Abstrakt ORL Březen 2011

“Transoral robotic surgery and human papillomavirus status: Oncologic results.”

Cohen, M. A., G. S. Weinstein, et al. (2011).

Head and Neck 33(4): 573-580.


BACKGROUND: Patients with oropharyngeal squamous cell carcinoma (OPSCC) have been shown to have distinct outcome profiles based on their human papillomavirus (HPV) status. The purpose of this study was to assess HPV-related outcomes after transoral robotic surgery (TORS) with adjuvant therapy as indicated. METHODS: This study consisted of a retrospective review of 50 patients with OPSCC within a prospective single-arm cohort study. Outcome measures included HPV status, margin status, relapse pattern, and survival. RESULTS: Thirty-seven patients were HPV-positive (74.0%) with 34 patients (91.9%) being serotype-16. Negative margins were achieved in 92.3% (HPV-negative) and 94.6% (HPV-positive). In the HPV-negative group, there were no local recurrences and 1 patient had both regional and distant recurrence (7.7%). In the HPV-positive group, there were no local or regional recurrences and 2 patients (5.4%) had distant recurrences. There were no statistically significant differences in survival between the 2 cohorts (overall survival, disease-specific survival, disease-free survival). CONCLUSION: TORS as a primary surgical modality, followed by adjuvant therapy as indicated, offers disease control in both HPV-negative and HPV-positive groups. We believe that multi-institutional studies are warranted to further evaluate this novel approach for patients who are HPV negative and HPV positive. (c) 2010 Wiley Periodicals, Inc. Head Neck, 2011.




“Combined transoral transnasal robotic-assisted nasopharyngectomy: a cadaveric feasibility study.”

Dallan, I., P. Castelnuovo, et al. (2011).

European Archives of Oto-Rhino-Laryngology.


Surgical management of the nasopharynx is complex. Both traditional and endoscopic transnasal techniques are demanding. Purely transoral robotic nasopharyngectomy has been described but it needs a palatal splitting and is performed with an inferior to superior perspective with a difficult vision of the upper regions. The aim of this study is to investigate a new robotic surgical setting, which is able to overcome the actual limits. The DaVinci Surgical System was used in two cadavers. Dissection was carried out through a combined transnasal-transoral approach and a purely transoral procedure. A complete nasopharyngectomy was performed with both settings. Working and setting times are comparable. The combined approach avoids palatal spitting and permits a more panoramic view of the surgical field with an easier dissection of the upper areas. A robotic palatal sparing nasopharyngectomy is feasible. The combined transnasal-transoral setting seems to offer significant advantages with respect to traditionally purely transoral procedures.




“Robotic thyroidectomy using a transaxillary approach can be performed by experienced surgeons in selected surgical clinics.”

Enoz, M., H. M. Inancli, et al. (2011).

Surgical Endoscopy 25(3): 977.




“Are bilateral axillary incisions needed or is just a single unilateral incision sufficient for robotic-assisted total thyroidectomy?”

Kandil, E., M. A. Khalek, et al. (2011).

Archives of Surgery 146(2): 240-241.




“Transaxillary gasless robotic thyroid surgery with nerve monitoring: Initial 2 experince in a North American center.”

Kandil, E., R. Winters, et al. (2011).

Minim Invasive Ther Allied Technol.


Abstract Minimally invasive thyroid surgery using various techniques is well described. The present study reviews our initial experience with the technique with added intraoperative monitoring to assess its safety and feasibility. The study group consisted of ten consecutive patients with suspicious thyroid nodules who were candidates for thyroid lobectomy from September to December 2009. All patients underwent intraoperative nerve integrity monitoring and postoperative direct laryngoscopy. The patients’ demographic information, operative times, learning curve, complications, and postoperative hospital stay were evaluated. All procedures were successfully completed with intraoperative nerve monitoring. No cases were converted to an open procedure. The median age was 38.5 years (sigma = 13.5) and nine of the ten patients were females. The mean operating time was 131 minutes (range 101-203 minutes) and the mean operating time with the da Vinci system was 55 minutes. All patients were discharged home after an overnight stay. One patient developed transient radial nerve neuropathy that resolved spontaneously. There were no other postoperative complications. None of the patients complained of postoperative neck pain. Postoperative laryngoscopy showed intact and mobile vocal cords in all patients. Robotic endoscopic thyroid surgery with gasless transaxillary approach is feasible and safe in the treatment of suspicious thyroid nodules. Monitoring of the RLN during this approach is feasible.




“Robotic thyroid surgery: An initial experience with North American patients.”

Kuppersmith, R. B. and F. C. Holsinger (2011).

Laryngoscope 121(3): 521-526.


Objective: To review the initial experience of gasless transaxillary robot-assisted endoscopic thyroid surgery in a series of patients and describe modifications of the technique for the North American patients, selection criteria, and other issues related to this technology. Methods: Retrospective review of the first 31 consecutive cases at a single institution. Results: Thirty-one patients underwent robotic thyroid surgery. Twenty thyroid lobectomies and 11 total thyroidectomies were performed. Improvements in the length of time to perform components of the procedure were noted from the early group of cases to later group of cases. No major or permanent complications occurred. Conclusions: Robotic thyroid surgery is feasible in North American patients and can be safely performed. The procedure has potential complications and a definite learning curve exists for both surgeons and operating room staff. Training methods need to be validated to ensure safe adoption. More studies need to be performed to further evaluate the relative benefits of this technique. © 2010 The American Laryngological, Rhinological, and Otological Society, Inc.




“Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands.”

Landry, C. S., E. G. Grubbs, et al. (2011).

Surgery 149(4): 549-555.


BACKGROUND: Robotic assisted transaxillary surgery (RATS) is a minimally invasive approach for the removal of the thyroid and/or parathyroid glands through the axilla. This anatomically directed technique, popularized by Chung, eliminates a visible scar and affords excellent high definition optics of the cervical anatomy. We report an initial series of single access RATS in the U.S. METHODS: The prospective endocrine surgery database at a tertiary care center was used to capture all patients who underwent RATS between October 2009 and March 2010. All procedures were performed using a single transaxillary incision. RESULTS: Fourteen operations were performed on 13 patients. Indications for RATS were indeterminate thyroid nodules in 11 patients, the need for completion thyroidectomy in 1 patient, and primary hyperparathyroidism in 2 patients. For patients who underwent robotic assisted thyroid lobectomy, the median thyroid nodule size was 2.1 cm (range, 0.8-2.8 cm), and the median body mass index was 25.33 (range, 21.3-34.4). Mean and median total operative times for robotic assisted thyroid lobectomies were 142 minutes and 137 minutes respectively (range, 113-192 minutes). Operative time for the 2 patients who underwent robotic assisted parathyroidectomy was 115 and 102 minutes. Minor complications occurred in 4 patients (28.5%), with no significant perioperative morbidity or mortality. CONCLUSION: RATS is feasible. We believe that further study of the RATS technique for removing thyroid lobes and parathyroid glands is warranted. This initial series suggests that careful, continued investigation is necessary prior to routine implementation into clinical practice across the U.S.




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

Lawson, G., N. Matar, et al. (2011).

European Archives of Oto-Rhino-Laryngology: 1-7.


Transoral robotic surgery (TORS) is an emerging technique for the treatment of head and neck tumors. The objective of this study is to describe our first steps and present our experience on the technical feasibility, safety, and efficacy of TORS for the treatment of selected malignant lesions. From April 2008 to September 2009, 24 patients were enrolled in this prospective trial. Inclusion criteria were: adults with T1, T2 and selected T3 tumors involving the oral cavity, pharynx, and supraglottic larynx and a signed informed consent was obtained from the patient. Exclusion criteria were: tumors not accessible to TORS after unsuccessful attempts to expose properly the lesion to operate. The ethical committee’s approval was obtained to perform this study. Twenty-four patients were included in this study: 10 supraglottic tumors, 10 pharyngeal tumors and 4 oral cavity tumors. Nine patients had T1 tumors, 12 had T2 tumors, and 1 patient had a T3 tumor. In all cases, tumor resection could be performed by robotic surgery exclusively and negative resection margins were achieved with control by frozen section. None of them received intraoperative reconstruction. None of the patients required tracheotomy. There was no intraoperative complication related to the use of the robot. The average setup time was 24 ± 14 min (range 10-60 min). The average surgical time was 67 ± 46 min (range 12-180 min). Surgical and setup time decreased after the first cases. The mean hospital stay was 9 days. Oral feeding was resumed at 3 days. TORS seems to be a safe, feasible, minimally invasive treatment modality for malignant head and neck tumors with a short learning curve for surgeons already experienced in endoscopic surgery. © 2011 Springer-Verlag.




“Multicenter Study of Robotic Thyroidectomy: Short-Term Postoperative Outcomes and Surgeon Ergonomic Considerations.”

Lee, J., S. W. Kang, et al. (2011).

Annals of Surgical Oncology: 1-10.


Background: Robotic thyroidectomy (RT) has recently emerged as a viable approach to thyroid surgery, resulting in better functional and cosmetic outcomes than afforded by open thyroidectomy (OT). The present multicenter study assessed the perioperative outcomes of RT and compared physician perspectives on the musculoskeletal ergonomic parameters associated with OT, endoscopic thyroidectomy (ET), and RT. Materials and Methods: We reviewed the medical records of 2014 consecutive patients who underwent RT, conducted by 7 surgeons, at 4 centers between October 2007 and June 2010. Patient characteristics, perioperative clinical results, complications, and pathologic outcomes were analyzed. Moreover, surgeons were surveyed to gather data on musculoskeletal discomfort experienced during OT, ET, and RT. Results: Of the 2014 patients, 740 underwent total and 1274 subtotal thyroidectomy. Mean tumor diameter was 0.8 cm, and the mean number of retrieved central lymph nodes was 4.5 ± 3.9 (range 0-28). The rates of permanent recurrent laryngeal nerve injury and permanent hypocalcemia were 0.4 and 0.05%, respectively. Neck and/or back pain after OT, ET, and RT was experienced by 100, 85.7, and 28.6% of surgeons, respectively. When surgeons ranked the operative approaches in decreasing order of associated pain, 57.1% indicated ET > OT > RT, 28.6% selected OT > ET > RT, and 14.3% responded ET > RT > OT. Conclusion: RT is a feasible and safe procedure that may facilitate radical cervical lymph node dissection. Moreover, for surgeons, the RT resulted in less musculoskeletal discomfort than did OT or ET. A larger prospective study, with a longer follow-up, is needed to determine whether RT offers real benefits for both patients and surgeons. © 2011 Society of Surgical Oncology.



“Perioperative clinical outcomes after robotic thyroidectomy for thyroid carcinoma: a multicenter study.”

Lee, J., J. H. Yun, et al. (2011).

Surgical Endoscopy 25(3): 906-912.


OBJECTIVES: Robotic thyroidectomy and lymph node dissection is rapidly emerging as an alternative to conventional endoscopic thyroidectomy for thyroid carcinoma. Robot techniques incorporate the advantages of endoscopic procedures while overcoming some of the problems. We present the largest multi-institution clinical study of robotic thyroidectomy for thyroid carcinomas. The robotic thyroidectomy involved gasless transaxillary approach using the da Vinci surgical robot system. METHODS: We reviewed a database of 1,043 consecutive patients with low-risk differentiated thyroid carcinoma who underwent robotic thyroidectomy between October 2007 and August 2009. Operations were performed by five surgeons at four academic centers. We analyzed perioperative, clinical, and pathological data. RESULTS: The study involved 71 men and 972 women, with a mean age of 39 (range, 15-70) years. All operations were performed successfully without any need for conventional open or endoscopic conversion. There were 366 total thyroidectomies and 677 subtotal thyroidectomies with cervical lymph node dissection. The mean overall operation time and console time were 132.4 and 63.9 min, respectively. There were ten (1%) major postoperative morbidities. The mean tumor size was 0.8 (range, 0.1-6.0) cm, and the mean number of retrieved central lymph nodes was 5.1 +/- 3.8 (range, 0-26). The mean postoperative hospital stay was 2.9 (range, 1-8) days. CONCLUSIONS: Robotic thyroidectomy using gasless transaxillary method was feasible, safe, and provided good outcomes for patients with differentiated thyroid carcinoma. Robotic technology overcame some technical limitations associated with conventional endoscopy.




“Transoral robot-assisted excision of a lingual thyroid gland.”

May Iv, J. T., J. G. Newman, et al. (2011).

Journal of Robotic Surgery: 1-4.


Lingual thyroid is a rare condition in which ectopic thyroid tissue is present in the base of tongue. We present a case of a 46-year-old patient with a symptomatic lingual thyroid that was successfully removed with minimal morbidity using transoral robotic surgery. The traditional treatment algorithm for lingual thyroid is reviewed. The advantages of using transoral robotic surgery to remove lingual thyroid tissue are described along with the reasons why the addition of this technique should shift treatment of lingual thyroid towards more frequent use of surgical ablation. This report is, to our knowledge, the first describing the use of transoral robotic surgery for treating lingual thyroid. © 2011 Springer-Verlag London Ltd.




“Are bilateral axillary incisions needed or is just a single unilateral incision sufficient for robotic-assisted total thyroidectomy?: Reply.”

Perrier, N. D. (2011).

Archives of Surgery 146(2): 241.




“Postoperative Adjuvant Therapy after Transoral Robotic Resection for Oropharyngeal Carcinomas: Rationale and Current Treatment Approach.”

Quon, H., B. W. O’Malley, Jr., et al. (2011).

ORL; Journal of Oto-Rhino-Laryngology and Its Related Specialties 73(3): 121-130.


The advancement of transoral surgical techniques for the management of oropharyngeal carcinomas has raised questions about how adjuvant therapy can best be integrated. Some of these questions have come from the application of established oncologic principles of adjuvant therapy, and some are unique to the evolving experience with transoral surgery and in particular with the recent advancement of robotic surgery. It is important for all members of the multidisciplinary treatment team to have a clear understanding of the foundation for adjuvant therapy and the issues unique to transoral robotic surgery to provide optimal patient care as this new treatment paradigm gains popularity for its safe application.




“Transoral robotic-assisted thyroidectomy: A preclinical feasibility study in 2 cadavers.”

Richmon, J. D., K. M. Pattani, et al. (2011).

Head and Neck 33(3): 330-333.


Background Technological advances in thyroid surgery have included various “minimally invasive” thyroidectomy techniques, both open and endoscopic. These include not only minimally invasive video-associated approaches but also variations of the transaxillary approach. More recently, a transoral technique using video assistance has been reported for thyroidectomy. Use of the robot was also recently published in a transaxillary approach to the thyroid. We hypothesized that the robot in combination with the previously described transoral technique would facilitate this novel surgical approach. Methods In 2 human cadavers the da Vinci robot was used to perform a transoral thyroidectomy. The dissection was performed with successful removal of the thyroid gland through the floor of the mouth. Results A total thyroidectomy was performed in 2 cadavers using the da Vinci robot transoral technique. The recurrent laryngeal nerve was preserved. Conclusions Transoral robotic-assisted thyroidectomy (TRAT) provides an attractive approach to the central compartment for thyroidectomy in a field of “minimally invasive” and “scarless” techniques. Copyright © 2009 Wiley Periodicals, Inc.




“[Initial experience with transoral robotic surgery using the da Vinci(R) surgical system.].”

Simon, C., B. El-Baba, et al. (2011).

HNO 59(3): 261-265.


Transoral robotic surgery (TORS) can be considered an extension of transoral microscopic laser surgery. The microscope is replaced by an endoscope that provides the surgeon with a three-dimensional view of the surgical field. The surgeon operates from a console that controls the arms of the patient cart. These arms hold miniaturized surgical instruments that are transorally inserted into the patient, enabling tumor resection. Exposure is ensured by various mouth gags. The use of various endoscopes (0 degrees , 30 degrees ), a work radius of 540 degrees for instruments, and a zoom function provides significant advantages over the common transoral laser techniques. With this article we report our first experience with this technique and believe that it may provide significant advantages. However, thorough clinical testing in Germany is required before conclusions can be drawn.




“Transoral robotic surgery of the tongue base in obstructive sleep Apnea-Hypopnea syndrome: Anatomic considerations and clinical experience.”

Vicini, C., I. Dallan, et al. (2011).

Head and Neck.


BACKGROUND: The purpose of our work was to describe, through cadaveric dissection, the anatomy of the tongue base with a robotic perspective and to demonstrate the feasibility of this approach in case of tongue base hypertrophy in Obstructive Sleep Apnea-Hypopnea Syndrome (OSAHS). METHODS: Forty-four patients with OSAHS underwent tongue base resection in the last 2 years. Twenty patients with a 10-month minimum follow-up were evaluated. The anatomic details of 3 tongue bases dissected from above are illustrated. RESULTS: The cadaveric study shows that no constant landmarks are identifiable, with no significant neurovascular structures present in the midline. Clinically, transoral robotic surgery (TORS) for the tongue base was feasible, with no major complications and satisfaction of the majority of patients. Mean apnea hypopnea index (AHI) improvement was 24.6 +/- 22.2 SD, mean Epworth Sleepiness Scale (ESS) improvement was 5.9 +/- 4.4 SD. CONCLUSION: Tongue base hypertrophy can be safely and effectively managed by TORS in OSAHS. Our midterm data are encouraging and worthy of further evaluation. (c) 2011 Wiley Periodicals, Inc. Head Neck, 2011.




“Robotic-assisted transoral removal of a submandibular megalith.”

Walvekar, R. R., P. D. Tyler, et al. (2011).

Laryngoscope 121(3): 534-537.


The majority of salivary stones are less than 8 mm in size and most frequently occur in the submandibular gland. Traditional management of larger stones involves gland resection. Sialendoscopy combined with an external or a transoral sialolithotomy, also called the combined approach technique, permits stone removal and gland preservation. A 31-year-old male presented to our service with a 20-mm megalith in the left submandibular gland. Here we report the first description of a combined approach using the da Vinci Si Surgical System to facilitate transoral stone removal and salivary duct repair. © 2010 The American Laryngological, Rhinological, and Otological Society, Inc.




“Combined transnasal endoscopic and transoral robotic resection of recurrent nasopharyngeal carcinoma.”

Yin Tsang, R. K., W. K. Ho, et al. (2011).

Head and Neck.


BACKGROUND: We report a case of resecting a recurrent nasopharyngeal carcinoma using a combined technique of transoral robotic surgery and transnasal endoscopic surgery. METHOD: A small recurrent tumor was located in the roof of the nasopharynx. The inferior part of the resection was performed with a da Vinci surgical robot transorally after splitting the soft palate to expose the nasopharynx. The superior part of the resection, including removal of the anterior wall and floor of the sphenoid was performed transnasally under endoscopic vision. RESULTS: The tumor was removed enbloc with the sphenoid sinus wall with clear resection margin. Recovery was uneventful and the patient had minimal morbidity from the operation. CONCLUSION: For minimally invasive surgery to resect recurrent nasopharyngeal carcinoma, transnasal endoscopic surgery and transoral robotic surgery compliments each other, allowing improved resection. (c) 2011 Wiley Periodicals, Inc. Head Neck, 2011.