Transoral Robotic Surgery

Soft tissue necrosis in patients treated with transoral robotic surgery and postoperative radiotherapy: preliminary results

OBJECTIVE

Postoperative radiotherapy (PORT) is indicated in almost two-thirds of patients treated with transoral robotic surgery (TORS) for head and neck tumors. The aim of this study was to quantify the toxicity profile of patients treated with PORT after TORS in oropharyngeal and supraglottic laryngeal cancer focusing on soft tissue necrosis (STN).

METHODS

We retrospectively reviewed 28 patients. Acute and late toxicity were examined. Incidence and severity of STN were recorded.

RESULTS

No patient experienced acute grade 3 skin or mucosal toxicity; 1 patient had grade 3 dysphagia. At 12 months, no evaluated patient required enteral nutrition and 2 patients had tracheostomy. STN occurred in 4 (14%) patients: 3 out of 4 (75%) patients with STN had diabetes, whereas 6 out of 13 (25%) patients without STN had diabetes (p = 0.05).

CONCLUSION

We found an acceptable toxicity profile of PORT performed after a TORS procedure. Diabetes mellitus might be a risk factor for STN.

Robotic surgery of head and neck cancers, a narrative review

Head and neck cancers are the most common cancers in the body. Treatments are determined on the basis of the location and stage of the primary tumor. The goal of treatment is to eliminate the tumor, prevent recurrence or metastasis, and maintain the quality of life. There are several treatments available for the management of head and neck cancers, including surgery, radiation therapy, chemotherapy, new molecular agents, and a combination of them. Transoral robotic technique is a short-time operation using a type of robotic machine in which the patient undergoes anesthesia for a shorter time and the side effects of this operation and the time of hospitalization are less than open surgery. Due to the importance of speed and accuracy in head and neck cancer surgery and the importance of application of robotics in surgery, the present study was designed and implemented to review the application of robotics in the management of head and neck cancers. In this review study, the keywords: application, robotic, surgical, head cancer, transoral robotic surgery (TORS), and neck cancer, were searched in ISI, PubMed, Scopus, Google scholar databases. Related articles written domestically or abroad that have covered areas such as the background of transoral robotic surgery, maintaining organ function and approaches, the advantages and disadvantages of TORS, the affordability of TORS, the combination of TORS with other therapeutic approaches published from 2003 to 2019 were reviewed. The use of robotic surgery for precise operations such as head and neck cancers seems to be essential. More advanced robotic devices are expected to expand the surgery treatment for head and neck cancers as well as the results of using TORS for oncologic optimization and acceptability of results while maintaining organ function and patient's quality of life.

A Phase 2 Trial of Alternative Volumes of Oropharyngeal Irradiation for De-intensification (AVOID): Omission of the Resected Primary Tumor Bed After Transoral Robotic Surgery for Human Papilloma Virus-Related Squamous Cell Carcinoma of the Oropharynx

PURPOSE

This trial tested the safety and efficacy of a novel, deintensified radiation therapy (RT) approach after initial surgical resection for patients with human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC).

METHODS AND MATERIALS

This single-arm phase 2 prospective clinical trial enrolled 60 patients with stage pT1-pT2 N1-3 HPV-associated OPSCC treated with transoral robotic surgery (TORS) and selective neck dissection at a single institution between May 2014 and September 2017. Patients had favorable features at the primary site (negative surgical margins ≥2 mm, no perineural invasion, and no lymphovascular invasion) but required adjuvant therapy based on lymph node involvement. Surgeries were all performed at a high-volume head and neck cancer center with expertise in TORS. Patients received postoperative RT to at-risk areas in the involved neck (60-66 Gy) and uninvolved neck (54 Gy). The resected primary site was treated as an active avoidance structure in the treatment planning of postoperative RT. Concurrent chemotherapy was administered for patients with extranodal extension.

RESULTS

Median follow-up of the 60 patients enrolled was 2.4 years (range, 8.5-53.8 months). A single patient recurred at the primary site, for 2-year local control of 98.3%. One patient (1.7%) developed a regional neck recurrence, and 2 patients (3.3%) developed distant metastases. Measured 2-year local recurrence-free survival was 97.9% (95% confidence interval, 86.1%-99.7%). Overall survival was 100% at the time of analysis. The mean radiation dose to the primary site was 36.9 Gy (standard deviation, 10.3 Gy). Two patients (3.3%) experienced late soft tissue necrosis in the primary site surgical bed that resolved within 2 months. Feeding tube dependence rates were 0% during RT, 3.3% temporarily during follow-up, and 0% at last follow-up.

CONCLUSIONS

Deintensified postoperative RT that avoids the resected primary tumor site and targets only the at-risk neck after TORS for selected patients with HPV-associated OPSCC may be safe and is worthy of further study.

Cervical-transoral robotic nasopharyngectomy: A preclinical study

BACKGROUND

We performed a preclinical study to assess the feasibility of the cervical-transoral robotic pharyngectomy procedure in surgery for nasopharyngeal cancer, where deep margins and vascular safety are key issues.

MATERIALS AND METHODS

Four cadaveric dissections were performed with the da Vinci Xi system. The first step was a robotic parapharyngeal dissection along the internal carotid artery (ICA). The second step was a type 3 transoral robotic nasopharyngectomy.

RESULTS

In each procedure, a comprehensive dissection of the parapharyngeal space was performed along the ICA up to the foramen lacerum. A type 3 nasopharyngectomy was performed transorally with an "en-bloc" removal of the parapharyngeal space, and with complete removal of the eustachian tube up to its bony part.

CONCLUSION

A comprehensive cervical-transoral robotic type 3 nasopharyngectomy with "en-bloc" removal of the parapharyngeal space and the eustachian tube proved to be technically feasible in a preclinical study.

Transoral Surgery Alone for Human-Papillomavirus–Associated Oropharyngeal Squamous Cell Carcinoma

The aim of this retrospective study was to describe the oncologic and functional results of treating oropharyngeal squamous cell carcinoma with transoral robotic surgery and neck dissection as monotherapy. A review was performed, including all patients who underwent transoral robotic surgery and neck dissection as the only means of therapy for oropharyngeal carcinoma from March 2007 to July 2009 at a single tertiary care academic medical center. We reviewed all cases with ≥ 24-month follow-up. Functional outcomes included tracheostomy dependence and oral feeding ability. Oncologic outcomes were stratified by human papillomavirus (HPV) status and tobacco use and included local, regional, and distant disease control, as well as disease-specific and recurrence-free survival. Eighteen patients met study criteria. Ten patients (55.6%) were able to eat orally in the immediate postoperative period, and 8 (44.4%) required a temporary nasogastric tube for a mean duration of 13.6 days (range 3 to 24 days) before returning to an oral diet. No patient required placement of a gastrostomy tube, and all patients are tracheostomy-tube–free. Among the HPV-positive nonsmokers (12/18, 66.7%), Kaplan-Meier estimated 3-year local, regional, and distant control rates were 90.9%, 100%, and 100%, respectively. Kaplan-Meier estimated disease-specific survival and recurrence-free survival were 100% and 90.9%, respectively. No complications occurred.

Endoscopic Transoral Hybrid Supracricoid Partial Laryngectomy with Cricohyoidoepiglottopexy

Objectives:

The hybrid supracricoid partial laryngectomy with cricohyoidoepiglottopexy (SCPL-CHEP, that is, open partial horizontal laryngectomies OPHL Type IIa) has been described using a flexible next generation robotic surgical platform for manipulation. We sought to evaluate the feasibility of performing this procedure using endoscopic transoral (EndoT) surgical techniques without robotics.

Methods:

Preclinical cadaveric study using two human cadavers. Hybrid SCPL-CHEP was performed with a flexible endoscope for visualization and hand-held instruments for manipulation (SILS Hook monopolar and Dissect, HAVAS LaryngoFIT malleable straight jaw instruments, and Stratafix 4-0 spiral knotless barbed suture).

Results:

EndoT hybrid SCPL-CHEP was successfully performed. The hand-manipulated rigid instruments allowed for transoral incisions and mucosal suturing. We provide the procedural steps of EndoT hybrid techniques.

Conclusions:

EndoT hybrid SCPL-CHEP was technically feasible in the preclinical cadaveric laboratory setting and appeared comparable to the hybrid SCPL-CHEP via transoral robotic surgery (TORS). Selected handheld instruments and flexible endoscopy appear to facilitate minimally invasive surgery of the larynx. This novel procedure and technique warrant further clinical study for consideration of feasibility, applicability, and patient benefit.

Evaluation of robotic surgery for transoral resection of T1-2 squamous cell carcinoma of the tonsillar fossa

GOAL

To evaluate transoral robotic surgery (TORS) for isolated previously untreated squamous cell carcinoma (SCC) of the tonsillar fossa classified as T1-2.

METHOD

Retrospective analysis of two cohorts of isolated untreated T1-2 tonsillar fossa SCC consecutively operated on by a transoral approach, with (R=21) and without (NR=24) robotic assistance, in the period 2006-2014. Three main (survival, local control, and operative morbidity) and three secondary (pathologic data, incidence and duration of tracheotomy and nasogastric intubation, and hospital stay) endpoints were compared between groups. The significance threshold was set at P< .005.

RESULTS

Three- and five-year actuarial survival estimates were 80.2% and 74.5% respectively in group R, and 91.5% and 82.5% respectively in group NR (NS: P=.34). Three- and five-year actuarial local control estimates were 90% and 90% respectively in group R, and 95.8% and 91% respectively in group NR (NS: P=.81). There were no significant differences in morbidity, tracheotomy/nasogastric intubation time, or hospital stay. Positive resection margins (R1) were noted in 38.1% and 16.7% in groups R and NR, respectively (NS: P=.05) without significant impact on 5-year actuarial local control (P=0.78).

CONCLUSION

Robotic assistance in transoral lateral oropharyngectomy for T1-2 tonsillar fossa SCC did not significantly impact oncologic or functional outcome.

Robotic compared with open operations for cancers of the head and neck: a systematic review and meta-analysis

To compare the effectiveness and safety of robotic surgery with that of open operations for patients with cancers of the head and neck we made an electronic search of the CENTRAL, MEDLINE, EMBASE, CNKI, CBM, Opengray and Sciencepaper Online databases, and then made a manual search of specific online databases and the reference lists of relevant papers. Our most recent searches were made on 18 July 2018, and we included randomised controlled trials (RCT), case-control studies, cohort studies, and cross-sectional surveys in which robotic was compared with open surgery for cancer of the head and neck. Data from all the studies included were extracted by two independent workers. The risk ratio was chosen to measure dichotomous effects of treatment for prospective studies including RCT or cohort studies, while the odds ratio was chosen for case-control or cross-sectional studies. The weighted mean difference or standard mean difference was chosen to summarise continuous effects. A random-effects model was used for all data analyses. Thirteen studies were included: one RCT, nine cohort studies, and three cross-sectional studies. Robotic surgery was associated with fewer invaded resection margins, lower recurrence, less need for intraoperative tracheostomy, and less need and shorter duration of postoperative nasal feeding than open operations. Robotic surgery is a safe and feasible approach with remarkable superiority over open surgery for the treatment of cancers of the head and neck.

Outcomes in surgically resectable oropharynx cancer treated with transoral robotic surgery versus definitive chemoradiation

PURPOSE

Optimal treatment strategies for the management of oropharyngeal squamous cell carcinoma (OPSCC) remain unclear. The objective of this study is to examine the role of transoral robotic surgery (TORS) on functional and treatment outcomes.

MATERIALS AND METHODS

A retrospective review of patients with OPSCC (tonsil/base of tongue) who underwent TORS with neck dissection± adjuvant therapy between January 2011 to December 2016 were compared to a stage matched cohort of patients treated with primary chemoradiation. Demographic, treatment, and outcome data were collected.

RESULTS

54 patients received primary chemoradiation and 65 patients (surgical group) received TORS ± adjuvant therapy for clinically staged disease meeting study criteria. 25% (N = 17) were treated with surgery alone. The remainder of the surgical group received postoperative radiation (N = 48), half of which received adjuvant chemotherapy (N = 24) in addition to radiation. 63% (N = 41) of the patients did not have risk factors for chemotherapy. No differences in overall or disease free survival were observed with TORS compared to chemoradiation (p = 0.9), although Charlson Comorbidity Index (CCI) was higher in the surgical group (p = 0.01). The strongest predictor of prolonged gastrostomy tube use was not treatment, but rather co-morbidity (p = 0.03), with no significant differences beyond 12 months.

CONCLUSION

Although no significant survival differences were observed across treatment groups, this was maintained despite increased comorbidity index in the surgical patients. Given the ability to de-escalate and/or eliminate adjuvant therapy, particularly in a less healthy population, TORS would appear to be the viable treatment option it has become.

The dawn of robotic surgery in otolaryngology-head and neck surgery

Transoral robotic surgery (TORS) utilizing the da Vinci robotic system has opened a new era for minimally-invasive surgery (MIS) in Otolaryngology-Head and Neck Surgery. Awareness of the historical steps in developing robotic surgery (RS) and understanding its current application within our field can help open our imaginations to future of the surgical robotics. We compiled a historical perspective on the evolution of surgical robotics, the road to the da Vinci surgical system, and conducted a review of TORS regarding clinical applications and limitations, prospective clinical trials and current status in Japan. We also provided commentary on the future of surgical robotics within our field. Surgical robotics grew out of the pursuit of telerobotics and the advances in robotics for non-medical applications. Today in our field, cancers and diseases of oropharynx and supraglottis are the most common indications for RS. It has proved capable of preserving the laryngopharyngeal function without compromising oncologic outcomes, and reducing the intensity of adjuvant therapy. TORS has become a standard modality for MIS, and will continue to evolve in the future. As robotic surgical systems evolve with improved capabilities in visual augmentation, spatial navigation, miniaturization, force-feedback and cost-effectiveness, we will see further advances in the current indications, and an expansion of indications. By promoting borderless international collaborations that put 'patients first', the bright future of surgical robotics will synergistically expand to the limits of our imaginations.

Reconstruction of TORS oropharyngectomy defects with the nasoseptal flap via transpalatal tunnel

The nasoseptal flap (NSF) has been described as reconstructive option for soft palate defects following transoral robotic surgery (TORS). As described, this technique is does not provide adequate coverage of the lateral oropharyngeal wall, parapharyngeal space, exposed vessels, or exposed mandibular bone. The NSF for TORS reconstruction has been limited to soft palate reconstruction, given the limitations on length when passed via the nasopharynx. In this article, we describe (1) a novel technique for TORS reconstruction using direct transposition of the ipsilateral NSF into the oropharynx via a transpalatal tunnel at the hard-soft palate junction, and (2) its use in select patients.

Systematic Review of Validated Quality of Life and Swallow Outcomes after Transoral Robotic Surgery

Objective

To systematically review the available evidence on the effects of transoral robotic surgery (TORS) on the posttreatment quality of life (QOL) and swallow function of patients with head and neck cancer.

Data Sources

PubMed and Ovid electronic databases were searched from inception to July 6, 2016. Specific database functions were applied to maximize the search.

Review Methods

Articles in the database were reviewed for inclusion by 2 independent reviewers according to predetermined eligibility criteria. The references of relevant articles were then hand-searched to identify additional manuscripts. For included articles, the study characteristics and relevant data were extracted.

Results

Of 103 articles screened, 20 reporting validated measures of QOL and/or swallow outcomes for 659 patients were eligible for inclusion. Fourteen were observational studies or case series and did not compare the TORS group with another intervention. Two were prospective nonrandomized clinical trials that compared outcomes between TORS and primary chemoradiation. Four were cohort studies comparing TORS with other treatment approaches and modalities, including open surgical approaches and transoral laser microsurgery. Overall, most patients who underwent TORS ± adjuvant therapy reported a return to baseline QOL and swallow function by 6 to 12 months posttreatment. Several studies demonstrated superior QOL and swallowing outcomes when compared with primary chemoradiation or open approaches.

Conclusions

Available evidence suggests that patients who undergo TORS for head and neck cancer have good QOL and swallowing outcomes after treatment, but outcomes are dependent on baseline function, T stage, and adjuvant treatment status.

Functional Organ Preservation Surgery in Head and Neck Cancer: Transoral Robotic Surgery and Beyond

In recent years, interest in functional organ preservation surgery (FOPS) in the treatment of head and neck cancer has increased dramatically as clinicians seek to minimize the adverse effects of treatment while maximizing survival and quality of life. In this context, the use of transoral robotic surgery (TORS) is becoming increasingly common. TORS is a relatively new and rapidly-evolving technique, with a growing range of treatment indications. A wide range of novel, flexible surgical robots are now in development and their commercialization is expected to significantly expand the current indications for TORS. In the present review, we discuss the current and future role of this organ-preserving modality as the central element in the multimodal treatment of head and neck cancer.

The 100 most influential manuscripts in robotic surgery: a bibliometric analysis

Since the first robotic assisted surgery in 1985, the number of procedures performed annually has steadily increased. Bibliometric analysis highlights the key studies that have influenced current practice in a field of interest. We use bibliometric analysis to evaluate the 100 most cited manuscripts on robotic surgery and discuss their content and influence on the evolution of the platform. The terms 'robotic surgery,' 'robot assisted surgery' and 'robot-assisted surgery' were used to search Thomson Reuters Web of Science database for full length, English language manuscripts. The top 100 cited manuscripts were analyzed by manuscript type, surgical specialty, first and last author, institution, year and journal of publication. 14,980 manuscripts were returned. Within the top 100 cited manuscripts, the majority featured urological surgery (n = 28), followed by combined results from multiple surgical subspecialties (n = 15) and colorectal surgery (n = 13). The majority of manuscripts featured case series/reports (n = 42), followed by comparative studies (n = 24). The most cited paper authored by Nelson et al. (432 citations) reviewed technological advances in the field. The year and country with the greatest number of publications were 2009 (n = 15) and the USA (n = 68). The Johns Hopkins University published the most top 100 manuscripts (n = 18). The 100 most cited manuscripts reflect the progression of robotic surgery from a basic instrument-holding platform to today's articulated instruments with 3D technology. From feasibility studies to multicenter trials, this analysis demonstrates how robotic assisted surgery has gained acceptance in urological, colorectal, general, cardiothoracic, orthopedic, maxillofacial and neuro surgery.

Perioperative safety, feasibility, and oncologic utility of transoral robotic surgery with da Vinci Xi platform

Transoral robotic surgery (TORS) is a common modality for treatment of oropharyngeal and laryngeal cancer. Current FDA approval extends to the da Vinci S and Si platforms. Many hospitals are adopting the da Vinci Xi platform. Reports of head and neck surgical outcomes with this platform are scant. This study reports outcomes of TORS procedures performed with the da Vinci Xi platform including perioperative adverse events, functional outcomes, and short-term local control. A retrospective review of TORS performed with the da Vinci Xi platform is undertaken. Twenty-two consecutive TORS cases with the Xi platform are reviewed. Procedures performed include radical tonsillectomy, base of tongue resection, and lingual tonsillectomy. Two bleeding events occurred (9% of cases), both of intermediate severity as per Mayo criteria. Three procedures resulted in positive margin status, early in the case series, and two were cleared with revision resection. One-year local control rate, where available, is 100%. There were no perioperative deaths, long-term gastrostomy dependence, or performance of tracheostomy. Advantages of this platform include ease of robot deployment and setup. Disadvantages include increased width of instrumentation compared with previous platforms with crowding of access. The availability of a specific robotic platform may be dictated by hospital-wide policy across service lines. This report suggests that the da Vinci Xi permits performance of TORS with safety and oncologic outcomes similar to previous platforms; however, long-term follow-up is needed.

How I do it: transnasal retraction during transoral robotic oropharyngeal resection

Collapse of the resection plane presents a frustrating problem during transoral robotic resection, in a situation already typified by limited vision and access for instruments. We present a quick and cost-effective retraction technique to effectively mitigate this issue and increase the ease and reliability of robotic oropharyngeal resection. This technique utilises a simple transnasal apparatus to create greater exposure of the resection plane. A Y-suction catheter is inserted into the oropharynx via the nasal cavity. A silk suture is then used to attach it to the oropharyngeal resection specimen. When pulled from the nasal cavity, this apparatus adds a non-intrusive, tremor-free fixation point that pulls the resected specimen along a unique cephalo-posterior vector. This significantly improves access and vision of the desired dissection plane. The entire process takes approximately 1-2 min per side to properly execute. It can be adapted for various pathologies and subsites of the oropharynx. This transnasal technique is a simple, minimally invasive, and inexpensive method for improving wound tension during transoral oropharyngeal resection.

Management of clinically N0 neck in oropharyngeal carcinoma

Purpose

Only a minority of patients with oropharyngeal squamous cell carcinoma (OPSCC) are diagnosed without regional metastasis (cN0). Studies focusing on the management of cN0 neck in OPSCC are scarce.

Methods

We reviewed all OPSCC patients treated at our institution with cN0 neck between 2000 and 2009. The treatment of neck and pattern of regional control was analyzed. Median follow-up was 5 years (range 3.5–9.0) or until death.

Results

Of the total 313 OPSCC patients treated within the period, 56 (18%) presented with cN0 neck. Of them, 51 (91%) received completed treatment with curative intent: 46 (90%) underwent elective neck treatment with either neck dissection ± (chemo)radiotherapy (C)RT (n = 23) or (C)RT (n = 23). A regional recurrence occurred in three patients (6%) and they all had a p16-negative soft palate midline primary tumor. Two of these patients had received RT on the neck.

Conclusions

While the overall prognosis of OPSCC is generally favorable and regional recurrences are infrequent, soft palate tumors, that are usually p16 negative, may form an subgroup warranting more aggressive treatment despite the clinical appearance of early stage.

Comparison of TORS with Conventional Surgery for Oropharyngeal Carcinomas in T1-T4 Lesions

Objectives:

Transoral Robotic Simulation (TORS) is an innovative surgical technique indicated for resection of selected head-and-neck cancers. The authors conducted a systematic review discussing the indications, advantages, and disadvantages of this technique.

Data Sources:

The search included MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, COCHRANE, and bibliographies of relevant studies through January 2006.

Materials and Methods:

Studies included patients treated for T1–T4 stage oropharynx cancer with TORS. Study retrieval and data extraction were conducted in duplicate and resolved by consensus. Treatment specific details, as well as recurrence, survival, and adverse events, were collected. Methodological quality for each study was appraised.

Results:

Nine studies were included which met the inclusion criteria. Patients receiving TORS required adjuvant radiotherapy (26%) or chemoradiotherapy (41%). Two-year overall survival estimates ranged from 82% to 94% for TORS.

Conclusion:

The minimally invasive transoral robotic simulation (TORS) for the treatment of oropharyngeal cancers is proved to be less time-consuming, compliant to the patients, and having less complications as compared to the more invasive techniques involving conventional surgery although the quality of this evidence is limited.

Treatment of Tonsillar Carcinoma following Nononcologic Tonsillectomy: Efficacy of Transoral Robotic Revision Tonsillectomy

OBJECTIVE

To evaluate whether transoral robotic surgery (TORS) is a suitable treatment approach for patients diagnosed with tonsillar carcinoma after a standard palatine tonsillectomy.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care medical center.

SUBJECTS AND METHODS

Patients who underwent TORS at the University of Washington from 2010 to 2017 (n = 150) were identified. All patients who were diagnosed with tonsillar carcinoma following a nononcologic tonsillectomy and subsequently underwent TORS radical tonsillectomy were included (n = 14). Tumor stage-matched subjects (n = 44) were included who did not undergo standard tonsillectomy prior to TORS. Our primary outcome was final margin status. Secondary outcomes were presence of residual tumor, receipt and dose of postoperative adjuvant therapy, disease-free survival (DFS), and disease-specific survival. Patients with <6 months of follow-up following definitive treatment were excluded from survival analyses.

RESULTS

Final margin status was clear in all subjects. Residual tumor was not identified in 13 of 14 (92.9%) prior-tonsillectomy subjects following TORS radical tonsillectomy. Seven of 14 (50%) prior-tonsillectomy subjects and 12 of 44 (27.3%) TORS-matched subjects did not require adjuvant therapy due to favorable pathology. Among subjects who received post-TORS radiation therapy (RT) at our institution, RT dose reduction was achieved in 3 of 4 (75%) prior-tonsillectomy subjects and 21 of 24 (87.5%) TORS-matched subjects. Ten of 14 (71.4%) prior-tonsillectomy subjects and 31 of 44 (70.5%) TORS-matched subjects avoided post-TORS chemotherapy. DFS was not significantly different ( P = .87) between prior-tonsillectomy and TORS-matched groups, and no subjects died of related disease.

CONCLUSIONS

Patients diagnosed with tonsillar carcinoma following a prior nononcologic standard palatine tonsillectomy are suitable candidates for revision surgery with TORS radical tonsillectomy.

Recent advances in the understanding and management of oropharyngeal cancer

Oropharyngeal squamous cell carcinoma (OPSCC) is an increasing health problem in the developing and developed world. In recent years, there have been major changes in the treatment paradigms for OPSCC. This is because of a number of reasons: the understanding and discovery of a new viral etiology (the human papillomavirus [HPV]), changes in practice patterns owing to advances in radiotherapy, and then an organ preservation strategy with the increased use of chemotherapy. Next came the development of new surgical technologies and the emergence of a new treatment modality, immunotherapy. In this article, we discuss the evolution of OPSCC treatments, starting with the traditional tobacco era. Treatment paradigms then evolved during the organ preservation era, the HPV era, and the minimally invasive surgery era. We are currently in the immunotherapy era, with a number of new drugs becoming available both on trial and by approval for use in the clinical setting for head and neck cancer patients. We discuss a number of trials and the reasons behind attempts at both treatment escalation and treatment de-escalation.

Transoral surgery (TOS) in oropharyngeal cancer: Different tools, a single mini-invasive philosophy

Surgery with or without adjuvant therapy and radiotherapy with or without chemotherapy have traditionally represented the possible treatment options for oropharyngeal cancer. The adverse effects of non-surgical treatments and recent technical innovations have prompted a new interest in the surgical approach. However, in parallel to the possibility of achieving radical cancer clearance, we should remember the impact that traditional open surgery has on the patient's cosmesis, functionality and quality of life. As a result, transoral surgery is an attractive option for oropharyngeal tumors. The term "transoral surgery" only indicates that the tumor is accessed and resected via the oral cavity, but the surgeon can choose among different resection methods, such as transoral laser microsurgery, transoral robotic surgery, transoral videolaryngoscopic surgery, endoscopic laryngo-pharyngeal surgery, and transoral ultrasound surgery. The aim of this paper is to review the recent literature on the transoral treatment of oropharyngeal cancer, to standardize the terminology of transoral procedures, analyzing the common aspects, main differences and future perspectives of the various forms of transoral surgery.

Management of the Airway for Transoral Robotic Supraglottic Partial Laryngectomy

Introduction: Over the last several decades, transoral resection techniques for treatment of supraglottic lesions have become increasingly favored to reduce the need for either open transcervical resection or primary chemoradiation. Transoral robotic surgery (TORS) offers advantages in visualization, dissection control, and access to remove bulky tumors en bloc. However, the management of the airway for these cases tends to vary, without clear guidelines as to when a tracheostomy is necessary. Materials and Methods: A retrospective review of all patients who underwent transoral robotic supraglottic partial laryngectomy at a large academic center from May 2005 through December 2016 was performed. Airway management was examined, specifically as it pertains to whether a tracheostomy was performed at the time of surgery or otherwise. Demographic and tumor characteristics were also evaluated. Results: Sixty-three patients were included. Forty (63%) were male, the average age at surgery was 63.6, and the majority (90.5%) underwent resection for squamous cell carcinoma of the supraglottis. Thirty-nine patients (62%) underwent the procedure with standard endotracheal intubation using a wire-reinforced tube. Of these, four patients required subsequent tracheostomy- 2 for laryngeal edema postoperatively, one for airway management during a postoperative bleeding event, and one for laryngeal edema following initiation of adjuvant chemoradiation. Twenty patients (32%) underwent tracheostomy at the time of transoral resection for airway management, 17 of whom were decannulated an average of 12.2 weeks following surgery. Those who underwent tracheostomy at the time of surgery had a higher percentage of tumors involving multiple supraglottic subsites (p = 0.031), 85 vs. 54% in the group who did not undergo tracheostomy. No difference in age, BMI, clinical T-stage, or clinical N stage was found between the two groups. Conclusion: Performing a tracheostomy at the time of surgery should be considered for those patients with more extensive malignant disease (≥T2 tumors). While avoiding tracheostomy is often preferred by the patient, the maintenance of the patent airway peri-operatively should be first priority when considering airway management. Furthermore, as the majority of those patients receiving tracheostomy are decannulated within 4 months of surgery, the tracheostomy could be considered a short-term adjunct to the procedure.

Transoral Robotic Surgery in the Nordic Countries: Current Status and Perspectives

Background: The five Nordic countries with a population of 27 M people form a rather homogenous region in terms of health care. The management of head and neck cancer is centralized to the 21 university hospitals in these countries. Our aim was to gain an overview of the volume and role of transoral robotic surgery (TORS) and to evaluate the need to centralize it in this area as the field is rapidly developing.

Materials and Methods: A structured questionnaire was sent to all 10 Departments of Otorhinolaryngology—Head and Neck Surgery in the Nordic countries having an active programme for TORS in December 2017.

Results: The total cumulative number of performed robotic surgeries at these 10 Nordic centers was 528 and varied between 5 and 240 per center. The median annual number of robotic surgeries was 38 (range, 5–60). The observed number of annually operated cases remained fairly low (<25) at most of the centers.

Conclusions: The present results showing a limited volume of performed surgeries call for considerations to further centralize TORS in the Nordic countries.

Initiating a Robotic Thyroidectomy Program in India

Robotic surgery has been successfully used for many surgical indications in head and neck surgery. Robotic thyroidectomy is getting accepted worldwide, but the majority of the literature is from South Korea. The purpose of the paper is to review and give a personal perspective on how a robotic thyroidectomy program was initiated in a tertiary care academic medical institution in India. Advantages of robotic approaches are the three-dimensional visualization, precision, dexterity, and surgeon ergonomics. Cost is an important concern. Training includes basic robotics skill training, cadaveric training, observership, and hands-on training. Sufficient preclinical and clinical training is essential before embarking onto the newer surgical modality. Surgeon credentialing, though institution dependent, has specific guidelines. Case selection is the key, especially in the initial learning curve. The authors prefer the retroauricular approach for robotic thyroidectomy, and our initial experience in the first ten cases of total thyroidectomy was encouraging.

Use of the EndoMaster robot-assisted surgical system in transoral robotic surgery: A cadaveric study

BACKGROUND

The EndoMaster is a novel robot-assisted surgical system originally designed for endoscopic resection of gastrointestinal polyps and tumours. It incorporates two robotic arms (a grasper and a probe for monopolar diathermy) into the end of a flexible endoscope, creating improved manoeuvrability, with two arms allowing for 9 degrees of movement and triangulation; this enables fine manipulation and dissection of tissues.

METHODS

The EndoMaster was used in two human cadavers to perform 4 radical tonsillectomies to evaluate its performance in transoral robotic surgery (TORS).

RESULTS

The EndoMaster allowed for good visualization of the surgical field and its compact form factor allowed for quick docking and avoided the problem of clashing of the working arms.

CONCLUSION

The EndoMaster system shows promising potential for use in TORS. Further refinements to movements of the effector arms are required.

Robotics in oral and maxillofacial surgery

How trans-oral robotic surgery can treat cancer in the oropharyngyal space

Margin Analysis: Squamous Cell Carcinoma of the Oropharynx

Because of the common shared risk factors of smoking and heavy alcohol consumption, literature involving oropharyngeal squamous cell carcinoma (OPSCC) is often combined with oral squamous cell carcinoma. Human papilloma virus is now confirmed to be a major risk factor of OPSCC with its distinct epidemiology and favorable treatment outcome. The impact of adjuvant chemoradiation in the setting of positive surgical margins remains unclear but is likely influenced by tumor biology. This article reviews the tumor biology of OPSCC and summarizes recent findings on outcomes following surgical treatment of OPSCC.

Head and neck cancer in Hong Kong

Head and neck cancer is a major cause of morbidity and mortality in Hong Kong. HNC is well-known for its heterogeneity in epidemiology, clinical behavior, clinic-pathological features and patient characteristics. Treatment strategies for this heterogeneous disease vary greatly in different parts of the world, depending on availability of resources, local expertise and experience. Extensive research in head and neck cancer, particularly nasopharyngeal carcinoma, has been conducted in Hong Kong in the past few decades. In this article, we will review the available local evidence and summarize common practice in management of head and neck cancer in Hong Kong.

Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer

Objective

We analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical‐transoral robotic oropharyngectomy course with free flap reconstruction.

Methods

Patients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre‐operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery.

Results

Three patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous‐cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications.

Conclusions

In our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations.

Level of evidence

4.

[Robotic Surgery - Who is The Boss?]

In the head and neck region, great potential is seen in robot-assisted surgery (RAS). Mainly in cancer surgery, the use of robotic systems seems to be of interest. Until today, two robotic systems (DaVinci® und FLEX®) have gained approval for clinical use in the head and neck region, and multiple other systems are currently in pre-clinical testing. Although, certain groups of patients may benefit from RAS, no unbiased randomized clinical studies are available. Until today, it was not possible to satisfactorily prove any advantage of RAS as compared to standard procedures. The limited clinical benefit and the additional financial burden seem to be the main reasons, why the comprehensive application of RAS has not been realized so far.This review article describes the large variety of clinical applications for RAS in the head and neck region. In addition, the financial and technical challenges, as well as ongoing developments of RAS are highlighted. Special focus is put on risks associated with RAS and current clinical studies. We believe, that RAS will find its way into clinical routine during the next years. Therefore, medical staff will have to increasingly face the technical, scientific and ethical features of RAS.

Transoral robotic surgery for residual and recurrent oropharyngeal cancers: Exploratory study of surgical innovation using the IDEAL framework for early-phase surgical studies

BACKGROUND

The purpose of this study was to identify the role of transoral robotic surgery (TORS) in the management of residual and recurrent oropharyngeal cancer.

METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term Follow-up) 2a framework.

RESULTS

Of 26 patients assessed for TORS, 21 underwent the procedure, 5 underwent open resection (4 due to unsuitable anatomy/tumor extent and 1 on the basis of patient choice). Three patients underwent intraoperative ultrasound-assisted robotic resection, and 3 received robotic-assisted free flap inset. A technical refinement for TORS of residual and recurrent oropharyngeal cancer of the tongue base is described. Actuarial plots showed estimated overall survival of 48.2%, local control of 76.6%, and disease-specific survival of 77.1% at 42.6 months.

CONCLUSION

TORS is a valid management option for residual and recurrent oropharyngeal cancer. Oncologic outcomes are comparable to open surgery and transoral laser microsurgery, with the added advantages of en bloc resections, facility for intraoperative ultrasound imaging, and inset of free flaps without mandibular split.

Using Technology in Global Otolaryngology

Technology is integral to the diverse diagnostics and interventions of Otolaryngology. Historically, major advances in this field derive from advances of associated technologies. Challenges of visualization and surgical access are increasingly overcome by integrating endoscopic, electronic, and robotic instruments. Otolaryngology is often limited to urban areas and large academic centers, making it difficult to allocate care and resources to many underserved populations. The widespread use of technology has important implications in regards to global access to this field as telemedicine is most effectively applied to specialties that are heavily reliant on data and visuals that may be electronically disseminated.

Staging Neck Dissection and Transoral Robotic Surgery Treatment Algorithm in Palatine Tonsil Cancer

Objective

This study introduces a treatment algorithm based on staging neck dissection to identify patients with palatine tonsil squamous cell carcinoma who can be effectively treated with single-modality transoral robotic surgery while maintaining quality of life.

Study Design

Retrospective case series.

Setting

Kaiser Permanente Southern California Medical Group from 2012 to 2017.

Subjects and Methods

Patients with early-stage (T1/2) palatine tonsil squamous cell carcinoma with clinically and radiographically N0 necks underwent staging neck dissection. Those with pN2/3 disease or extracapsular extension on final pathology were triaged to definitive chemoradiation treatment. Patients with confirmed pN0/1 necks without extracapsular extension were treated definitively with transoral robotic surgery.

Results

Nineteen patients with cN0 disease underwent selective neck dissection. All were p16 positive. Of these, 14 had pathologically confirmed N0/1 necks without extracapsular extension and were treated with primary surgical resection via transoral robotic surgery. Clear margins were obtained on all patients. There were no significant intra- or postoperative complications. No patients required gastrostomy tube or tracheostomy placement. Mean and median follow-up was 28 months with no recurrences to date.

Conclusion

Up-front staging neck dissection accurately triages low-risk patients, determining candidates for single-modality definitive treatment with transoral robotic surgery. This approach provides excellent survival outcomes and minimal morbidity and maintains quality of life among appropriately selected patients with palatine tonsil cancer.