceration, tooth injury, mucosal laceration, mandible fracture, cervical spine fracture, and ocular injury. We hypothesize that these particular risks of transoral surgery are similar with robotic assistance compared with conventional transoral surgery. METHODS: To test this hypothesis, we attempted to intentionally injure a human cadaver with the daVinci Surgical System by impaling the facial skin and pharyngeal and laryngeal mucosa with the robotic instruments and endoscope. We also attempted to extract or fracture teeth and fracture the cadaver's mandible and cervical spine by applying maximal pressure and torque with the robotic arms. Experiments were documented with still and video photography. RESULTS: Impaling the cadaver's skin and mucosa resulted in only superficial lacerations. Tooth, mandible, and cervical spine fracture could not be achieved. CONCLUSIONS: Initial experiments performing TORS on a human cadaver with the daVinci Surgical System demonstrate a safety profile similar to conventional transoral surgery. Additionally, we discuss several strategies to increase patient safety in TORS.     

Robotic skull base surgery: preclinical investigations to human clinical application

OBJECTIVE: To develop a minimally invasive surgical technique for the treatment of parapharyngeal space and infratemporal fossa skull base neoplasms using the technical and optical advantages of robotic surgical instrumentation. DESIGN: A robotics skull base surgery program at the University of Pennsylvania, Philadelphia, was initiated in the fall of 2005. Six experimental procedures focusing on developing approaches to the parapharyngeal space and infratemporal fossa were performed on a total of 2 cadavers and 1 mongrel dog. Based on the preclinical work, transoral robotic surgery (TORS) was then performed in February 2007 on 1 human patient with a parapharyngeal to infratemporal fossa cystic neoplasm as part of a large prospective human trial. SETTING: In each cadaver and in the dog, a TORS approach to parapharyngeal space and infratemporal fossa was performed bilaterally and in an approved training facility using the da Vinci Surgical System. For the human surgical case, a TORS approach was evaluated on one side for a benign neoplasm. The human patient underwent TORS of the parapharyngeal space and infratemporal fossa under an institutional review board-approved prospective clinical trial. PATIENTS: For the human clinical trial, a TORS approach was evaluated for a patient with a benign neoplasm of the parapharyngeal space and infratemporal fossa. MAIN OUTCOME MEASURES: The ability to access and dissect tissues within the various areas of the parapharynx and infratemporal fossa was evaluated, and techniques to enhance visualization and instrumentation were developed. RESULTS: Using TORS approaches permitted excellent access, visualization, and tissue dissection within the parapharyngeal space and infratemporal fossa in both the cadaver and canine experiments. In the first known human surgical case, TORS was used to remove a parapharyngeal space and infratemporal fossa cystic neoplasm. Wide visualization, followed by complete resection using the identical techniques developed in the preclinical models, was achieved. The robotic procedure allowed adequate and safe identification of the internal carotid artery and cranial nerves, and excellent hemostasis was achieved with no complications during or after surgery. CONCLUSIONS: The TORS approaches provided excellent 3-dimensional visualization and instrument access that allowed successful parapharyngeal space and infratemporal fossa surgical resections from cadaver models to the first known human patient application. Robotic surgery for the skull base holds potential as a minimally invasive approach to skull base neoplasms; however, continued development and investigation is warranted in a prospective human clinical trial before final conclusions can be drawn as to the full advantages and limitations of this approach.     

Transoral robotic surgery for neurogenic tumors of the prestyloid parapharyngeal space

The parapharyngeal space is a difficult area for a surgical approach due to anatomical complexity. We performed a minimally invasive and precise surgical technique to remove neurogenic tumors of the prestyloid parapharyngeal space using transoral robotic instrumentation. The mass was successfully removed in the two cases with three-dimensional visualization providing an excellent view of the resection margin and the dissection plane preserving the vital structures. An adequate resection margin was acquired, and no violation of the tumor capsule occurred. No significant complications were noted. Transoral robotic surgery was feasible for neurogenic tumors of the prestyloid parapharyngeal space, providing a sufficient resection margin and delicate dissection through excellent surgical views and instrumentation.     

A new paradigm for the diagnosis and management of unknown primary tumors of the head and neck: A role for transoral robotic surgery

Objectives/Hypothesis:

In 2% to 3% of patients with cancer metastatic to cervical lymph nodes, a primary tumor will not be found despite exhaustive diagnostic efforts. The treatment for these patients includes cervical lymphadenectomy followed by radiation to areas with increased risk of harboring a mucosal primary. Wide‐field radiation therapy increases the incidence of xerostomia and dysphagia. Localizing a primary tumor has thus both therapeutic and quality‐of‐life implications, allowing possible complete surgical excision, concentrated radiation therapy, and potential deintensification of adjuvant therapy. With improved visualization and freedom of motion, transoral robotic surgery (TORS) is an innovative surgical modality that allows resection of oropharyngeal subsites with minimal morbidity.

Study Design:

Retrospective chart review.

Methods:

Ten patients with unknown primary tumors of the head and neck were identified. All patients underwent a cervical biopsy, positron‐emission tomography/computed tomography, formal endoscopy, and bilateral tonsillectomy. When the initial endoscopy and biopsies did not localize a primary tumor, all patients underwent transoral robotic base of tongue resection.

Results:

Evaluation of the patients' oropharyngeal mucosa using the robot did not reveal an obvious lesion and no palpable tumors were appreciated in the resected specimens. In 9/10 (90%) patients, pathologic examination revealed invasive squamous cell carcinoma (SCCA) with a mean diameter of 0.9 cm.

Conclusions:

Unknown primary SCCA presents a diagnostic challenge to the head and neck surgeon. We present a small series of tumors that would have been treated as unknown primaries under traditional diagnostic and therapeutic algorithms. TORS base of tongue resection identified primary tumors in 90% patients with minimal morbidity. Laryngoscope, 2013     

内镜下口内径路咽旁隙肿瘤切除术的临床分析

目的探讨内镜下口内径路咽旁隙肿瘤切除术的临床疗效及可行性。方法回顾性分析江门市中心医院2013年7月~2017年8月采用内镜下口内径路切除的15例咽旁隙肿瘤患者的临床资料。15例患者主要症状表现为咽部异物感、吞咽梗阻感、打鼾及发声含糊等,但部分患者无任何症状,仅影像学检查显示咽旁隙占位性病变。所有患者采用内镜下口内径路切除肿瘤。结果15例患者手术均进行顺利,术后均无面颈部皮肤切口瘢痕,无一例出现术区感染、出血、声嘶等并发症,随访6个月至4年,肿瘤均未见复发。结论内镜下口内径路咽旁隙肿瘤切除术是一种治疗咽旁隙肿瘤的有效方法。通过内镜系统的辅助,该术式有效的解决了视野暴露小、操作空间狭小、手术存在盲目性等弊端,具有创伤小、恢复快、治愈率高及美容等优点,值得临床推广。     

内镜下经口径路咽旁间隙肿瘤摘除5例

目的 探讨内镜下经口内径路摘除咽旁间隙肿瘤的适应证、手术技巧和优点。方法 回顾性分析咽旁间隙肿瘤5例患者的病历资料,均在内镜下经口径路摘除。结果 肿瘤摘除完整,出血20～60 mL,无严重并发症发生,术后5 d内出院。随访1～2年,无复发。结论 CT和MRI可较好地反映肿瘤所在位置、大小、范围,以及肿瘤与周围重要结构的关系和肿瘤的可能起源,为术前评估及选择合适的手术径路提供重要的依据。内镜下经口径路能完整切除位于颈动脉鞘内侧的良性肿瘤,且有颈部无瘢痕、并发症少等优点,不适用于包绕颈动脉鞘内结构、位于颈动脉后方及后外侧的肿瘤。     

Transoral robotic surgery using an image guidance system

Objectives: To describe a novel technique using the image guidance system for transoral robotic surgery of the pharyngeal and parapharyngeal spaces. Study Design: Case series presentation. Methods: Three cases of oropharyngeal and pharyngeal space lesions are reviewed for presentation, workup, and original management. Results: Final pathology of a vascular malformation, an acinic cell adenocarcinoma, and a squamous cell carcinoma were located and minimally invasively removed by a transoral robotic approach with the aid of image guidance. No complications or recurrences were observed on an average of 7 month follow‐up. Conclusions: Transoral robotic surgery using an image guidance system seems safe and effective in assisting dissection.     

内镜辅助下咽旁隙肿瘤切除术的临床应用

目的探讨内镜辅助下咽旁隙肿瘤切除术的临床应用的价值。方法收集2016年2月~2018年2月于上海交通大学医学院附属第九人民医院耳鼻咽喉头颈外科行内镜辅助下咽旁隙肿瘤切除术患者16 例,其中颈外径路12 例,经口径路2 例,联合径路2 例,分析并总结将内镜应用于咽旁隙肿瘤切除术的方法及优势。结果16 例患者均完整切除肿瘤,其中恶性肿瘤4 例,良性肿瘤12 例。所有患者均无永久性并发症。所有原发性咽旁隙良恶性肿瘤患者术后随访12~34个月均无复发。 结论内镜辅助下咽旁隙肿瘤切除术可以完整切除咽旁隙肿瘤而无需截断下颌骨,具有手术创伤小,并发症发生率低的优点,值得研究及推广应用。     

内镜下低温等离子射频消融切除高位咽旁隙肿瘤的临床疗效分析

目的探讨内镜下低温等离子射频消融切除高位咽旁隙肿瘤手术的安全性和疗效。方法收集上海长征医院耳鼻咽喉头颈外科2013年5月~2016年5月诊断为咽旁隙肿瘤的患者13例,根据肿瘤部位选择不同的手术径路,全麻后,沿术前设计切口切开组织,暴露肿瘤,在内镜辅助下低温等离子射频消融切除肿瘤,其中经颈侧径路7例,经口径路6例。术中出血前者约40 ml后者约80 ml,恶性肿瘤患者术后接受了60 Gy剂量放疗。结果13例患者肿瘤均完全切除,术后病理结果示良性肿瘤12例（多形性腺瘤8例、神经鞘膜瘤2例、脉管瘤1例、脑膜瘤1例）,恶性肿瘤1例（黏液表皮样癌1例）。13例患者随访2年以上,均无复发。结论内镜辅助下低温等离子射频消融切除高位咽旁隙肿瘤,能清晰暴露深部不可直视的肿瘤,达到完全切除的效果,手术局部切口小,术中出血量少,并发症少,进一步证实了这种方法的可行性和安全性。     

内镜经口入路行鼻咽癌放疗后肿瘤残留切除或咽旁隙转移及复发淋巴结清扫术

 目的探讨内镜经口入路行鼻咽癌放疗后咽旁隙残留或复发淋巴结清扫术的有效性及可行性。方法回顾性分析2015年3月～2017年10月南方医科大学珠江医院耳鼻咽喉科收治的12例鼻咽癌放疗后咽旁隙淋巴结残留或复发患者的临床资料,所有患者术前均行影像学检查诊断,其中5例单纯行内镜下经口入路咽旁隙淋巴结清扫术,7例因有鼻咽癌原发灶残留或者复发同时行鼻咽-颅底肿瘤切除术。结果12例（共13侧）患者手术顺利,术后均未出现声嘶、进食呛咳及颈内动脉损伤等并发症,1例患者出现口内切口感染,1例患者切口部分缝线松脱,均经对症处理后痊愈。术后随访至2018年4月,中位随访23个月（6～36个月）,所有患者术后均未出现咽旁隙内再发转移灶。结论内镜下经口入路行鼻咽癌放疗后咽旁隙淋巴结清扫术可有效地切除转移灶,且手术创伤小,并发症少,术后恢复快,具有临床应用价值。     

Intraoperative imaging during minimally invasive transoral robotic surgery using near-infrared light

Purpose

The purpose of this study was to determine if the use of the FIREFLY imaging system could be an asset in transoral robotic surgery (TORS) for oropharyngeal squamous cell carcinoma (OPSCC). The system uses indocyanine green dye (ICG), which fluoresces when illuminated by near-infrared light from the Da Vinci robot. The system may improve visualization of tumor margins, highlight important vascular structures, and help identify the location of tumors and unknown primary head and neck cancers.

Transoral robotic surgery: supraglottic partial laryngectomy

OBJECTIVES: We assessed the feasibility of performing transoral supraglottic partial laryngectomy with robotic instrumentation. METHODS: Transoral robotic surgery (TORS) was performed on 3 human patients with supraglottic carcinoma in a prospective human trial. The study was approved by our institutional review board and involved the da Vinci Surgical Robot (Intuitive Surgical, Inc, Sunnyvale, California). RESULTS: All procedures were completed robotically. The median overall operation time to perform the robotic procedure was 120 minutes (range, 1:32:48 to 2:58:18), including 18 minutes (range, 00:6:07 to 00:30:39) for exposure and robotic positioning. There were no intraoperative or postoperative complications or surgical mortality. CONCLUSIONS: The preliminary results of our series suggest that application of the da Vinci robotic surgical system for TORS to supraglottic partial laryngectomy is technically feasible and relatively safe. Furthermore, TORS provides excellent surgical exposure that allows complete tumor resection. Most importantly, TORS provides an alternative to open approaches and "conventional" transoral supraglottic partial laryngectomy.     

Transoral robotic surgery for head and neck carcinomas

The objective of this study was prospectively to assess the feasibility and safety of transoral robotic surgery (TORS) in head and neck carcinomas and to report our learning curve and 2-year outcomes. Patients with oropharyngeal, hypopharyngeal and laryngeal tumors treated with TORS were prospectively included. We evaluated: the feasibility of TORS, robotic set-up time, transoral robotic surgery time, blood loss, surgical margins, tracheotomy, feeding tube, time to oral feeding and surgery-related complications. Twenty-three patients were treated for 25 carcinomas. Twenty-two patients underwent successful robotic resection for 24 carcinomas (96%). One patient required conversion to open surgery due to massive bleeding. The mean robotic set-up time was 25?min (range: 15–100?min) and mean TORS operating time was 70?min (range: 20–150?min). Positive margin of resection was observed in one patient (classified pT3) out of the 24 cancers and was managed by postoperative chemoradiation. No tracheotomy was performed. Three patients required prolonged intubation for a mean of 22?h. Two patients required a temporary gastrostomy (for 2 and 3.5?months, respectively). All other patients resumed oral feeding between the first and third postoperative day. The mean hospital stay was 6.4?days (range: 4–19?days). No postoperative complication occurred. Mean follow-up was 20?months (median: 19, range: 14–26). No death and no case of local or metastatic failure were observed. TORS is feasible and safe for the resection of selected head and neck carcinomas. The occurrence of intraoperative bleeding emphasizes the need for surgeons to be skilled in both transoral and open approaches.     

Transoral robotic-assisted free flap reconstruction after radiation therapy in hypopharyngeal carcinoma: report of two cases

The objective was to assess the feasibility and safety of transoral robotic surgery (TORS)-assisted free flap reconstruction for hypopharyngeal carcinoma after radiation therapy. The study evaluated the feasibility, surgical margins, the need for a tracheotomy, a nasogastric tube as well as surgery-related complications. Two patients underwent TORS-assisted free flap reconstruction after radiation therapy. The resection margins were free of tumor in both patients. A tracheotomy was performed in one patient who had been decannulated on the sixth postoperative day. One patient resumed satisfactory oral feeding in the fourth postoperative month and the second patient on postoperative day 7. No intraoperative complication and one postoperative complication (neck hematoma) were reported. After a follow-up period of 24 and 30 months, no local recurrence was observed. TORS is feasible for hypopharyngeal resection and assisted free flap reconstruction after radiation therapy. It represents a further step in the development of minimally invasive surgery for the treatment of head and neck cancers with laryngeal preservation.     

Transoral robotic surgery of the central skull base: preclinical investigations

In this study we explored possible applications of the da Vinci system in approaching the skull base at optic chiasm level on two cryopreserved cadavers, using an entirely transoral robotic technique (TORS). We used a standard 12 mm endoscopy and 8 mm terminals. Bone drilling was performed manually. The da Vinci system is equipped with very good illumination and 3D viewing, thus providing excellent vision and great maneuverability even in the less accessible areas of the skull. Our experience demonstrates that an entirely transoral skull base robotic approach to this complex anatomical region has many advantages as compared to traditional techniques.     

Cost comparison of open approach,transoral laser microsurgery and transoral robotic surgery for partial and total laryngectomies

Activity-based costing is used to give a better insight into the actual cost structure of open, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) supraglottic and total laryngectomies. Cost data were obtained from hospital administration, personnel and vendor structured interviews. A process map identified 17 activities, to which the detailed cost data are related. One-way sensitivity analyses on the patient throughput, the cost of the equipment or operative times were performed. The total cost for supraglottic open (135–203 min), TLM (110–210 min) and TORS (35–130 min) approaches were 3,349 € (3,193–3,499 €), 3,461 € (3,207–3,664 €) and 5,650 € (4,297–5,974 €), respectively. For total laryngectomy, the overall cost were 3,581 € (3,215–3,846 €) for open and 6,767 € (6,418–7,389 €) for TORS. TORS cost is mostly influenced by equipment (54 %) where the other procedures are predominantly determined by personnel cost (about 45 %). Even when we doubled the yearly case-load, used the shortest operative times or a calculation without robot equipment costs we did not reach cost equivalence. TORS is more expensive than standard approaches and mainly influenced by purchase and maintenance costs and the use of proprietary instruments. Further trials on long-term outcomes and costs following TORS are needed to evaluate its cost-effectiveness.     

原发性咽旁间隙肿瘤67例回顾性分析

目的分析原发性咽旁间隙肿瘤的临床特点及手术径路选择,探讨不同手术径路的优缺点及预后。方法回顾性分析67例咽旁间隙肿瘤患者资料,所有患者术前均行CT和(或)MRI检查,三种手术路径分别为颈侧径路45例、口内径路20例、颈-腮径路2例。术后病理学检查明确诊断,对所有手术患者进行术后定期随访,随访时间8~110个月,中位随访时间45个月。结果67例中良性肿瘤共59例(88.1%),恶性肿瘤8例(11.9%);24例(35.8%)患者出现术后并发症,其中颈侧径路20例(29.9%),口内径路3例(4.5%),颈-腮径路1例(1.5%),其中7例(10.4%)随访后好转。复发患者7例(10.4%),颈侧径路4例(6.0%),口内径路3例(4.5%)。结论咽旁间隙解剖毗邻复杂,病理类型繁多,肿瘤以良性为主,治疗以手术切除为主。术前根据影像学检查结果,肿瘤大小及解剖关系决定手术径路。颈侧径路仍是咽旁间隙肿瘤切除的首选方法,但在肿瘤最大直径<6 cm并位于动脉内侧的良性肿瘤患者中,可考虑口内径路。     

Transoral robotic surgery for the management of head and neck tumors: learning curve

Transoral robotic surgery (TORS) is an emerging technique for the treatment of head and neck tumors. The objective of this study is to describe our first steps and present our experience on the technical feasibility, safety, and efficacy of TORS for the treatment of selected malignant lesions. From April 2008 to September 2009, 24 patients were enrolled in this prospective trial. Inclusion criteria were: adults with T1, T2 and selected T3 tumors involving the oral cavity, pharynx, and supraglottic larynx and a signed informed consent was obtained from the patient. Exclusion criteria were: tumors not accessible to TORS after unsuccessful attempts to expose properly the lesion to operate. The ethical committee’s approval was obtained to perform this study. Twenty-four patients were included in this study: 10 supraglottic tumors, 10 pharyngeal tumors and 4 oral cavity tumors. Nine patients had T1 tumors, 12 had T2 tumors, and 1 patient had a T3 tumor. In all cases, tumor resection could be performed by robotic surgery exclusively and negative resection margins were achieved with control by frozen section. None of them received intraoperative reconstruction. None of the patients required tracheotomy. There was no intraoperative complication related to the use of the robot. The average setup time was 24 ± 14 min (range 10–60 min). The average surgical time was 67 ± 46 min (range 12–180 min). Surgical and setup time decreased after the first cases. The mean hospital stay was 9 days. Oral feeding was resumed at 3 days. TORS seems to be a safe, feasible, minimally invasive treatment modality for malignant head and neck tumors with a short learning curve for surgeons already experienced in endoscopic surgery.     

Cervical-transoral robotic oropharyngectomy and thin anterolateral thigh free flap

The transoral robotic oropharyngectomy surgical technique was initially described for resection of small stage T1 or T2 lesions and the surgical defect is usually allowed to heal by secondary intention. We propose a refined surgical approach adapted to more complex situations such as salvage surgery and surgery in an irradiated field, based on previous experience in open approaches for oropharyngeal cancer. Via a combined cervical-transoral approach, we perform en bloc resection of the parapharyngeal space combined with transoral robotic lateral oropharyngectomy. Reconstruction of the surgical defect is performed with a thin anterolateral thigh free flap.     

光纤CO2激光在经口机器人手术中的应用：4例恶性肿瘤患者的可行性分析

本研究进行新型光纤C02激光（CO2 laser wave guide，LWG）机器人外科手术（transoral robotic surgery，TORS）可行性分析，纳入年龄大于18岁的恶性头颈肿瘤患者共4例。分别患T1期舌底癌，T1及T2期声门上型喉癌，扁桃体癌，平均年龄56岁，400均已签署知情同意书。手术器械包括马里兰分离钳，0°内镜，光纤CO2激光机器人手术臂。激光参数如下：超脉；中或连续波模式，功率7～15W，连续曝光，平均准备时间30min，平均手术时间94min，每台手术使用一根光纤，平均组织凝固深度200μm（范围：100-300μm）。术中均未出现并发症，平均住院时间6d。光纤CO2激光对于机器人外科手术是一个可靠引导工具，它可使手术时间缩短1h有余而不带来负面后果。