Transoral robotic surgery vs transoral laser microsurgery for resection of supraglottic cancer: a pilot surgery

Survival, Surgical, and functional outcomes of transoral laser microsurgery for cT1-T3 supraglottic laryngeal Cancers: A systematic review

BACKGROUND

This review aimed to investigate the surgical, functional, and oncological outcomes of transoral laser microsurgery supraglottic laryngectomy (TOLM-SGL) for cT1-T3 laryngeal cancers.

METHODS

PubMed, Scopus, and Cochrane Library were searched by two independent investigators for studies investigating the surgical, functional, and oncological outcomes of TOLM-SGL using the PRISMA statements. A bias analysis was carried out with MINORS.

RESULTS

Twenty-four studies were included (937 patients), including 206 (25.9 %) cT1, 467 (58.7 %) cT2, and 123 (15.4 %) cT3 cases. Most patients were cN0 (63.9 %). The mean hospital stay of TOLM was 10.1 days. Aspiration (5.5 %), and bleeding (5.3 %) were the most prevalent complications. The laryngeal preservation rate was 93.7 %. Temporary tracheotomy was performed in 18.0 % of patients, with a mean time of decannulation of 6.8 days. A feeding tube was placed in 59.9 % of patients. The oral diet restarted after 6.4 days. Definitive gastrostomy was necessary in 2.4 % of cases. The 5-year OS and DFS were 70.1 % and 82.0 %, respectively. Distant metastasis, local, and regional recurrence occurred in 4.6 %, 11.6 %, and 5.1 % of patients. There was an important heterogeneity between studies for inclusion criteria, patient profiles, TOLM indications, and details of surgical, functional, and oncological outcomes.

CONCLUSION

TOLM supraglottic laryngectomy is a safe, and effective procedure associated with adequate functional, surgical, and oncological outcomes. Future studies are needed to define the place of TOLM in advanced LSCC; the role and timing of concomitant bilateral neck dissection, the indications of tracheotomy and feeding tube.

Surgical, Functional, and oncological outcomes of transoral robotic surgery for cT1-T3 supraglottic laryngeal Cancers: A systematic review

BACKGROUND

This systematic review investigated the surgical, functional, and oncological outcomes of transoral robotic supraglottic laryngectomy (TORS-SGL) for cT1-T3 laryngeal squamous cell carcinoma (LSCC).

METHODS

Two investigators conducted an updated PubMed, Scopus, and Cochrane Library systematic review for studies investigating the surgical, functional, and oncological outcomes of TORS-SGL using the PRISMA statements. The bias analysis was conducted with the MINORS.

RESULTS

Twenty-one studies were included, accounting for 896 patients. TORS-SGL was primarily performed for cT1 (39.1 %), cT2 (46.9 %), and some selected cT3 (7.7 %) LSCCs. Surgical margins were positive in 10.8 % of cases. The mean hospital stay was 8.6 days. Hemorrhage (6.3 %), pneumonia (5.5 %), and aspiration (1.7 %) are the primary complications. The surgical margins were positive in 10.6 % of cases. Feeding tubes, temporary tracheotomy, and definitive percutaneous gastrostomy are found in 65.6 %, 19.7 %, and 5.2 % of patients, respectively. The oral diet is restarted after a mean of 7.2 days. The 5-year OS and DFS of TORS-SGL were estimated to be 78.3 %, and 91.7 %, with 5-year local-relapse-free survival and nodal-relapse-free survival of 90.8 %, and 86.6 %, respectively.

CONCLUSION

The TORS-SGL is a safe, and effective surgical approach for cT1-T3 SGL. The functional and surgical outcomes appear comparable with TOLM-SGL. The oncological outcomes of TORS-SGL could be better than TOLM and open SGLs, but further large cohort-controlled studies are needed to draw reliable conclusions.

Features related to temporary tracheotomy in patients undergoing Transoral Robotic Surgery (TORS) for supraglottic squamous cell cancer of the larynx: A systematic review

OBJECTIVE

The aim of this systematic review is to assess a relation between demographical, clinical and tumoral features and the need for a prophylactic tracheotomy during TORS procedure in patients affected by supraglottic laryngeal cancer.

METHODS

PRISMA 2020 guidelines were applied in this systematic literature review. A computerized search was performed using the Embase/Pubmed, Scopus and Cochrane database, for articles published from 2007 to December 2023. A statistical univariate analysis including selected papers with low or intermediate risk of bias was performed.

RESULTS

Through a study selection process 8 full texts were eligible for statistical univariate analysis. The most relevant factor related to a prophylactic tracheotomy was a contextual bilateral cervical nodes dissection, which increased the need for a tracheotomy of about 3 times. Other factors contribute with a minor impact, such as a patients age >60 years at the time of the diagnosis, a cervical lymph node metastasis and a false vocal fold involvement. Each ones increase by 20-70 % the need for a tracheotomy. However, this rate is decreased by about 60 % by the epiglottis involvement.

CONCLUSIONS

The prophylactic tracheotomy is considered a temporary protection strategy to achieve a valid recovery after TORS procedure. However, there are no guidelines regarding its routinely use. Only 25 % of patients undergone tracheotomy during TORS to treat supraglottic laryngeal cancer. These preliminary results may add more significant evidence regarding the use of tracheotomy during the TORS procedure, in order possibly to help the surgeon decide preoperatively whether to perform it or not.

Transoral robotic surgery for supraglottic cancer. A review of oncological and functional outcomes compared to open surgery

Objective

Supraglottic squamous cell carcinoma (SCC) represents a major surgical challenge in organ-preserving treatment. Type I open partial horizontal laryngectomy (OPHL I) is considered the most popular. To date, minimally-invasive approaches such as laser microsurgery and transoral robotic surgery (TORS) have gained increasing relevance. The aim of this narrative review is to obtain a descriptive comparison of functional and oncological outcomes from studies on patients with supraglottic SCC treated with OPHL I and TORS, respectively.

Material and methods

A computerised search was performed using the Pubmed database for articles published from 2000 to 2023. A comparative analysis on functional and oncological outcomes of patients treated by TORS and OPHL I was performed.

Results

The present narrative review shows a superiority of TORS compared to open surgery for supraglottic SCC in terms of functional outcomes, while maintaining comparable oncological outcomes.

Conclusions

Although recently introduced in the treatment of laryngeal pathology, TORS has been shown to be a reliable technique not only for functional but also for oncological outcomes, ensuring good overall survival, disease-free survival, and disease control rates comparable to OPHL I.

Transoral robotic surgery vs. non-robotic surgeries for oropharyngeal squamous cell carcinoma: systematic review and meta-analysis

To compare the effectiveness of transoral robotic surgery (TORS) and non-robotic surgeries (NRES) in patients with oropharyngeal squamous cell carcinoma (OPSCC), medical databases were searched including PubMed, Web of Science, Medline, Embase, and Cochrane Library up to January 2023. The methodology follows PRISMA guidelines, including the PRISMA flow diagram. Data from the included studies were extracted independently by two researchers. Seven studies involving five hundred seventy-seven patients were included. Of these, 275 underwent TORS and 302 underwent NRES. The disease-free survival rate was significantly higher in the TORS group than in the NRES group (OR = 3.43, 95% CI 1.92-6.15, P < 0.0001). However, there were no significant differences in positive surgical margins, hospital stays, operation time, blood loss, postoperative bleeding rate, perioperative tracheostomy, perioperative feeding tube, and overall survival rate. These findings can initially guide the preoperative counseling of TORS in patients with OPSCC, and preliminarily confirm that the adoption of TORS deserves careful consideration.

Role of transoral robotic surgery in surgical treatment of early-stage supraglottic larynx carcinoma

BACKGROUND

There are several options for primary surgical treatment of early-stage supraglottic squamous cell carcinoma (SCC), including transoral robotic surgery (TORS). The purpose of this study was to compare outcomes of TORS to open partial laryngectomy and transoral laser microsurgery (TLM).

METHODS

Patients with clinical classification T1-2 supraglottic SCC diagnosed 2010-2019, treated with TORS, open partial laryngectomy, or TLM in the National Cancer Database were selected.

RESULTS

One thousand six hundred three patients were included: 17% TORS, 26.5% TLM, 56.5% open. TORS patients had the lowest rates of adjuvant treatment (28.4% vs. TLM: 45.0%, open: 38.5%, p < 0.001), and lower positive margin rates than TLM (16.9% vs. 30.5%, p < 0.001). Thirty-day and ninety-day post-operative mortality did not differ between the approaches. Five-year survival was higher following TORS compared to open surgery (77.8% vs. 66.1%, p = 0.01); this difference persisted following matched-pair analysis.

CONCLUSIONS

TORS may be a safe and effective surgical approach for early-stage supraglottic SCC in appropriate patients.

Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps

Minimally invasive surgery is a growing field in surgical oncology. After acquiring its first Food and Drug Administration approval in 2009 for T1–T2 malignancies of the oral cavity, oropharynx, and larynx, transoral robotic surgery (TORS) has gained popularity thanks to its wristed instruments and magnified three-dimensional view, enhancing surgical comfort in remote-access areas. Its indications are expanding in the treatment of head and neck cancer, i.e., resection of tumors of the larynx, hypopharynx, or parapharyngeal space. However, this expansion must remain cautious and based on high-level evidence, in order to guarantee safety and oncological outcomes which are comparable to conventional approaches. This narrative review assesses the current role of TORS in head and neck cancer from an evidence-based perspective, and then identifies what knowledge gaps remain to be addressed.

Evaluation and application of CO2 laser fiber delivery for single port transoral robotic surgery

BACKGROUND

Transoral robotic surgery (TORS) using the Single-Port system (SPS) relies on electrocautery, limiting its applications in the upper aerodigestive tract. We evaluated the feasibility of a CO₂ delivery system for the SPS.

METHODS

Otolaryngology residents performed a cutting exercise using a handheld CO₂ laser and participated in a cadaveric oropharyngeal dissection using the SPS with monopolar cautery (SP + EC) and CO₂ laser (SP + CO₂ ). Residents completed the System Usability Scale (SUS) questionnaire to evaluate these techniques.

RESULTS

The same laser fiber was used for all combined dissections. The handheld CO₂ laser, SP + EC, and SP + CO₂ demonstrated similar SUS scores. On individual domain scores, SP + CO₂ received less favorable ratings compared to the handheld CO₂ laser for complexity, integration, and cumbersome experience (p < 0.05). On subgroup stratification, less TORS experience was associated with worse SUS scores.

CONCLUSION

SP-guided CO₂ laser delivery is a viable alternative to electrocautery in robotic surgery, and should be considered when performing TORS.

Coblation-assisted transoral supraglottic laryngectomy

BACKGROUND

Transoral supraglottic laryngectomy (TSL) has been widely applied in the treatment of supraglottic cancers. The aim of this study is to evaluate a simplified technique for excising properly selected supraglottic tumors with a transoral coblation-assisted system.

METHODS

Eight patients with T1-3N2M0 supraglottic cancer were treated with TSL with the coblation-assisted system.

RESULTS

Tumors in all patients were en bloc resected with negative surgical margins and the selective neck dissection was also performed. The mean operation time for TSL was 39 minutes (25-65 minutes). The average time for the removal of the nasogastric tube was 8.6 days (1-28 days). All patients were extubated and shifted to the ward after operation. None of the patients required tracheotomy.

CONCLUSION

Coblation-assisted TSL is a relatively simple, easy approach with low risk. It could be a feasible and safe procedure for patients with properly selected supraglottic cancer.

Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery

Robotic systems for head and neck surgery are at different stages of technical development and clinical application. Currently, robotic systems are predominantly used for transoral surgery of the pharynx and larynx. Robotic surgery of the neck, the thyroid, and the middle and inner ear is much less common; however, some oncological and functional outcomes have been reported. This article provides an overview of the current state of robot-assisted head and neck surgery with a special emphasis on patient benefit and postoperative quality of life (QoL). The focus is placed on the role of transoral robotic surgery (TORS) for the resection of oropharyngeal carcinomas. For this application, reported long-term outcomes show functional post-operative advantages for selected oropharyngeal cancer patients after TORS compared to open surgery and primary radiotherapy. Since TORS also plays a significant role in the context of potential therapy de-escalation for HPV-positive oropharyngeal cancer patients, ongoing trials are presented. Regarding the evaluation of the therapeutic benefit and the QoL of cancer patients, special attention has to be paid to the large degree of variability of individual patients' preferences. Influencing factors and tools for a detailed assessment of QoL parameters are therefore detailed at the beginning of this article. Notably, while some robotic systems for ear and skull base surgery are being developed in Europe, TORS systems are mainly used in North America and Asia. In Europe and Germany in particular, transoral laser microsurgery (TLM) is a well-established technology for transoral tumor resection. Future trials comparing TORS and TLM with detailed investigation of QoL parameters are therefore warranted and might contribute to identifying suitable fields for the application of the different techniques.

Presentation and outcomes of patients with clinically T1-2, N0 supraglottic squamous cell carcinoma: The role of definitive radiotherapy compared to primary partial laryngectomy

BACKGROUND

Early-stage supraglottic squamous cell carcinoma (SCC) is usually treated with a single modality. The aim of this study is to examine the role of radiotherapy (RT) versus partial laryngectomy (open, robotic-assisted, or endoscopic) with elective neck dissection (PL + END).

METHODS

A retrospective analysis of the National Cancer Database, 2010-2016. The study population included adult patients with clinically T1-2, N0 supraglottic SCC.

RESULTS

3301 patients were included. RT was performed in 93.52%, open PL + END in 2.64%, robotic-assisted PL + END in 1.33%, and endoscopic surgical resection in 2.51%. In the surgery group, T was upstaged in 23.36% and N was upstage in 16.36%. Five-year survival in the primary surgery group compared to RT group was 61.89% versus 77.46% (HR: 0.56, 95%CI: 0.43, 0.72).

CONCLUSIONS

T was upstaged in 23% of surgical patients. This accurate staging is likely missed in patients who undergo RT and possibly contributes to lower overall survival of this treatment group.

Preclinical implementation of a steerable, Da Vinci Xi® compatible CO2 -laser fibre carrier for transoral robotic surgery (TORS): A cadaveric feasibility study

INTRODUCTION

Monopolar electrocautery is the most common dissection and coagulation tool during transoral robotic surgery (TORS) but causes significant collateral tissue damage as opposed to CO₂ laser. We aimed at combining both modalities in one robotic instrument arm.

METHODS

We developed a steerable CO₂ -laser fibre carrier serving as an add-on to the existing Endowrist® monopolar spatula of the Da Vinci Xi. Feasibility and safety were assessed in a preclinical setting.

RESULTS

One radical tonsillectomy with monopolar cautery and three with the instrument prototype were performed in two cadavers by two surgeons. No serious prototype-related intra-operative difficulties were observed. Safe and efficient switching between energy sources proved possible in all simulated intra-operative bleeding events. Prototype use allowed for the identification of the majority of key anatomical structures and was scored favourably on NASA-TLX questionnaires.

DISCUSSION

The reported prototype successfully combines the advantages of CO₂ -laser with the advantages of TORS.

HPV/p16-positive oropharyngeal cancer treated with transoral robotic surgery: The roles of margins, extra-nodal extension and adjuvant treatment

PURPOSE

Human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC) treatment outcomes are re-defining management. Traditional margins, the role of extranodal extension (ENE) and adjuvant treatment intensity continue to be debated. This study aimed to determine the impact of margins, ENE and adjuvant therapy on survival following transoral robotic surgery (TORS).

METHODS

Patients treated with TORS at an academic center were retrospectively identified (2013-2019). Survival outcomes were evaluated using Kaplan-Meier curves.

RESULTS

48 patients were included. 40 (83%) were male. Mean age was 61.2 years. 43 (90%) were stage I. 22 (45.8%) had ENE. 31 (65%) had margins >1 mm. 38 (79%) had indications for radiation therapy; 9 (24%) refused. Chemotherapy was recommended in 36 (75%) patients; 24 (67%) refused. Locoregional control was 98%, metastasis-free survival was 96%, and disease-specific survival was 100% at 5-years. Overall survival was 95%.

CONCLUSIONS

Given the high survival rate seen after TORS, it is likely that margins, ENE and adjuvant treatment may not significantly contribute to outcomes.

Head and neck robotic surgery combined with sentinel lymph node biopsy. Fascinating, but feasible?

Robotic approaches and sentinel lymph node (SLN) biopsy are both strategies that evolved driven by the need to reduce impact of head and neck oncological surgery in terms of operative timing, morbidity, hospitalization time, and aesthetic results. A comprehensive review of the scientific literature was performed on PubMed, Embase, ResearchGate, Cochrane, and CENTRAL electronic databases with the aim to discuss the role that these two approaches can play together in the management of head and neck cancers (HNCs) of various sites. Dedicated publications on the combined robotics and SLN biopsy approaches resulted, up to now very limited, while their separated application in non-shared fields is gaining strength. However, the possibility to implement and combine technologies to minimize sequelae of head and neck surgery is an interesting and evolving topic.

Surgical, Oncological, and Functional Outcomes of Transoral Robotic Supraglottic Laryngectomy

OBJECTIVES/HYPOTHESIS

To investigate the surgical, oncological, and functional outcomes of transoral robotic surgery (TORS) for the treatment of supraglottic squamous cell carcinoma.

STUDY DESIGN

Retrospective chart review.

METHODS

The charts of patients treated by TORS supraglottic laryngectomy (SGL) in an academic medical center were reviewed. The following outcomes were studied according to the tumor location: average robotic setup and operative times, mean estimated blood loss, postoperative complications, need of tracheotomy, refeeding characteristics, mean hospital stay, need of neck dissection and adjuvant therapy, 5-year local and regional controls, overall survival (OS), and disease-free survival (DFS).

RESULTS

Seventy-five patients underwent TORS SGL. Tumors were classified as cT1 (32%), cT2 (52%), and cT3 (16%). Average robotic setup and operative times and the mean estimated blood loss were 15 minutes, 55 minutes, and 20 mL, respectively. The mean follow-up period ranged from 2 to 5 years. The 5-year OS and DFS were 80.2% and 94.3%, respectively. Overall, 34.6% of patients received adjuvant radiotherapy. The majority of patients (92%) restarted an oral diet within 24 to 48 hours postsurgery. Transient tracheotomy was performed in 8% of patients. Postoperative hemorrhages occurred in 12 patients (16.0%), lengthening the hospital stay (mean = 6.8 days). There were no outcome differences regarding the tumor location.

CONCLUSIONS

TORS is an effective and safe therapeutic approach for early- and intermediate-stages cancers. Oncological outcomes may be quite similar to other surgical approaches, including transoral laser and open surgeries. Future randomized controlled studies are needed for comparing TORS SGL with other surgical procedures.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1060-1065, 2021.

Adding Flexible Instrumentation to a Curved Videolaryngoscope: A Novel Tool for Laryngeal Surgery

OBJECTIVES

Transoral surgery of the larynx with rigid instruments is not always possible. This may result in insufficient therapy or in an increased need for open surgery. For these patients, alternative surgical systems are needed. Here, we demonstrate a curved prototype for laryngeal surgery equipped with flexible instruments.

STUDY DESIGN

Pre-clinical user study in an ex vivo porcine laryngeal model.

METHODS

The prototype was built from established medical devices, namely a hyperangulated videolaryngoscope and modified flexible instruments as well as three-dimensional printed parts. Feasibility of laryngeal manipulation was evaluated in a user study (n = 19) with a porcine ex vivo laryngeal model. Using three different visualization technologies, the participants performed various fine motor skills tasks and rated the usability of the system on a 5-point Likert scale.

RESULTS

Exposure, accessibility, and manipulation of important laryngeal structures were always possible using the new prototype. The participants needed considerably less time (mean, 96.4 seconds ± 6.4 seconds vs. 111.5 seconds ± 4.5 seconds, P = .18), reported significantly better general impression (mean score 3.0 vs. 3.8, P = .041) and significantly lower user head and neck strain (2.6 vs. 1.7, P = .022) using a 40-inch television screen as compared to a standard videolaryngoscope monitor.

CONCLUSION

The results indicate that our curved prototype and large monitor visualization may provide a cost-effective minimally invasive alternative for difficult laryngeal exposure. Its special advantages include avoiding the need for a straight line of sight and a simple and cost-effective construction. The system could be further improved through advances in camera chip technology and smaller instruments. Laryngoscope, 131:E561-E568, 2021.

Surgical, clinical and functional outcomes of transoral robotic surgery for supraglottic laryngeal cancers: A systematic review

BACKGROUND

The aim of this systematic review is to shed light the current indications and outcomes of transoral robotic surgery (TORS) supraglottic laryngectomy (SGL) in patients with supraglottic laryngeal cancer.

METHODS

PubMed, Scopus and Cochrane Library were searched by three independent otolaryngologists from the Young Otolaryngologists of IFOS for studies investigating the indications, effectiveness and safety of TORS SGL. Surgical, functional, and survival outcomes have been investigated. Inclusion/exclusion criteria; demographic data; and clinical outcome evaluation of papers were analyzed using PRISMA criteria.

RESULTS

A total of 14 papers met our inclusion criteria, accounting for 422 patients (335 males & 87 females). The tumor location mainly consisted of epiglottis (55.4%), aryepglottic fold (31.2%), and ventricular band (5.1%). The following tumor stages were considered: cT1 (35.8%); cT2 (48.6%) and cT3 (13.9%). Feeding tube and percutaneous endoscopic gastrostomy were used in 62.5% and 8.82% of patients, respectively. The 24-month local & regional control rates ranged from 94.3% to 100% and 87.5% to 94.0%, respectively. The 2-year and 5-year overall survival rates ranged from 66.7% to 88.0% and 78.7% to 80.2%, respectively. There was an important heterogeneity between studies with regard to the inclusion/exclusion criteria, follow-up times, complications analysis; surgical and functional outcomes.

CONCLUSION

TORS SGL is an effective approach for treating patients with early stages supraglottic cancers. Future controlled studies are needed to compare functional and survival outcomes between TORS SGL and other surgical approaches. Recommendations have been provided for future studies for better inclusion of patients, analysis of complications and functional outcomes.

Novel Energy Devices in Head and Neck Robotic Surgery - A Narrative Review

The advent of trans-oral robotic surgery (TORS) has facilitated removal of tumors previously deemed unresectable, by providing access to the deep structures of the head and neck. Despite this, the wider dissemination of TORS has been restricted due to issues with line of access, as the da Vinci robot was never designed with head and neck surgery in mind. Flexible instruments and novel energy delivery devices offer great potential in overcoming some of the existing challenges surrounding TORS. This review aimed to summarize the existing literature surrounding energy delivery in TORS and highlight areas of future innovation. MEDLINE was searched for studies relating to energy delivery in TORS in November 2019. The existing literature surrounding monopolar and bipolar electrocautery, LASER (CO₂, Tm:YAG and blue LASER), Ligasure and Harmonic was reviewed. Additionally, the latest iteration of the da Vinci; the SP, and the FLEX robot were evaluated as novel methods of energy delivery in TORS. Overall, these novel energy devices and robotic systems are predicted to further improve energy delivery to the head and neck. The use of flexible LASER in particular is well substantiated in the literature. This has the potential to achieve treatment de-escalation, based on the excellent outcomes demonstrated for disease-free margins and post-operative morbidity.

Mechanical Dilation With a Nylon Monofilament for 0.1-mm Anastomoses

Despite advances in supermicrosurgical techniques, the ability to anastomose vessels with a diameter of less than 0.2 mm remains limited. One of the reasons for this limitation is that the dilation methods currently available, such as inserting the tip of a microforceps into the lumen or topical application of a vasodilator such as papaverine hydrochloride or xylocaine spray, are not effective in very small vessels. To overcome this problem, we have developed a method whereby nylon monofilaments are placed inside the vessel lumen to act as a dilator. Using this method, a smaller nylon monofilament is inserted into the vessel as a guide before inserting a larger nylon monofilament as a dilator. After the smaller guide monofilament has been inserted, it is then much easier to insert another monofilament for dilation, even if it is a larger one. Using this method, even a vessel with a diameter of less than 0.1 mm could be dilated to greater than 0.2 mm. The dilator monofilament can also be used as an intravascular stent in the anastomosis. We have found that anastomosis of vessels with a diameter of less than 0.1 mm is possible using this method. In our experience, the immediate patency rate has been 100%. We believe mechanical dilation with a nylon monofilament is helpful for supermicrosurgery and even ultramicrosurgery.

Limitations and Opportunities in Open Laryngeal Organ Preservation Surgery: Current Role of OPHLs

The current trend for treatment of intermediate-early advanced laryngeal cancer is essentially oriented toward preservation of organ and laryngeal function, and with a good potential for treating the disease. This goal can be achieved by adopting open laryngeal organ preservation surgery (OLOPS), at present mainly represented by open partial horizontal laryngectomies (OPHLs). An approach using rigorous selection criteria based on both the general condition of the patient and the local and regional extent of the disease gives excellent oncological and functional results in untreated patients. Similar outcomes, albeit slightly worse, are also obtainable in radio-recurrent and laser-recurrent patients. Troublesome postoperative management and the inconsistency of functional recovery are the main limitations for extensive application of this therapeutic strategy. The future direction is represented by simplification of the indications identifying iso-prognostic sub-categories within the T-stage, wider consensus on rehabilitation protocols, hybrid approaches to the larynx, and open minimally invasive access.

Robotics in otorhinolaryngology - head and neck surgery

A look at the past, present and future.

A Contemporary Review of Evidence for Transoral Robotic Surgery in Laryngeal Cancer

Numerous studies have shown that transoral robotic surgery (TORS) for oropharyngeal cancers is safe and that it yields satisfactory functional and oncological outcomes. For many teams worldwide, it is therefore a standard surgical approach with eligible patients. In the same time, TORS is increasingly being used and described in the context of laryngeal cancer surgery. It is proposed as an alternative to open approaches, which may yield inconsistent functional results and significant rates of postoperative complications. It may also be an alternative to definitive radiotherapy, which entails significant early and late toxicities. Moreover, it has been explored as an alternative to endoscopic laser surgery in patients with difficult exposure, even though there is still a lack of evidence about which procedure provides better vizualization of the vocal cords. This article provides a review of the indications for TORS in laryngeal cancer, the peri-operative morbidity, functional outcomes, and oncological results.

Functional outcomes of supraglottic squamous cell carcinoma treated by transoral laser microsurgery compared with horizontal supraglottic laryngectomy in patients younger and older than 65 years

The treatment of supraglottic carcinoma remains a controversial issue. Five accepted surgical and non-surgical oncological treatments have been currently established: standard horizontal supraglottic laryngectomy (HSL), supraglottic CO2 laser microsurgery (TLM), transoral robotic surgery, radiotherapy alone and radiotherapy in combination with chemotherapy. Some studies have shown that complications of head and neck surgeries increase significantly in patients over 65 years compared to younger patients. We designed a retrospective analysis to assess the rate of complications and functional outcomes of patients treated by TLM and HSL in cases of T1-T3 supraglottic squamous cell carcinomas (SCC) in a tertiary University Hospital. Results were compared between patients younger and older than 65 years. We found significant differences in the rate of aspiration pneumonia (p = 0.026), mean time to decannulation (p = 0.001) and mean hospital stay (p = 0.007) in patients treated by TLM, which was higher and longer in the group of patients over 65 years of age. Regarding HPL, we only found significant differences in the mean time to decannulation (p = 0.001), which was longer in the group of patients younger than 65 years. According to our results, TLM or HPL can both be a safe surgical option for patients older than 65 years, but previous evaluation of lung function before surgery is mandatory because of an increased risk of aspiration pneumonia in patients with lung problems, especially when treated by TLM. Concerning functional outcomes in patients older than 65 years, TLM reduces the postoperative rate of tracheostomy, mean time required for decannulation and mean hospital stay compared with HPL. However, no significant difference in the occurrence of aspiration pneumonia, dysphagia or in the mean length of NGT feeding was found.

Minimally Invasive Procedures for Laryngeal Carcinoma: Transoral Endoscopic Laser and Transoral Robotic Surgery

Open partial or total laryngectomies with or without radiotherapy (RT) or chemoradiotherapy (CRT) are the only mainstays in the treatment of laryngeal carcinomas. However, minimally invasive procedures such as transoral endoscopic carbondioxide laser microsurgery (TLM) or transoral robotic surgeries (TRS) are now being increasingly used in selected patients. The laryngeal framework is not disturbed in these procedures; therefore, the postoperative swallowing function improves more rapidly, and routine tracheotomy is not usually required. Moreover, they have oncological results comparable with open procedures.

Is There a Role for Robotic Surgery in the Treatment of Head and Neck Cancer?

OPINION STATEMENT

Given the potential for long-term toxicities from concurrent chemoradiation, there is great interest in surgery as a primary treatment modality for head and neck cancers, particularly in the younger HPV-positive oropharyngeal cancer patient. Transoral robotic surgery (TORS) has proven to be an effective technique to safely treat oropharyngeal and select supraglottic tumors surgically. Sound, traditional surgical principles are employed using improved endoscopic visualization and precise instrumentation to perform oncologic surgery without the morbidity of transmandibular or transcervical approaches. Although level 1 evidence prospective clinical trials are currently underway for TORS, the literature supports its safety and efficacy based on numerous studies. Currently, prospective randomized trials are underway to provide better evidence for or against TORS in oropharyngeal cancer. Patient selection based on comorbidities, anatomy, and available pathological data is critical in choosing patients for TORS.

Robotic surgical systems in maxillofacial surgery: a review

Throughout the twenty-first century, robotic surgery has been used in multiple oral surgical procedures for the treatment of head and neck tumors and non-malignant diseases. With the assistance of robotic surgical systems, maxillofacial surgery is performed with less blood loss, fewer complications, shorter hospitalization and better cosmetic results than standard open surgery. However, the application of robotic surgery techniques to the treatment of head and neck diseases remains in an experimental stage, and the long-lasting effects on surgical morbidity, oncologic control and quality of life are yet to be established. More well-designed studies are needed before this approach can be recommended as a standard treatment paradigm. Nonetheless, robotic surgical systems will inevitably be extended to maxillofacial surgery. This article reviews the current clinical applications of robotic surgery in the head and neck region and highlights the benefits and limitations of current robotic surgical systems.

Guidelines for the Surgical Management of Laryngeal Cancer: Korean Society of Thyroid-Head and Neck Surgery

Korean Society of Thyroid-Head and Neck Surgery appointed a Task Force to develop clinical practice guidelines for the surgical treatment of laryngeal cancer. This Task Force conducted a systematic search of the EMBASE, MEDLINE, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to the key questions. Evidence-based recommendations were then created on the basis of these articles. An external expert review and Delphi questionnaire were applied to reach consensus regarding the recommendations. The resulting guidelines focus on the surgical treatment of laryngeal cancer with the assumption that surgery is the selected treatment modality after a multidisciplinary discussion in any context. These guidelines do not, therefore, address non-surgical treatment such as radiation therapy or chemotherapy. The committee developed 62 evidence-based recommendations in 32 categories intended to assist clinicians during management of patients with laryngeal cancer and patients with laryngeal cancer, and counselors and health policy-makers.

Evidence and evidence gaps of laryngeal cancer surgery

Surgical treatment of laryngeal cancer has been established for decades. In addition to total laryngectomy, which was first performed in 1873, a large number or organ preservation surgical techniques, like open partial laryngectomy, transoral laser microsurgery, and transoral robotic surgery have been developed. Studies on laryngeal cancer surgery are mainly retrospective case series and cohort studies. The evolution of chemoradiation protocols and their analysis in prospective randomized trials have led to an increasing acceptance of non-surgical treatment procedures. In addition to an improvement of prognosis, in recent years the preservation of function and maintenance of life quality after primary therapy of laryngeal cancer has increasingly become the focus of therapy planning. Significant late toxicity after chemoradiation has been identified as an important issue. This leads to a reassessment of surgical concepts and initiation of studies on laryngeal cancer surgery which was additionally stimulated by the advent of transoral robotic surgery in the US. Improving the evidence base of laryngeal cancer surgery by successful establishment of surgical trials should be the future goal.

Transoral Robotic Surgery in Oropharyngeal Carcinoma

Context

The incidence of oropharyngeal squamous cell carcinoma has increased during the past decade and is related primarily to the human papillomavirus. This change in etiology, from tobacco and alcohol to human papillomavirus, has resulted in improved survival for the disease. In the United States, open resection had largely been replaced by concurrent chemotherapy and/or radiotherapy by the early 2000s. The advent of transoral surgery has led to an increase in surgery as the primary treatment for both early- and advanced-stage oropharyngeal squamous cell carcinoma because it has potential advantages over open surgery and nonsurgical modalities.

Objective

To provide an overview of transoral robotic surgery for oropharyngeal squamous cell carcinoma and contrast it with other surgical and nonsurgical modalities.

Data Sources

Articles from 2000 to 2014 were accessioned on PubMed and reviewed for utility by the primary authors.

Conclusions

Transoral surgery has become more commonly used as a minimally invasive approach to treat oropharyngeal tumors. Other strategies, including radiation, chemotherapy with radiation, and open surgery, are still important treatment approaches. The treatment options for an individual patient rely on multiple factors, including the tumor location and size, features of the tumor, and patient comorbidities. The continued study of these techniques is important to match the patient with the most appropriate treatment.

Transoral robotic surgery (TORS) for laryngeal and hypopharyngeal cancers

Transoral robotic surgery (TORS) is increasingly used in laryngeal/hypopharyngeal cancer surgery. Ablative procedures described in these anatomical sites include: (i) supraglottic laryngectomy, (ii) total laryngectomy, (iii) glottic cordectomy, and (iv) partial pharyngectomy. TORS supraglottic laryngectomy remains the most commonly performed of these procedures. Initial oncologic and functional outcomes with these procedures are promising and comparable to other treatment options. As robotic instrumentation technology advances a rise in TORS laryngeal/hypopharyngeal surgery is anticipated.

Applications for transoral robotic surgery in the pediatric airway

OBJECTIVES/HYPOTHESIS

To report preliminary experience in the utilization of transoral robotic surgical (TORS) techniques in pediatric airway surgery.

STUDY DESIGN

Retrospective case series.

METHODS

A retrospective chart review was performed on all pediatric patients undergoing robotic airway surgery at a university-based children's hospital between August 2010 and December 2012.

RESULTS

Three pediatric patients underwent robotic repair of various airway anomalies between August 2010 and December 2012. Case 1 is a 15-year-old boy with posterior glottic stenosis for which a robotic-assisted posterior cricoid split with cartilage graft placement was attempted but ultimately required conversion to an open technique. Case 2 is a 6-year-old male with Trisomy 21 who had robotic-assisted endoscopic repair of a type II laryngeal cleft, with subsequent resolution of his chronic aspiration and successful initiation of oral feeding. Case 3 is a 3-year-old female who underwent robotic-assisted left posterior cordectomy and subtotal arytenoidectomy for idiopathic bilateral vocal cord paralysis, resulting in improved Passy-Muir valve tolerance.

CONCLUSION

TORS is being increasingly utilized in the field of head and neck surgery as it is frequently less invasive and often demonstrates improved outcomes compared with traditional approaches. This study details our experience utilizing TORS in the management of pediatric airway anomalies and represents one of the earliest such series in the literature. Although TORS has the potential to improve the management of pediatric airway disorders, larger, prospective studies are needed to better elucidate its feasibility and efficacy.

LEVEL OF EVIDENCE

4.

Assessment of margins in transoral laser and robotic surgery

The growing practice of endoscopic surgery has changed the therapeutic management of selected head and neck cancers. Although a negative surgical margin in resection of neoplasm is the most important surgical principle in oncologic surgery, controversies exist regarding assessment and interpretation of the status of margin resection. The aim of this review was to summarize the literature considering the assessment and feasibility of negative margins in transoral laser microsurgery (TLM) and transoral robotic surgery (TORS). Free margin status is being approached differently in vocal cord cancer (1-2 mm) compared with other sites in the upper aerodigestive tract (2-5 mm). Exposure, orientation of the pathological specimen, and co-operation with the pathologist are crucial principles needed to be followed in transoral surgery. Piecemeal resection to better expose deep tumor involvement and biopsies taken from surgical margins surrounding site of resection can improve margin assessment. High rates of negative surgical margins can be achieved with TLM and TORS. Adjuvant treatment decision should take into consideration also the surgeon's judgment with regard to the completeness of tumor resection.