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Virós Porcuna D, Suen KH, Stein H, Pollán Guisasola C. New Approaches for Robot-Assisted Neck Surgery: Clavicular and Submental Approaches Using the da Vinci SP System. J Craniofac Surg 2024:00001665-990000000-01642. [PMID: 38810240 DOI: 10.1097/scs.0000000000010297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 04/11/2024] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Minimally invasive robot-assisted thyroid surgery or neck dissection can improve cosmetic results and reduce surgical trauma. Several approaches have been described but each has both advantages and limitations. We aimed to determine the feasibility of performing robot-assisted neck surgery using the da Vinci SP system. METHODS The clavicular approach using the da Vinci SP system was done in 1 cadaveric model. Lateral neck dissection was carried out with parapharyngeal space dissection, lateral thyroid gland exposure, and anatomical references. The submental approach was performed in the same cadaveric model. Total thyroidectomy plus lateral neck dissection was performed. RESULTS The required 2.5-cm skin incision, minimal flap development to insert the SP Access Port plus docking was done in 5 minutes for each procedure. The neck dissection by clavicular access took 77 minutes, the parapharyngeal dissection 60 minutes, and hemi-thyroidectomy 30 minutes. The neck dissection by submental access took 60 minutes and the total thyroidectomy took 45 minutes. CONCLUSION We have demonstrated the feasibility of single-incision clavicular and submental approaches in neck surgery using the da Vinci SP system. The amount of skin flap dissection was minimal, the system docking was rapid, and no additional ports or retractors were required. Further studies on patients are warranted.
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Affiliation(s)
- David Virós Porcuna
- Otolaryngology Section, Head and Neck Surgery, Hospital Germans Trias i Pujol, Badalona, Spain
| | | | | | - Carlos Pollán Guisasola
- Otolaryngology Section, Head and Neck Surgery, Hospital Germans Trias i Pujol, Badalona, Spain
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Molteni G, Bassani S, Arsie AE, Zampieri E, Mannelli G, Orlandi E, Bossi P, De Virgilio A. Role of TORS as De-Escalation Strategy in HPV-Related Oropharyngeal Cancer, What We Need to Know. Healthcare (Basel) 2024; 12:1014. [PMID: 38786424 PMCID: PMC11121063 DOI: 10.3390/healthcare12101014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/04/2024] [Accepted: 05/10/2024] [Indexed: 05/25/2024] Open
Abstract
Human papillomavirus (HPV)-related oropharyngeal squamous cell carcinoma (OPSCC) presents unique challenges and opportunities for treatment, particularly regarding de-escalation strategies to reduce treatment morbidity without compromising oncological outcomes. This paper examines the role of Transoral Robotic Surgery (TORS) as a de-escalation strategy in managing HPV-related OPSCC. We conducted a comprehensive literature review from January 2010 to June 2023, focusing on studies exploring TORS outcomes in patients with HPV-positive OPSCC. These findings highlight TORS's potential to reduce the need for adjuvant therapy, thereby minimizing treatment-related side effects while maintaining high rates of oncological control. TORS offers advantages such as precise tumor resection and the ability to obtain accurate pathological staging, which can guide the tailoring of adjuvant treatments. Some clinical trials provide evidence supporting the use of TORS in specific patient populations. The MC1273 trial demonstrated promising outcomes with lower doses of adjuvant radiotherapy (RT) following TORS, showing high locoregional tumor control rates and favorable survival outcomes with minimal side effects. ECOG 3311 evaluated upfront TORS followed by histopathologically directed adjuvant therapy, revealing good oncological and functional outcomes, particularly in intermediate-risk patients. The SIRS trial emphasized the benefits of upfront surgery with neck dissection followed by de-escalated RT in patients with favorable survival and excellent functional outcomes. At the same time, the PATHOS trial examined the impact of risk-adapted adjuvant treatment on functional outcomes and survival. The ongoing ADEPT trial investigates reduced-dose adjuvant RT, and the DART-HPV study aims to compare standard adjuvant chemoradiotherapy (CRT) with a reduced dose of adjuvant RT in HPV-positive OPSCC patients. These trials collectively underscore the potential of TORS in facilitating treatment de-escalation while maintaining favorable oncological and functional outcomes in selected patients with HPV-related OPSCC. The aim of this scoping review is to discuss the challenges of risk stratification, the importance of HPV status determination, and the implications of smoking on treatment outcomes. It also explores the evolving criteria for adjuvant therapy following TORS, focusing on reducing radiation dosage and volume without compromising treatment efficacy. In conclusion, TORS emerges as a viable upfront treatment option for carefully selected patients with HPV-positive OPSCC, offering a pathway toward treatment de-escalation. However, selecting the optimal candidate for TORS-based de-escalation strategies is crucial to fully leverage the benefits of treatment de-intensification.
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Affiliation(s)
- Gabriele Molteni
- Department of Otolaryngology-Head and Neck Surgery, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
- Department of Medical and Surgical Sciences, Alma Mater Studiorum-University of Bologna, 40126 Bologna, Italy
| | - Sara Bassani
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Athena Eliana Arsie
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Erica Zampieri
- Otolaryngology-Head and Neck Surgery Department, University of Verona, 37129 Verona, Italy; (A.E.A.)
| | - Giuditta Mannelli
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Firenze, Italy
| | - Ester Orlandi
- Department of Clinical, Surgical, Diagnostic, and Pediatric Sciences, University of Pavia, 27100 Pavia, Italy;
- Clinical Department, National Center for Oncological Hadrontherapy (Fondazione CNAO), 27100 Pavia, Italy
| | - Paolo Bossi
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Italy;
- IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
| | - Armando De Virgilio
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Italy
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Sampieri C, Pirola F, Costantino A, Kim D, Ho JJ, Lee K, De Virgilio A, Park YM, Kim SH. Single-Port Versus Multiport da Vinci System for Transoral Robotic Surgery of Hypopharyngeal and Laryngeal Carcinoma. Otolaryngol Head Neck Surg 2023; 169:548-555. [PMID: 36939577 DOI: 10.1002/ohn.287] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 11/21/2022] [Accepted: 12/17/2022] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Da Vinci single port (SP) has been recently approved for transoral robotic surgery (TORS). Its characteristics make it particularly feasible for laryngeal and hypopharyngeal surgery. We report our experience comparing intra- and postoperative outcomes, technical advantages, and shortcomings of transoral laryngeal and hypopharyngeal resections performed with the da Vinci SP and the da Vinci Si/Xi systems. STUDY DESIGN Retrospective database review. SETTING Single academic tertiary care hospital. METHODS Subjects included adult patients with laryngeal and hypopharyngeal carcinoma who underwent TORS between 2008 and 2022. The SP and multiport (MP) systems were compared in terms of intraoperative times, short-term postoperative outcomes, and TORS-related complications after a propensity score matching. RESULTS A total of 185 patients were enrolled (56 SP vs 129 MP patients), and a cohort of 112 patients was analyzed after matching. The docking time was reduced in the SP group (8.84 ± 4.67 vs 6.45 ± 3.11 minutes; p = .003), as well as console time (53.91 ± 29.38 vs 42.70 ± 13.72 minutes; p = .035). Positive margins were more frequent in the MP group (52% vs 43%; p = .34). The mean decannulation time was 1.86 days longer in the SP group (p = .046). No significant differences emerged from the analysis of the duration of hospitalization, enteral feeding, and TORS-related complications. CONCLUSION SP safety profile is comparable to that of previous models, while it showed advantages in terms of reduced docking times. Console times were also shortened due to improved maneuverability and field visualization.
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Affiliation(s)
- Claudio Sampieri
- Unit of Otorhinolaryngology-Head and Neck Surgery, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Francesca Pirola
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Andrea Costantino
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Dahee Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung J Ho
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Kyuin Lee
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Armando De Virgilio
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Otorhinolaryngology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Young M Park
- Department of Otorhinolaryngology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Se-Heon Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
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Mella MH, Chabrillac E, Dupret-Bories A, Mirallie M, Vergez S. Transoral Robotic Surgery for Head and Neck Cancer: Advances and Residual Knowledge Gaps. J Clin Med 2023; 12:jcm12062303. [PMID: 36983308 PMCID: PMC10056198 DOI: 10.3390/jcm12062303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
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.
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Affiliation(s)
- Mariam H. Mella
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
| | - Emilien Chabrillac
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Agnès Dupret-Bories
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Mathilde Mirallie
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
| | - Sébastien Vergez
- Department of Otolaryngology, Head and Neck Surgery, Toulouse University Hospital—Larrey Hospital, 24 Chemin de Pouvourville, CEDEX 9, 31059 Toulouse, France
- Department of Surgery, University Cancer Institute of Toulouse—Oncopole, 31100 Toulouse, France
- Correspondence: ; Tel.: +33-5-67-77-17-32
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Kienle LL, Schild LR, Böhm F, Grässlin R, Greve J, Hoffmann TK, Schuler PJ. A novel 3D-printed laryngoscope with integrated working channels for laryngeal surgery. Front Surg 2023; 10:906151. [PMID: 36998594 PMCID: PMC10043209 DOI: 10.3389/fsurg.2023.906151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 02/20/2023] [Indexed: 03/15/2023] Open
Abstract
BackgroundFor the surgical treatment of early-stage laryngeal cancer, the use of transoral laser microsurgery (TLM) has emerged as the gold standard. However, this procedure requires a straight line of sight to the operating field. Therefore, the patient's neck needs to be brought into a hyperextended position. In a considerable number of patients, this is not possible due to anomalies in the cervical spine anatomy or soft tissue scarring, e.g., after radiation. In these cases, adequate visualization of relevant laryngeal structures cannot be ensured using a conventional rigid operating laryngoscope, which may negatively affect the outcome of these patients.MethodsWe present a system based on a 3D-printed prototype of a curved laryngoscope with three integrated working channels (sMAC). The curved profile of the sMAC-laryngoscope is specifically adapted to the nonlinear anatomy of the upper airway structures. The central working channel provides access for flexible video endoscope imaging of the operating field while the two remaining channels provide access for flexible instrumentation. In a user study (n = 11), visualization and reachability of relevant laryngeal landmarks as well as the feasibility of basic surgical procedures with the proposed system were examined in a patient simulator. In a second setup, the system was evaluated for its applicability in a human body donor.ResultsAll participants of the user study were able to visualize, reach and manipulate the relevant laryngeal landmarks. Reaching those took significantly less time in the second attempt compared to the first one (27.5 s ± 5.2 s vs. 39.7 s ± 16.5 s, p = 0.008) indicating a significant learning curve for handling the system. Instrument changes were performed quickly and reliably by all participants (10.9 s ± 1.7 s). All participants were able to bring the bimanual instruments into position for a vocal fold incision. Relevant laryngeal landmarks could be visualized and reached in the human body donor setup.ConclusionPossibly, the proposed system may develop into an alternative treatment option for patients with early-stage laryngeal cancer and restricted mobility of the cervical spine in the future. Further improvements of the system could include finer end effectors and a flexible instrument with a laser cutting tool.
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Affiliation(s)
- Linus L. Kienle
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Leon R. Schild
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Felix Böhm
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Rene Grässlin
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Thomas K. Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Patrick J. Schuler
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, Ulm, Germany
- Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
- Correspondence: Patrick J. Schuler
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Dreifuss NH, Chang B, Schlottmann F, Cubisino A, Mangano A, Masrur MA, Bianco FM. Robotic inguinal hernia repair: is the new Da Vinci single port platform providing any benefit? Surg Endosc 2023; 37:2003-2013. [PMID: 36282359 DOI: 10.1007/s00464-022-09737-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 10/13/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The utilization of the robot for inguinal hernia repairs has increased in the past years. The new Da Vinci Single Port (SP) system provides the benefits of single-incision procedures and might overcome the technical difficulties of previous single-incision techniques. The aim of this study was to evaluate the safety and feasibility of the SP transabdominal preperitoneal inguinal hernia repair (SP-TAPP) and compare its outcomes to the robotic multiport technique (MP-TAPP). METHODS A prospective cohort of patients who underwent a robotic SP-TAPP and MP-TAPP between 2012 and 2022 was analyzed. Primary endpoints were same-day discharge, morbidity, and inguinal recurrence rates. Secondary endpoints included conversion, operative time, port-site incisional hernia, and chronic pain. RESULTS MP-TAPP and SP-TAPP were performed in 378 (81.3%) and 87 (18.7%) patients, respectively. Demographics were similar between groups. There were no conversions or intraoperative complications. Mean operative (MP-TAPP: 93.2 vs. SP-TAPP: 78.1 min, p = 0.003) and recovery time (MP-TAPP: 160.8 vs SP-TAPP: 112.6 min, p < 0.001) were significantly shorter in the SP group. Same-day discharge rate was higher (MP-TAPP: 86.5% vs. SP-TAPP: 97.7%, p = 0.001) after SP-TAPP; 30-day morbidity, readmissions, and chronic pain rates were similar between groups. After a mean follow-up of 30.6 months for MP-TAPP and 13.3 months for SP-TAPP, inguinal hernia recurrence and port-site incisional rates were similar between groups. CONCLUSION Robotic SP-TAPP is safe and feasible. When compared to MP-TAPP, it showed similar postoperative morbidity, higher same-day discharge rates, and a quicker postoperative recovery. Further studies are needed to confirm the benefits of the SP platform.
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Affiliation(s)
- Nicolas H Dreifuss
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA.
| | - Betty Chang
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA
| | - Francisco Schlottmann
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA
| | - Antonio Cubisino
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA
| | - Alberto Mangano
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA
| | - Mario A Masrur
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA
| | - Francesco M Bianco
- Division of General, Minimally Invasive, and Robotic Surgery, Department of Surgery, University of Illinois at Chicago, 820 S Wood Street, Rm 611 Clinical Sciences North, Chicago, IL, 60612, USA
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Alkhatib HH, Ali KM, Tufano RP, Russell JO. Postauricular Robotic Facelift Thyroid Lobectomy on a Patient Using a Single-Port Robotic Surgical System. VideoEndocrinology 2022. [DOI: 10.1089/ve.2022.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Hosam H. Alkhatib
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Khalid M. Ali
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ralph P. Tufano
- Department of Otolaryngology-Head and Neck Surgery, Sarasota Memorial Health Care System, Sarasota, Florida, USA
| | - Jonathon O. Russell
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Hussain T. Patient Benefit and Quality of Life after Robot-Assisted Head and Neck Surgery. Laryngorhinootologie 2022; 101:S160-S185. [PMID: 35605618 DOI: 10.1055/a-1647-8650] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Timon Hussain
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen
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Lai KWK, Lai R, Lorincz BB, Wang CC, Chan JYK, Yeung DCM. Oncological and Functional Outcomes of Transoral Robotic Surgery and Endoscopic Laryngopharyngeal Surgery for Hypopharyngeal Cancer: A Systematic Review. Front Surg 2022; 8:810581. [PMID: 35464886 PMCID: PMC9021537 DOI: 10.3389/fsurg.2021.810581] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022] Open
Abstract
Objectives Hypopharyngeal carcinoma (HPC) is a head and neck carcinoma with poor prognosis. Traditional laryngopharyngectomy offered promising oncological outcomes at the cost of functional outcomes. The recent advent in transoral robotic surgery (TORS), an organ-preserving surgery, has opened up new perspectives in the treatment for HPC. Here, we evaluate minimally invasive organ preservation surgery [TORS and endoscopic laryngopharyngeal surgery (ELPS)] for HPC in terms of feasibility and oncological and functional outcomes. Methods This is a systematic review. Six databases [CUHK Full-Text Journals, Embase 1910 to 2021, Ovid Emcare, Ovid MEDLINE (R), CINAHL, PubMed] were searched for articles and primary studies for TORS and ELPS for HPC. Screening was completed using predefined inclusion or exclusion criteria. Results A total of 8 studies on TORS and 3 studies on ELPS were eventually chosen after full-text review. For studies on TORS, 61.3% of patients (84 out of 137) still survived at the last follow-up with a mean follow-up time of 23.20 months (range: 12.8–37.21 months). Severe intraoperative and postoperative complications have not been reported. No cases of TORS required a conversion to open surgery. Swallowing function was optimal postoperatively with only 6 patients eventually required a percutaneous endoscopic gastrostomy (PEG) for feeding. Disease-specific survival was taken as the parameter for the measurement of oncological outcomes. A total of 2 studies reported a disease-specific survival of 100% within their follow-up period of 1 and 1.5 years, respectively. Another 2 studies reported a 2-year DSS of 89 and 98%, respectively. A 5-year DSS of 100% in early stage and 74% in late stage were achieved in one study. Another study also reported a 5-year DSS of 91.7%. For studies of ELPS, a 5- and 3-year disease-specific survival of 100% were achieved in 2 studies. Patients who underwent ELPS had good postoperative swallowing function with no PEG placement. There were also no other fatal complications. Conclusions Both TORS and ELPS for HPC provide satisfactory long-term oncological and functional outcomes improving postoperative quality of life of patients.
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Affiliation(s)
- Katherine W. K. Lai
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Princes of Wales Hospital, Shatin, Hong Kong SAR, China
| | - Ronald Lai
- Affiliated Teaching Unit of the Chinese University of Hong Kong, Department of Ear, Nose, and Throat, United Christian Hospital, Kwun Tong, Hong Kong SAR, China
| | - Balazs B. Lorincz
- Department of ENT, Head, and Neck Surgery, Agaplesion Frankfurter Diakonie Kliniken, Bethanien and Markus Hospitals, Frankfurt am Main, Germany
| | - Chen-Chi Wang
- Department of Otolaryngology-Head and Neck Surgery, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Jason Y. K. Chan
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Princes of Wales Hospital, Shatin, Hong Kong SAR, China
- *Correspondence: Jason Y. K. Chan
| | - David C. M. Yeung
- Department of Otorhinolaryngology, Head and Neck Surgery, The Chinese University of Hong Kong, Princes of Wales Hospital, Shatin, Hong Kong SAR, China
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Chen J, Ding Q, Yan W, Yan K, Chen J, Chan JYK, Cheng SS. A Variable Length, Variable Stiffness Flexible Instrument for Transoral Robotic Surgery. IEEE Robot Autom Lett 2022. [DOI: 10.1109/lra.2022.3147454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Development and experiments of a continuum robotic system for transoral laryngeal surgery. Int J Comput Assist Radiol Surg 2022; 17:497-505. [PMID: 35028888 DOI: 10.1007/s11548-022-02558-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/31/2021] [Indexed: 11/05/2022]
Abstract
PURPOSE Currently, self-retaining laryngoscopic surgery is not suitable for some patients, and there are dead zones relating to surgical field exposure and operation. The quality of the surgery can also be affected by the long periods of time required to complete it. Teleoperated continuum robots with flexible joints are expected to solve these issues. However, at the current stage of developing transoral robotic surgery systems, their large size affects the precision of surgical operative actions and there are high development and treatment costs. METHODS We fabricated a flexible joint based on selective laser melting technology and designed a shallow neural network-based kinematic modeling approach for a continuum surgical robot. Then, human model and animal experiments were completed by master-slave teleoperation to verify the force capability and dexterity of the robot, respectively. RESULTS As verified by human model and animal experiments, the designed continuum robot was demonstrated to achieve transoral laryngeal surgical field exposure without laryngoscope assistance, with sufficient load capability to finish the biopsy of vocal fold tissue in living animals. CONCLUSION The designed continuum robotic system allows the biopsy of vocal fold tissue without laryngoscope assistance. Its stiffness and dexterity indicate the system's potential for applications in the diagnosis and treatment of vocal fold nodules and polyps. The limitations of this robotic system as shown in the experiments were also analyzed.
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Finegersh A, Voora RS, Panuganti B, Faraji F, Holsinger FC, Brumund KT, Coffey C, Califano J, Orosco RK. Robotic surgery may improve overall survival for T1 and T2 tumors of the hypopharynx: An NCDB cohort study. Oral Oncol 2021; 121:105440. [PMID: 34329867 DOI: 10.1016/j.oraloncology.2021.105440] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 05/08/2021] [Accepted: 06/30/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Hypopharyngeal cancer is associated with poor survival. Robotic surgery is emerging as a treatment for hypopharyngeal tumors, but no rigorous data are available to assess its effect on survival. METHODS The National Cancer Database (NCDB) was used to identify patients with T1 and T2 hypopharyngeal tumors undergoing robotic surgery, laser surgery, and primary radiation with or without chemotherapy from 2010 to 2016. All adult patients with available staging and no distant metastasis were included. RESULTS We compared 57 patients undergoing robotic surgery, 236 undergoing laser surgery, and 5,742 undergoing primary radiation. Compared to laser surgery, patients undergoing robotic surgery were significantly more likely to have negative margins, neck dissection, lower incomes, and care at an academic center. Rates of robotic surgery also significantly increased from 2010 to 2015. After multivariate regression, robotic surgery was associated with significantly improved overall survival compared to laser surgery and primary radiation. CONCLUSION Robotic surgery improves overall survival for T1 and T2 hypopharyngeal tumors compared to laser surgery and primary radiation in this NCDB cohort. This effect may be mediated by decreased positive margin rates relative to laser surgery. Rates of hypopharyngeal robotic surgery are expected to increase with wider adoption of robotic platforms and may improve overall survival rates for hypopharyngeal cancer.
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Affiliation(s)
- Andrey Finegersh
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Rohith S Voora
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Bharat Panuganti
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | - Farhoud Faraji
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA
| | | | - Kevin T Brumund
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA; Division of Otolaryngology, Department of Surgery, VA San Diego Health System, La Jolla, CA, USA; Moores Cancer Center, La Jolla, CA, USA
| | - Charles Coffey
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA; Division of Otolaryngology, Department of Surgery, VA San Diego Health System, La Jolla, CA, USA; Moores Cancer Center, La Jolla, CA, USA
| | - Joseph Califano
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA; Moores Cancer Center, La Jolla, CA, USA
| | - Ryan K Orosco
- Division of Otolaryngology, Department of Surgery, University of California San Diego, San Diego, CA, USA; Moores Cancer Center, La Jolla, CA, USA.
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13
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Evaluation of a curved surgical prototype in a human larynx. Eur Arch Otorhinolaryngol 2021; 278:2927-2935. [PMID: 33885971 PMCID: PMC8266771 DOI: 10.1007/s00405-021-06791-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 03/29/2021] [Indexed: 11/16/2022]
Abstract
Purpose It is not always possible to create linear access to the larynx using a rigid operating laryngoscope for microlaryngoscopy. In this study, we evaluate the usability of a novel curved surgical prototype with flexible instruments for the larynx (sMAC) in a simulation dummy and human body donor. Methods In a user study (n = 6), head and neck surgeons as well as medical students tested the system for visualization quality and accessibility of laryngeal landmarks on an intubation dummy and human cadaver. A biopsy of the epiglottis was taken from the body donor. Photographic and time documentation was carried out. Results The sMAC system demonstrated general feasibility for laryngeal surgery. Unlike conventional microlaryngoscopy, all landmarks could be visualized and manipulated in both setups. Biopsy removal was possible. Visibility of the surgical field remained largely unobstructed even with an endotracheal tube in place. Overall handling of the sMAC prototype was satisfactorily feasible at all times. Conclusion The sMAC system could offer an alternative for patients, where microlaryngoscopy is not applicable. A clinical trial has to clarify if the system benefits in clinical routine.
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14
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Iizuka T, Kikuchi D, Suzuki Y, Tanaka M, Takeda H. Clinical relevance of endoscopic treatment for superficial pharyngeal cancer: feasibility of techniques corresponding to each location and long-term outcomes. Gastrointest Endosc 2021; 93:818-827. [PMID: 32721490 DOI: 10.1016/j.gie.2020.07.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Superficial pharyngeal cancers are being detected and treated using endoscopy in many medical facilities with increasing frequency. However, the reports focus on the hypopharynx. We identified reliable treatments by adapting the method for each region of the pharynx. Here, we introduce our methods for treating various pharyngeal regions and show their long-term results. METHODS Of 308 consecutive patients who underwent pharyngeal endoscopic submucosal dissection between February 2007 and December 2018 at our institution, we selected 293 patients who were diagnosed histologically with squamous cell carcinoma. The patients were divided into 4 groups based on the specific location of superficial pharyngeal lesions and the short- and long-term outcomes, such as technical success, adverse events, overall survival, and case-specific survival, were evaluated. RESULTS The procedure time was 51 minutes at location A where cancer develops most commonly. The rate of en bloc resection was 99.4%, and the R0 resection rate was 82.6%. With regard to adverse events, there were 2 cases of postoperative hemorrhage, both treated with endoscopic hemostasis. The average observation period was 61.2 months overall, with 14 cases of recurrent lymph node metastasis. The 5-year survival rate was 84.1%, and cause-specific survival was 100%. CONCLUSIONS Adaptation of the treatment method according to the location of the lesion led to good results. Endoscopic treatment of superficial pharyngeal cancer is both feasible and beneficial.
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Affiliation(s)
- Toshiro Iizuka
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan; Department of Gastrointestinal Endoscopy, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Tokyo, Japan
| | - Daisuke Kikuchi
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Yugo Suzuki
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Masami Tanaka
- Department of Gastroenterology, Toranomon Hospital, Tokyo, Japan
| | - Hidehiko Takeda
- Department of Otolaryngology, Toranomon Hospital, Tokyo, Japan
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Boehm F, Graesslin R, Theodoraki MN, Schild L, Greve J, Hoffmann TK, Schuler PJ. Current Advances in Robotics for Head and Neck Surgery-A Systematic Review. Cancers (Basel) 2021; 13:1398. [PMID: 33808621 PMCID: PMC8003460 DOI: 10.3390/cancers13061398] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 03/15/2021] [Accepted: 03/17/2021] [Indexed: 02/07/2023] Open
Abstract
Background. In the past few years, surgical robots have recently entered the medical field, particularly in urology, gynecology, and general surgery. However, the clinical effectiveness and safety of robot-assisted surgery (RAS) in the field of head and neck surgery has not been clearly established. In this review, we evaluate to what extent RAS can potentially be applied in head and neck surgery, in which fields it is already daily routine and what advantages can be seen in comparison to conventional surgery. Data sources. For this purpose, we conducted a systematic review of trials published between 2000 and 2021, as well as currently ongoing trials registered in clinicaltrials.gov. The results were structured according to anatomical regions, for the topics "Costs," "current clinical trials," and "robotic research" we added separate sections for the sake of clarity. Results. Our findings show a lack of large-scale systematic randomized trials on the use of robots in head and neck surgery. Most studies include small case series or lack a control arm which enables a comparison with established standard procedures. Conclusion. The question of financial reimbursement is still not answered and the systems on the market still require some specific improvements for the use in head and neck surgery.
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Affiliation(s)
- Felix Boehm
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
| | - Rene Graesslin
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
| | - Marie-Nicole Theodoraki
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
| | - Leon Schild
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
| | - Thomas K. Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
| | - Patrick J. Schuler
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Center, 89075 Ulm, Germany; (R.G.); (M.-N.T.); (L.S.); (J.G.); (T.K.H.)
- Surgical Oncology Ulm, i2SOUL Consortium, 89075 Ulm, Germany
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Transoral robotic surgery in Ireland: the beginning. Ir J Med Sci 2021; 191:361-365. [PMID: 33559869 DOI: 10.1007/s11845-021-02539-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 02/01/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma. AIMS The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost. METHODS Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications. RESULTS We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1 day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8). CONCLUSIONS We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.
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Abstract
Robot-assisted surgery (RAS) has already been approved for several clinical applications in head and neck surgery. In some Anglo-American regions, RAS is currently the common standard for treatment of oropharyngeal diseases. Systematic randomized studies comparing established surgical procedures with RAS in a large number of patients are unavailable so far. Experimental publications rather describe how to reach poorly accessible anatomical regions using RAS, or represent feasibility studies on the use of transoral robotic surgery (TORS) in established surgical operations. With general application of RAS in clinical practice, the question of financial reimbursement arises. Furthermore, the technical applications currently on the market still require some specific improvements for routine use in head and neck surgery.
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Abstract
The global numbers of robotic gastrointestinal surgeries are increasing. However, the evidence base for robotic gastrointestinal surgery does not yet support its widespread adoption or justify its cost. The reasons for its continued popularity are complex, but a notable driver is the push for innovation - robotic surgery is seen as a compelling solution for delivering on the promise of minimally invasive precision surgery - and a changing commercial landscape delivers the promise of increased affordability. Novel systems will leverage the robot as a data-driven platform, integrating advances in imaging, artificial intelligence and machine learning for decision support. However, if this vision is to be realized, lessons must be heeded from current clinical trials and translational strategies, which have failed to demonstrate patient benefit. In this Perspective, we critically appraise current research to define the principles on which the next generation of gastrointestinal robotics trials should be based. We also discuss the emerging commercial landscape and define existing and new technologies.
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Schild LR, Böhm F, Boos M, Kahrs LA, Coburger J, Greve J, Dürselen L, Hoffmann TK, Schuler PJ. Adding Flexible Instrumentation to a Curved Videolaryngoscope: A Novel Tool for Laryngeal Surgery. Laryngoscope 2020; 131:E561-E568. [PMID: 32585046 DOI: 10.1002/lary.28868] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 05/05/2020] [Accepted: 05/26/2020] [Indexed: 11/10/2022]
Abstract
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.
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Affiliation(s)
- Leon R Schild
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Centre, Ulm, Germany
| | - Felix Böhm
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Centre, Ulm, Germany
| | - Marco Boos
- Institute of Orthopaedic Research and Biomechanics, Centre for Trauma Research Ulm, Ulm University Medical Centre, Ulm, Germany
| | - Lüder A Kahrs
- Department of Mathematical and Computational Sciences, University of Toronto Mississauga, Mississauga, Ontario, Canada
| | - Jan Coburger
- Department of Neurosurgery, Ulm University Medical Centre, Guenzburg, Germany.,Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Jens Greve
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Centre, Ulm, Germany.,Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Lutz Dürselen
- Institute of Orthopaedic Research and Biomechanics, Centre for Trauma Research Ulm, Ulm University Medical Centre, Ulm, Germany
| | - Thomas K Hoffmann
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Centre, Ulm, Germany.,Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
| | - Patrick J Schuler
- Department of Otorhinolaryngology, Head and Neck Surgery, Ulm University Medical Centre, Ulm, Germany.,Surgical Oncology Ulm, i2SOUL Consortium, Ulm, Germany
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20
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Van Abel KM, Yin LX, Price DL, Janus JR, Kasperbauer JL, Moore EJ. One‐year outcomes for da Vinci single port robot for transoral robotic surgery. Head Neck 2020; 42:2077-2087. [DOI: 10.1002/hed.26143] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 01/27/2020] [Accepted: 03/05/2020] [Indexed: 01/29/2023] Open
Affiliation(s)
- Kathryn M. Van Abel
- Department of Otolaryngology‐Head and Neck SurgeryMayo Clinic School of Medicine Rochester Minnesota USA
| | - Linda X. Yin
- Department of Otolaryngology‐Head and Neck SurgeryMayo Clinic School of Medicine Rochester Minnesota USA
| | - Daniel L. Price
- Department of Otolaryngology‐Head and Neck SurgeryMayo Clinic School of Medicine Rochester Minnesota USA
| | - Jeffery R. Janus
- Department of Otolaryngology‐Head and Neck SurgeryMayo Clinic School of Medicine Rochester Minnesota USA
| | - Jan L. Kasperbauer
- Department of Otolaryngology‐Head and Neck SurgeryMayo Clinic School of Medicine Rochester Minnesota USA
| | - Eric J. Moore
- Department of Otolaryngology‐Head and Neck SurgeryMayo Clinic School of Medicine Rochester Minnesota USA
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