Surgical robotic applications in otolaryngology

Robotic-assisted transoral removal of a submandibular megalith

The majority of salivary stones are less than 8 mm in size and most frequently occur in the submandibular gland. Traditional management of larger stones involves gland resection. Sialendoscopy combined with an external or a transoral sialolithotomy, also called the combined approach technique, permits stone removal and gland preservation. A 31-year-old male presented to our service with a 20-mm megalith in the left submandibular gland. Here we report the first description of a combined approach using the da Vinci Si Surgical System to facilitate transoral stone removal and salivary duct repair.

Extracervical approaches to endoscopic thyroid surgery

There is increasing demand for surgical procedures which avoid visible scars while maintaining optimal functional and ideal cosmetic results, without compromising the safety or effectiveness of the procedure. Endoscopic techniques have been adapted to abdominal and pelvic surgery and increasingly employed over the past three decades. Although hampered by the absence of a natural cavity, endoscopic techniques have been adapted to surgery in the neck for the past 15 years, particularly for the thyroid gland. While earlier attempts at endoscopic thyroid surgery were performed through incisions in or near the midline of the neck, recent techniques have been developed to place the incisions and endoscopic ports extracervically, or at least away from the midline region of the neck, rendering the cosmetic result more acceptable. Most of these approaches are through the axilla, breast, chest wall or a combination of approaches. Visualization of the thyroid and rate of complications with these approaches are equal to those attained with older endoscopic approaches. Careful patient selection is important for endoscopic surgery. Complications unique to the endoscopic approach are mostly related to insufflation of cervical tissues with pressurized CO(2).

Transoral endoscopic neck surgery: feasibility and safety in a porcine model based on the example of thymectomy

BACKGROUND

In anatomical studies and cadaver dissections, we developed an endoscopic transoral access to the anterior neck region to reduce surgical access trauma. Through a sublingual trocar and two additional trocars in the vestibule of the oral cavity, the pretracheal and thyroid region was reached with standard laparoscopic instruments.

METHODS

We conducted an experimental trial in five pigs under general anesthesia to estimate the safety and feasibility of the method; via this approach, the thymus was partially resected. Perioperative antibiotics were administered but analgesics were not given in the postoperative course. Oral intake and behavior were observed during the following 2 days. After necropsy, examination of the access route took place by means of dissections. The tissue surrounding the working trocar was histologically examined.

RESULTS

The pretracheal region could be reached without a problem and the procedure was performed almost "bloodlessly" in an anatomically defined layer. The intervention time decreased successively. Postoperative awakening was uneventful. Regular oral food intake was observed after 2-3 h. Pain reactions were not registered during the entire postoperative phase. After dissection, all relations appeared inconspicuous (no infections, fresh/old hematoma). Two local encapsulated seromas were observed. Histologically, only a mild tissue reaction was noted.

CONCLUSION

In this study, the endoscopic transoral approach to minimally invasive neck surgery seemed safe and feasible. Minimally invasive endoscopic procedures in the anterior neck region could be a possible application of this new approach.

Anesthetic considerations for transoral robotic surgery

During the past decade, robotic surgery has been progressively incorporated into the mainstream of cardio-thoracic and abdominopelvic surgery. With the recent US Food and Drug Administration approval of transoral robotic surgery (TORS) for the treatment of all benign tumors and select malignant tumors of the head and neck, robotic surgery has established its place in otolaryngologic surgery. Given the multispecialty applications and widespread use of robotic surgery, there exists a need for anesthesiologists to familiarize themselves with robotic surgery. This article focuses on TORS and the goal of which is to provide the anesthesiologist with a foundation for caring for the TORS patient in the perioperative period.

Feasibility and surgical approach of transaxillary robotic thyroidectomy without CO(2) insufflation

BACKGROUND

Our objective was to evaluate the anatomic basis for robotic-assisted transaxillary thyroidectomy and to determine its feasibility in a prospective clinical trial.

METHODS AND RESULTS

Using the da Vinci Surgical Robotic System, we performed 5 cadaveric dissections, via transaxillary approach without gas insufflation. Once the safety and feasibility of this approach had been demonstrated in cadavers, it was utilized to perform a thyroid lobectomy in a patient. The da Vinci system provided excellent visualization of the recurrent and superior laryngeal nerves, parathyroid glands, and paratracheal lymphatics. After the 5 cadaver dissections, the procedure time diminished from >90 minutes to <30 minutes.

CONCLUSION

Robotic-assisted transaxillary thyroidectomy is feasible with proper instrumentation and an understanding of the surgical anatomy. Based on this preclinical laboratory study and our experience in 1 patient, further evaluation of this approach in the setting of a prospective clinical trial is warranted to determine standardized criteria identifying patients who would benefit from this approach.

Robotic approaches to the posterior spine

STUDY DESIGN

This anatomic study described robotic approaches to the posterior thoracolumbar spine in a porcine model. Ergonomics, control, and approach and technical difficulties were noted.

OBJECTIVE

The objective of this study was to develop a robotic approach to the posterior thoracolumbar spine maximizing surgeon ergonomics and control.

SUMMARY OF BACKGROUND DATA

Surgery is both physically and mentally demanding, and strains from ergonomics and the aging process may negatively impact surgical skills. In spine surgery, control and precision are extremely important due to the close proximity to the spinal cord. The da Vinci robotic surgery system has offered better ergonomics and control in urology, gynecology, and cardiac surgery, and is rapidly gaining adoption. To date, there have been no published reports of da Vinci robotic spine surgery, motivating us to assess its potential in posterior spine surgery.

METHODS

Posterior spine da Vinci approaches were tested on a pig without spinal pathology with an open subperiosteal dissection. A laser instrument and prototype robotic burr and rongeur instruments were tested on laminotomy, laminectomy, disc incision, and dural suturing procedures.

RESULTS

Open dissection of the posterior spine provided sufficient access to successfully perform laminotomy, laminectomy, disc incision, and dural suturing procedures. Prototype burr and rongeur instruments were effective with good control. The laser instrument coagulated the epidural venous plexus and incised the anulus. Robot ergonomics allowed the surgeon to perform procedures for a full day with significantly less fatigue and reduced hand tremor.

CONCLUSION

The da Vinci could perform the major noninstrumented procedures of the posterior spine with improved ergonomics and control. Surgeon fatigue and tremor were reduced. With some modification of prototype and commercial instruments a posterior spine surgery instrument kit can be developed. Future clinical studies can better assess patient and surgeon benefits of using the da Vinci robot for posterior spine surgeries.

Robotic surgery in ear nose and throat

The arrival of a commercial surgical robotic platform at our institution has raised the question of its application and usefulness within the department of otolaryngology head and neck surgery. In order to answer this question, we sought to perform a qualitative review to examine the evolution of commercial surgical robotics and examine present and future applications of this emerging technology within our specialty. The main objective of this study is to examine the development and application of robotic surgery in otolaryngology, head and neck surgery. The study includes a qualitative systematic review. We have reviewed research papers and studies that specifically relate to the use of robots in otorhinolaryngology. More specifically, we have attempted to review those studies that have significantly added to the development of this field. In summary, we have examined eight animal studies, six cadaveric studies, nine human trials. Robotic surgery in ENT is a safe and feasible option. In certain procedures, it offers significant benefits over conventional surgery. Instrument and robotic arm size, and costs are limiting factors that prevent the use of robots being applied to many additional ENT procedures. We feel the development of new speciality-specific robots will yield a new era in the common use of robotics in ENT.

The voice-controlled robotic assist scope holder AESOP for the endoscopic approach to the sella

OBJECTIVE

To evaluate the feasibility of using a voice-controlled robot Automated Endoscopic System for Optimal Positioning (AESOP) for holding and maneuvering the endoscope in the trans-sphenoidal approach to the pituitary.

DESIGN

To compare the manual approach to the voice-activated robotic scope holder in maneuvering the endoscope and resecting pituitary lesions using a two-handed technique.

SETTING

Robotic laboratory at Louisiana State University Health Sciences Center, Shreveport.

CADAVERS

Ten fresh cadaver heads.

MAIN OUTCOME MEASURES

To determine the feasibility, advantages, and disadvantages of a single neurosurgeon maneuvering the endoscope, visualizing key anatomical features in the sphenoid, and resecting skull base lesions after the approach by an otolaryngologist.

RESULTS

The learning curve for utilization of the voice-controlled robotic arm was short. The compact cart with the AESOP took up little space and allowed the standard setup for this procedure. The elimination of the need for manual stabilization of the endoscope permitted the use of both hands for the actual procedure. The elimination of the tremor inherent with holding the endoscope manually allowed the scope to be placed closer to the target organ with fewer collisions. The most significant advantage was the ability of AESOP to save three anatomical positions, which could be returned to with a single voice command.

CONCLUSIONS

Recently, the endoscopic-endonasal approach to the sella has gained popularity. The voice-activated robotic scope holder is safe and has several advantages over current scope holders. Its utility may reduce operating time and eliminate the need for a second surgeon to hold the endoscope.

Robotic endoscopic surgery in a porcine model of the infant neck

Minimally invasive surgery is rapidly becoming the desired surgical standard, especially for pediatric patients. Infants and children are a particular technical challenge, however, because of the small size of target anatomical structures and the small surgical workspace. Computer-assisted robot-enhanced surgical telemanipulators may overcome these challenges by facilitating surgery in a small workspace. We studied the feasibility of performing robotic endoscopic neck surgery on a porcine model of the human infant neck. The study design was a prospective, feasibility pilot study of a small cohort for proof of concept and for a survival model. Sixteen non-survival piglets weighing 4.5–10 kg were used to develop the surgical approach and operative technique. Eight piglets aged 3–6 weeks old and weighing 4.0–9.1 kg underwent survival thyroidectomy by a cervical endoscopic approach using the Zeus surgical robot, which includes the Aesop endoscope holder and “Microwrist” microdissecting instruments. We succeeded in performing endoscopic robotic neck surgery on a piglet as small as 4 kg, in an operative pocket as small as 2 cm³. Total incision length for all three ports was ≤23 mm. There were no major complications, no major robotic instrument malfunctions or breakages, and no procedures required conversion to open surgery. These results support the feasibility of robotic endoscopic neck surgery on a neck the size of a human infant’s.

Endo-robotic resection of the submandibular gland in a cadaver model

BACKGROUND

By means of a prospective, nonrandomized investigation, we evaluated the feasibility of performing endo-robotic resection of the submandibular gland in a cadaver model and compared the results of robotically enhanced endoscopic surgery with those from a conventional endoscopic technique.

METHODS

Procedural times were recorded in a consecutive series of 11 endoscopic submandibular gland resections using the daVinci Surgical System (Intuitive Surgical, Sunnyvale, CA) and a modified endoscopic surgical approach previously developed in a porcine model. The presence of neurovascular injury was assessed postoperatively, and the specimens were examined histologically.

RESULTS

Eleven endo-robotic submandibular gland resections were successfully performed in six cadavers (no conversions to open resection were necessary). The median duration of the procedures was 48 minutes (range, 33-82 minutes). Creation of the operative pocket took an average (+/-SD) of 12.2 +/- 5.3 minutes, assembly of the robot required 9.3 +/- 4.1 minutes, and the mean time for submandibular gland resection was 29.4 +/- 8.9 minutes. The time required for robotic assembly was offset by the reduced operative time necessary compared with conventional endoscopic resection. Histologic examination confirmed the presence of normal glandular architecture, without evidence of excessive mechanical or thermal injury. There were no cases of apparent neurovascular injury.

CONCLUSIONS

Robotically enhanced endoscopic surgery in the neck is feasible and offers a number of compelling advantages over conventional endoscopic neck surgery. Clinical trials will be necessary to determine whether these advantages can be achieved in clinical practice.

Minimally Invasive Thyroidectomy: Basic and Advanced Techniques

OBJECTIVE

Minimal access surgery in the thyroid compartment has evolved considerably over the past 10 years and now takes many forms. We advocate at least two distinct approaches, depending on the disease process and multiple patient factors. The technical aspects are explored in depth with liberal use of videographic demonstration.

METHODS

The authors conducted a comparison of two distinct surgical techniques with photographic and videographic documentation of two distinct minimal access approaches to the thyroid compartment termed minimally invasive thyroidectomy (MITh) and minimally invasive video-assisted thyroidectomy (MIVAT). Both historic and previously unpublished data (age, gender, pathology, incision length, and complications) are systematically analyzed.

RESULTS

Patients who underwent minimally invasive thyroidectomy (n = 31) had a mean age of 39.4 +/- 10.7 years; seven were male and 24 were female. The most common diagnosis was follicular or Hürthle cell adenoma (29%), followed by papillary or follicular cancer (26%). The mean incision length was 4.9 +/- 1.0 cm. One patient developed a hypertrophic scar and one patient developed thrombophlebitis of the anterior jugular vein. There were 14 patients in the MIVAT group with a mean age of 43.7 +/- 11.4 years; one was male and 13 were female. The majority of patients had follicular adenoma (42.9%) or papillary carcinoma (21.4%) as their primary diagnosis. The mean incision length was 25 +/- 4.3 mm (range, 20-30 mm), and there were no complications.

CONCLUSIONS

Two distinct approaches to minimal access thyroid surgery are now available. The choice of approach depends on a number of patient and disease factors. Careful patient selection will result in continued safe and satisfactory performance of minimally invasive thyroid surgery.

Laserbasierte Qualitätssicherung für die robotergestützte Fräsabtragung an der Schädelbasis

BACKGROUND

Implanting active hearing devices in the lateral base of the skull requires high-precision, secure fixation of the electromagnetic transducer and long-life anchorage using osteosynthetic fixation plates referred to as mountain brackets. Nonlinear distortion in the acoustic signal path and consecutive implant loosening can only be avoided by exact osseous milling to create the necessary cavity bed while avoiding excessive milling. Robot technology is ideal for high-precision milling. However, safety measures are necessary in order to prevent errors from occurring during the reduction process. Ideally, a robot should be guided by a navigation system. However, robotic systems so far available do not yet have an integrated global navigation system.

MATERIALS AND METHODS

We used an animal model under laboratory conditions to examine the extent to which the semiautomatic ROBIN assistant system developed could be expected to increase osseous milling accuracy before implanting active electronic hearing devices into the recipient tissue in the cranium. An existing prototype system for robot-assisted skull base surgery was equipped with laser sensors for geometric measurement of the operation site. The three-dimensional measurement data was compared with CT simulation data before, during, and after the robot-assisted operation. The experiments were conducted on test objects as well as on animal models.

RESULTS

Under ideal conditions, the operation site could be measured at a spatial resolution of better than 0.02 mm in each dimension. However, reflections and impurities in the operation site from bleeding and rinsing fluids did have a considerable effect on data collection, necessitating specialised registering procedures. Using an error-tolerant procedure specifically developed, the effective registering error could be kept under 0.3 mm. After milling, the resulting shape matched the intended form at an accuracy level of 0.8 mm.

CONCLUSION

The results show that robot systems can reach the accuracy required for reliable microsurgery on the cranial base. High-resolution laser-based geometric measurement of the operation site enables head registration without additional artificial landmarks. During the navigated operation, the procedure can be used to ensure that the resulting cavity matches the intended shape as determined in the preoperative planning phase. This will enable quantitative analysis of, and improvement in the quality of robot-assisted surgery in the future.

Transoral robotic surgery: supraglottic laryngectomy in a canine model

OBJECTIVES/HYPOTHESIS

To develop a technique for computer enhanced robotic transoral supraglottic partial laryngectomy in the canine model.

STUDY DESIGN

Surgical procedure on the larynx in a canine model with a commercially available surgical robot.

METHODS

With use of the da Vinci Surgical Robot (Intuitive Surgical, Inc., Sunnyvale, CA), the supraglottic partial laryngectomy was performed on a mongrel dog that had been orotracheally intubated using general anesthesia. The videoscope and the 8 mm end-effectors of the robotic system were introduced through three ports, transorally. The surgical procedure was performed remotely from the robotic system console. The procedure was documented with still and video photography.

RESULTS

Supraglottic partial laryngectomy was successfully performed using the da Vinci Surgical Robot, with 8 mm instrumentation. The robotic system allowed for celerity and accuracy secondary to findings specific to the surgical approach, including excellent hemostasis, superb visualization of the operative field with expeditious identification of laryngeal submucosal soft tissue and skeletal landmarks, and multiplanar transection of tissues. In addition, the use of the robotic system also was found to have technical advantages inherent in robotic surgery, including the use of "wristed" instrumentation, tremor abolition, motion scaling, and three-dimensional vision.

CONCLUSIONS

The da Vinci Surgical Robot allowed for successful robotic transoral supraglottic partial laryngectomy in the canine model.

Macro Anatomical Investigations of the Cranial Cervical Ganglion in Domestic Pig (Sus scrofa domesticus)

In this study, the left and right cranial cervical ganglia (ganglion cervicale craniale) of eight young (four male, four female) domestic pigs weighing around 70-80 kg were inspected macro anatomically. The cranial cervical ganglion (CCG) was found cranio-ventrally of the distal ganglion of the vagus nerve, medial of the jugular process extremity, ventral of the atlas, dorsal of the epiglottis base and medial of the common root (CR) established by the internal carotid and occipital arteries. The internal carotid nerve and jugular nerve ramified from the cranial part of CCG. The jugular nerve gave branches that merged with the vagus and glossopharyngeal nerves. Other nerve branches originating from the cranial part of the ganglion reached to the external carotid artery and CR. The internal carotid nerve varied among cadavers in number of branches (two to four). These branches did not travel along the side of the internal carotid artery. The central part of CCG gave thin nerve branches that reached to various anatomical structures including the first and second cervical nerves, wall of the pharynx, accessory nerve, hypoglossal nerve, vagus nerve, external carotid artery and CR. The caudal part of CCG gave nerve branches that merged with the vagus, cranial laryngeal nerves, and common carotid artery. The external carotid nerves, which were two or three in number, also originated from the caudal part of CCG. In conclusion, the nerves ramifying from CCG of the pig varied in number among cadavers. Compared with literature raised in other species, there are also differences in number of nerve branches and course pattern of these nerves.

Robotic Microlaryngeal Surgery: A Technical Feasibility Study Using the daVinci Surgical Robot and an Airway Mannequin

OBJECTIVES/HYPOTHESIS

The trend toward minimally invasive surgery has led to the development and mastery of endoscopic and laparoscopic surgical techniques. These minimally invasive approaches, which only two decades ago were either novel or experimental, are now mainstream. More recently, robot-assisted surgery has evolved as an adjunct to open and endoscopic techniques. Surgical robots are now approved by the United States Food and Drug Administration for a variety of thoracic and abdominal/pelvic surgical procedures. The purpose of this study is to demonstrate the technical feasibility of robot-assisted microlaryngeal surgery.

STUDY DESIGN

Experimental surgical manipulation of the larynx in an airway mannequin with a surgical robot.

METHODS

A variety of laryngoscopes and mouthgags, coupled with the daVinci Surgical Robot's (Intuitive Surgical, Sunnyvale, CA) 0-degree and 30-degree, two-dimensional and three-dimensional endoscopes, were utilized to optimize visualization of the larynx in an airway mannequin. Five millimeter and 8 mm microinstruments compatible with the daVinci robot were utilized to manipulate different elements of the larynx. Experiments were recorded with both still and video photography.

RESULTS

The endoscope and robotic arms of the daVinci robot are well suited to airway surgery.

CONCLUSIONS

Robot-assisted laryngeal surgery can be performed with currently available technology. The potential for fine manipulation of tissues, increased freedom of instrument movement, and endolaryngeal suturing may increase the precision of endoscopic laryngeal microsurgery and offers the potential to increase the variety of laryngeal procedures that can be performed endoscopically.

Prospective evaluation of endoscopic approaches to the thyroid compartment

OBJECTIVE

To compare a number of endoscopic approaches to the thyroid compartment.

DESIGN

Prospective, nonrandomized, experimental investigation in a porcine model.

METHODS

We performed a consecutive series of 13 endoscopic thyroidectomies using 5 distinct approaches. The procedures differed by the direction of the approach, incision placement, and use of facilitative maneuvers. The parameters assessed included procedure duration, estimated blood loss, heart rate, blood pressure, temperature, oxygen saturation, and arterial blood gas levels. The thyroid specimens were weighed and examined histologically.

RESULTS

Four of the endoscopic approaches were successfully used for resection of the thyroid (12 of 13 animals). The mean operative times were as follows: superior approach (n = 4), 47 +/- 14.6 minutes; lateral axillary approach (n = 4), 67 +/- 11.8 minutes; and superficial axillary (n = 3), 67.7 +/- 22.3 minutes. The one axillary approach took 84 minutes. The precordial approach (n = 1) lasted 47 minutes and then required open conversion. The overall median estimated blood loss was 0 (range 0-100) mL. The mean change in blood pressure and pH from the beginning to the end of the procedure was -0.5 +/- 24.1 mm Hg and 0.16 +/- 0.07, respectively. The thyroid glands weighed 4.3 +/- 0.9 g and had normal glandular architecture with no evidence of significant tissue trauma or thermal injury. There were no cases of pneumothorax, subcutaneous emphysema, or air embolism.

CONCLUSION

A number of approaches to the thyroid compartment are conceivable. The superior approach proved to be the fastest and easiest, whereas the lateral axillary and superficial axillary were the best approaches from a cosmetic and clinical standpoint.

Surgical robotics in otolaryngology: expanding the technology envelope

PURPOSE OF REVIEW

Surgical robotics arose as an extension of virtual reality and robotic technology developed by the United States Department of Defense. Current surgical robotic systems have been used to perform a variety of minimally invasive surgical procedures.

RECENT FINDINGS

The Food and Drug Administration recently granted approval for the clinical use of two surgical robotic systems. Laboratory and clinical experience suggests that the use of surgical robotics is associated with some distinct advantages and disadvantages when compared with conventional open procedures. Robotic surgery has recently been described in the head and neck, and as a result the otolaryngologist should have a basic understanding of the potential applications of surgical robotics in head and neck surgery.

SUMMARY

Surgical robotic technology is evolving but appears to have a distinct place in the surgical armamentarium.

Robotics in pediatric surgery: perspectives for imaging

Robotic surgery will give surgeons the ability to perform essentially tremorless microsurgery in tiny spaces with delicate precision and may enable procedures never before possible on children, neonates, and fetuses. Collaboration with radiologists, engineers, and other scientists will permit refinement of image-guided technologies and allow the realization of truly remarkable concepts in minimally invasive surgery. While robotic surgery is now in clinical use in several surgical specialties (heart bypass, prostate removal, and various gastrointestinal procedures), the greatest promise of robotics lies in pediatric surgery. We will briefly review the history and background of robotic technology in surgery, discuss its present benefits and uses and those being explored, and speculate on the future, with attention to the current and potential involvement of imaging modalities and the role of image guidance.