Arens, C. (2012). “Transoral treatment strategies in head and neck tumors.” Transorale Therapiestrategien bei Kopf-Hals-Tumoren 91(SUPPL. 1): S86-S101.
Transoral Treatment Strategies in Head and Neck Tumors The introduction of transoral endoscopic surgery resulted in a significant reduction of surgical trauma and a paradigm change from transcervical to transoral surgical treatment in head and neck tumors. In selected cases minimally invasive transoral resections allow a reduction of morbidity without deteriorating oncological results. Thus, transoral surgical techniques gained more acceptance, led to an extension of the indications and technologies as well as an improvement of surgical instruments. Depending on the anatomical localization transoral treatment strategies and their indications are described and relevant literature is discussed according to new developments and results. © Georg Thieme Verlag KG Stuttgart · New York.
Aubry, K., M. Yachine, et al. (2011). “Transoral robot assisted surgery for upper aerodigestive tract cancer: A report of 17 cases.” La chirurgie trans-orale robot assistée des cancers des VADS: À propos de 17 cas 128(6): 339-345.
Benazzo, M., P. Canzi, et al. (2012). “Transoral Robotic Surgery with Laser for Head and Neck Cancers: A Feasibility Study.” ORL 74(3): 124-128.
Aims: To assess the feasibility of a flexible thulium laser coupled with a novel robotic introducer for head and neck cancers. Methods: In a prospective nonrandomized clinical trial, 58 patients were evaluated. When indicated, transoral robotic surgery (TORS) with laser was performed using an Intuitive da Vinci S System with the Intuitive Surgical® Endo Wrist Introducer, 5Fr to hold and position thulium surgical laser fibers. Results: Six patients underwent TORS with laser for early supraglottic and oropharyngeal squamous cell carcinomas. All approaches were successfully completed without the need for microscopic/open conversion or positive margins to the final pathological study. No intraoperative adverse events occurred and recovery was relatively quick, with no evidence of disease recurrence at the time of reporting, the short observation time notwithstanding. Conclusions: In our preliminary experience, TORS with laser showed feasible and promising results. Further studies are mandatory to demonstrate thulium laser benefits in surgical and oncological practice. Copyright © 2012 S. Karger AG, Basel.
Cognetti, D. M., A. J. Luginbuhl, et al. (2012). “Early Adoption of Transoral Robotic Surgical Program: Preliminary Outcomes.” Otolaryngology and Head and Neck Surgery.
Objective. The objective of this study is to demonstrate the feasibility and safety of establishing a transoral robotic surgical (TORS) program in the post-Food and Drug Administration (FDA) approval setting. Early outcomes are compared with the previously reported results of pioneering centers.Study Design. Clinical data from a prospective TORS study.Setting. Academic university institution.Subjects and Methods. Sixty-one patients treated with 63 TORS procedures. Main outcome measures: intraoperative times, margin status, complications, time to diet, and percutaneous endoscopic gastrostomy (PEG) tube retention rate. The authors also report oncologic outcomes on their first 30 patients.Results. The spectrum of subsites included tongue base, tonsil, parapharyngeal space, retromolar trigone, supraglottis, and posterior pharyngeal wall. Surgical console time averaged 79 +/- 53 minutes. After re-resection of 4 patients, final negative margin status was 94% (50/53). A subset of 30 patients with squamous cell carcinoma reaching an average of 18 months of follow-up had a local regional control rate of 97% with a disease-free survival rate of 90%. The PEG tube retention rate was 7%. Complications included 2 readmissions with dehydration, 1 aspiration pneumonia, and 2 with minor oropharyngeal bleeding. Ninety-one percent of patients resumed an oral diet by the first postoperative visit.Conclusion. The initiation of a TORS program in the post-FDA setting can be achieved in a safe and efficient manner. Early results of pioneering TORS centers are reproducible. Continued investigation of TORS as a treatment option for oropharygneal carcinoma is warranted.
Fan, L. J. and J. Jiang (2012). “Present and future of robot-assisted endoscopic thyroid surgery.” Chinese Medical Journal 125(5): 926-931.
Objective Robot-assisted endoscopic surgery has been increasingly accepted because of its unique three-dimensional vision and precise simulation-based technology. However, the utilization of robotic systems in thyroid surgery is limited. We conducted a systematic review to assess the application and development of robot-assisted endoscopic surgical technique in thyroid surgery. Data sources Articles published in PubMed before June, 2011 about robot-assisted endoscopic surgery were selected. Study selection Original articles and critical reviews selected were related to robot-assisted (thyroid) surgery or endoscopic thyroid surgery, and a total of 3540 relevant articles were retrieved and 34 were finally cited. Results Robot-assisted operation of benign thyroid diseases were successfully performed, although the operation time is too long to exhibit its advantages. Nevertheless, the superiority of robot-assisted endoscopic surgical technique compared to conventional endoscopic surgery in the treatment of thyroid carcinoma were obvious, since robotic radical thyroidectomy with central and lateral neck lymph node dissection could be achieved while maintaining operative results and cosmetic outcomes equivalent to or better than conventional endoscopic surgery. Furthermore, the learning curve duration of robot-assisted endoscopic thyroid surgery was shorter than that of conventional endoscopy, especially for the novices without any endoscopic surgical basis. Conclusion Robot-assisted endoscopic thyroid surgery, with its safety, feasibility, thoroughness, cosmetic benefits, and ability to overcome the limitations of conventional endoscopic surgery, will be further improved and applied, and is worthy of attention.
Giulianotti, P. C., P. Addeo, et al. (2012). “Robotic Thyroidectomy: An Initial Experience with the Gasless Transaxillary Approach.” Journal of Laparoendoscopic and Advanced Surgical Techniques. Part A.
Abstract Background: Thyroid surgery has recently emerged as one of the most promising fields for the application of robotic surgery. We report the results of the first year of experience with a gasless transaxillary thyroidectomy. Subjects and Methods: From January 2009 to December 2009, 10 consecutive patients (8 women) underwent robotic thyroidectomy through a gasless transaxillary approach. The median age was 44 years (range, 27-42 years). Eight total and two partial thyroidectomies (one left and one right) were performed using the da Vinci((R)) Robotic Surgical System (Intuitive Surgical, Sunnyvale, CA). Preoperative diagnosis included solitary nodules with a median size of 16+/-11 mm (range, 3-44 mm) at preoperative imaging. Results: All procedures were successfully completed robotically, except one that was converted because of difficulty in achieving an optimal exposure. The overall mean operative time was 177.4+/-40 minutes (range, 120-240 minutes) with minimal blood loss (<10 mL). Pathological diagnoses included papillary carcinoma (n=6), colloid nodule (n=2), and multinodular goiter (n=2). The mean number of lymph nodes harvested in the cases of malignant disease was 4+/-5 (range, 3-15).The median postoperative length of stay was 1.05 days (range, 1-1.4 days). Conclusions: Thyroid surgery using a gasless transaxillary approach can be performed safely for selected benign and malignant pathology. This approach offers superior cosmetic results and a short hospital stay over conventional thyroid surgery. For selected patients, this technique offers a promising scarless option for minimally invasive thyroid surgery.
Kandil, E., S. Noureldine, et al. (2012). “Robotic transaxillary thyroidectomy with gasless approach in a girl with goitre.” Int J Med Robot.
BACKGROUND: Robotic-assisted transaxillary thyroidectomy is a minimally invasive approach for the removal of the thyroid through the axilla. This technique eliminates a visible scar and affords excellent optics of the cervical anatomy. We sought to describe the technique and outcome for transaxillary gasless subtotal thyroidectomy in the paediatric population. METHODS: A 13 year-old female with an enlarged goitre underwent a transaxillary robot-assisted gasless subtotal thyroidectomy in an academic institution. The main outcome measures were feasibility of the robotic approach, patient and gland characteristics, operative time and complications. RESULTS: There was no conversion to laparoscopic or open surgery. The robotic docking time was 110 min and total operative time was 150 min. The patient tolerated the procedure well. Estimated blood loss was 10 ml. The patient was discharged within 24 h. There were no perioperative or postoperative complications. In addition there was no evidence of postoperative vocal cord palsy or paresis. CONCLUSIONS: This initial experience demonstrates that this technique can be a feasible, safe and effective method for subtotal thyroidectomy in the paediatric population. The use of robotic technology for endoscopic thyroid surgery could overcome the limitations of conventional endoscopic surgeries in the surgical management of thyroid disease. Copyright (c) 2012 John Wiley & Sons, Ltd.
Kiriakopoulos, A. and D. Linos (2012). “Gasless transaxillary robotic versus endoscopic thyroidectomy: exploring the frontiers of scarless thyroidectomy through a preliminary comparison study.” Surgical Endoscopy.
BACKGROUND: Robot-assisted thyroidectomy has been associated with lengthy operative times due to fussy robot preparation and docking maneuvers. The authors propose an endoscopic transaxillary approach using a novel platform, comparing its results with those of the former approach. METHODS: Eight patients (6 females and 2 males; mean age, 38.8 years) with a favorable body habitus (mean body mass index [BMI], 23.4 kg/m(2)) underwent robot-assisted thyroidectomy through a gasless transaxillary approach using the da Vinci S system. Another four female patients (mean age, 31 years) underwent an endoscopic procedure. The patients’ demographic data, operative time, complications, hospital stay, postoperative visual analog pain score (VAPS), and costs were compared. RESULTS: Three lobectomies, two near-total thyroidectomies, two total thyroidectomies, and one total thyroidectomy with lateral lymph node dissection were performed in the robotic group. Two lobectomies and two near total thyroidectomies were performed in the endoscopic group. The mean diameter of the largest nodule in the robotic series was 26.5 mm compared with 42.5 mm in the endoscopic group. The mean total operative time was 211 min for the robotic series compared with 160 min for the endoscopic series. There was one temporary recurrent laryngeal nerve paralysis in the robotic group. Two patients in the robotic group exhibited transient symptomatic hypocalcemia compared with one patient in the endoscopic group. Hypoesthesia in the flap dissection area was experienced by three patients in the robotic group and two patients of the endoscopic group. The mean hospital stay was 1.5 days (range 1-3 days) in both groups. The postoperative VAPS also was similar in the two groups (3.1 vs 2.8). The cost was significantly less for the endoscopic approach. CONCLUSIONS: The preliminary comparison in this study shows that both approaches are safe and feasible, with similar results. They also afford an excellent view of the critical neck anatomy that allows precise tissue handling and dissection. However, the endoscopic approach results in a significantly faster and more convenient thyroidectomy.
Lamarre, E. D., R. Seth, et al. (2012). “Intended single-modality management of T1 and T2 tonsillar carcinomas: Retrospective comparison of radical tonsillectomy vs radiation from a single institution.” American Journal of Otolaryngology – Head and Neck Medicine and Surgery 33(1): 98-103.
Background: T1 and T2 tonsillar squamous cell cancer with limited neck disease can be managed with single-modality radiation or surgery. Over 11 years, 17 patients underwent radical tonsillectomies; and 33 patients underwent radiation-based treatments for T1 and T2 and N0 to N2a tonsil cancer. Patients were intended to receive single-modality treatment based on presentation; however, some ultimately received adjuvant treatments. Methods: A retrospective chart review to compare overall survival (OS), disease-specific survival (DSS), and locoregional control (LRC) between the groups was used. Results: In surgical group, of 17 patients, 11 underwent surgery alone, 3 underwent surgery and radiation, and 3 underwent surgery with concurrent chemoradiation. Five-year OS for the surgical and radiation groups was 93% and 72%, respectively (no significance achieved). Five-year DSS rates (93% and 80%) and LRC (69% and 89%) similarly did not yield any significant difference. Conclusion: Surgery remains a viable option in the management of T1 and T2 tonsillar cancers with comparable LRC, OS, and DSS. © 2012 Elsevier Inc. All rights reserved.
Lawson, G., A. H. Mendelsohn, et al. (2012). “Transoral robotic surgery total laryngectomy.” Laryngoscope.
Lee, J., K. Y. Na, et al. (2012). “Postoperative Functional Voice Changes after Conventional Open or Robotic Thyroidectomy: A Prospective Trial.” Annals of Surgical Oncology: 1-8.
Purpose: To use objective and subjective voice function analysis to compare outcomes in patients who had undergone conventional open thyroidectomy or robotic thyroidectomy. Methods: The study involved 88 consecutive patients who underwent thyroid surgery between May 2009 and December 2009; 46 patients underwent a conventional open thyroidectomy, and 42 underwent a robotic thyroidectomy. Auditory perceptual evaluation was used to make subjective assessments of voice function, and videolaryngostroboscopy, acoustic voice analysis with aerodynamic study, electroglottography, and voice range profile were used to make objective assessments. Each assessment was made before surgery, and at 1 week and 3 months after surgery. Results: The conventional open and robotic thyroidectomy groups were similar in terms of age, gender ratio, and disease profile. We found that 18 (20.5%) of the 88 patients showed some level of voice dysfunction at 1 week after surgery; that the dysfunction resolved by 3 months after surgery in all cases; and that it was not permanent according to postoperative videolaryngostroboscopy. The conventional open and robotic thyroidectomy groups were found to have similar levels of dysfunction at 1 week after surgery, except for jitter, which was greater in the robotic group. For both groups, any such dysfunction spontaneously resolved by 3 months after surgery, and there were no significant differences between the groups in terms of any voice function parameter. Conclusions: Voice dysfunction was present after both open and robotic thyroidectomy (without any evident laryngeal nerve injury). However, function subsequently normalized to preoperative levels at 3 months after surgery in both groups. Voice function outcomes after robotic thyroidectomy are similar to those after conventional open thyroidectomy. © 2012 Society of Surgical Oncology.
Rivera-Serrano, C. M., P. Johnson, et al. (2012). “A transoral highly flexible robot: Novel Technology and Application.” Laryngoscope 122(5): 1067-1071.
Objectives/Hypothesis: Organ preservation surgery is a major focus in head and neck oncology. Current approaches are aimed toward improving quality of life and decreasing treatment-related morbidity. Transoral robotic surgery was developed to overcome the limitations of traditional surgical approaches. The most widely used robotic system is the da Vinci Surgical System. Although the da Vinci offers clear surgical advantages over traditional approaches, its rigid operative arms prevent complex maneuverability in three-dimensional space. The ideal surgical robot would configure to the anatomy of the patient and maneuver in narrow spaces. We present the first cadaveric trials of the use of a highly flexible robot able to traverse the nonlinear upper aerodigestive tract and gain physical and visual access to important anatomical landmarks without laryngeal suspension. Study Design: Feasibility. Methods: Using human cadavers, we investigated the feasibility of visualizing the endolarynx transorally with a highly flexible robot without performing suspension of the larynx. Two fresh and four preserved human specimens were used. Results: Unhampered visualization of the endolarynx was achieved in all specimens without performing laryngeal suspension. Standard mouth retractors facilitated the delivery of the robot into the endolarynx. Conclusions: The flexible robot technology mitigates laryngeal suspension and the limitations of current robotic surgery with rigid line-of-sight-directed instruments. Having demonstrated the feasibility of physical and visual access to the endolarynx, future work will study the feasibility of using the highly flexible robot in transoral robotic procedures with flexible instrumentation placed in the robot’s available working ports. Laryngoscope, 2012 Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.
Sanders, B. P. and P. Babbar (2012). “The need for further evaluation of objective parameters of swallowing function after transoral robotic surgery.” Archives of Otolaryngology–Head and Neck Surgery 138(4): 432-433.
Tae, K., Y. Bae Ji, et al. (2012). “Comparative study of robotic versus endoscopic thyroidectomy by a gasless unilateral axillo-breast or axillary approach.” Head and Neck.
Background: Robotic thyroidectomy and conventional endoscopic thyroidectomy have not been thoroughly compared. In this study, we compared the potential advantages of robotic versus endoscopic thyroidectomy. Methods: We analyzed 218 consecutive patients who underwent endoscopic (105 cases) or robotic (113 cases) thyroidectomy using a gasless unilateral axillo-breast or gasless unilateral axillary approach. Results: Because of the dexterity of robotic instruments and the improved surgical view, it was subjectively easier and took less time to perform a complete total thyroidectomy and central compartment neck dissection in robotic thyroidectomy. In the case of unilateral lobectomy, endoscopic and robotic thyroidectomy had quite similar surgical outcomes. Cosmetic satisfaction was excellent in both groups. Conclusion: In this series by a single surgeon, robotic thyroidectomy was superior to endoscopic thyroidectomy for performing total thyroidectomy and bilateral central compartment neck dissection. However, in terms of cost-effectiveness, endoscopic thyroidectomy was comparable to robotic thyroidectomy in patients who undergo unilateral lobectomy. © 2012 Wiley Periodicals, Inc.
Tsang, R. K. and C. Mohr (2012). “Lateral palatal flap approach to the nasopharynx and parapharyngeal space for transoral robotic surgery: a cadaveric study.” Journal of Robotic Surgery: 1-5.
The da Vinci surgical robot has been used for minimally invasive surgery of the head and neck region including resection of tumors in the nasopharynx. Access to and vision of the nasopharynx with the robot are difficult. A pure transoral approach and midline palatal split approach have been described. The disadvantage of these approaches is the limited lateral access to the parapharyngeal space. The objective of this study was to investigate the feasibility of accessing the nasopharynx and parapharyngeal space with a lateral palatal flap. Two complete nasopharyngectomies with resection of the parapharyngeal space and exposure of the internal carotid artery and branches of the mandibular nerves were performed on two fresh cadavers with the da Vinci surgical robot. The set up of the robot, the surgical procedure of elevating the lateral palatal flap, and robotic resection of the nasopharynx and parapharyngeal space are described. © 2012 The Author(s).
Vergez, S., B. Lallemant, et al. (2012). “Initial Multi-institutional Experience with Transoral Robotic Surgery.” Otolaryngology and Head and Neck Surgery.
Objective. To assess the initial experience for transoral robotic surgery (TORS), as observed in the French TORS group.Study Design. A multi-institutional prospective cohort study.Setting. Seven tertiary referral centers.Subjects and Methods. One hundred thirty consecutive patients who were scheduled for a TORS between October 2008 and March 2011 were included. The operative times, conversion rates, morbidity, and alternatives were described. The serious adverse effects encountered were analyzed, and recommendations for avoiding them are specified.Results. Most of the patients (65%) had a laryngeal (supraglottic) and/or hypopharyngeal resection. Thirty-nine of the 130 patients receiving TORS would have had a transoral laser resection as their alternative surgery. The tumor exposure was suboptimal in 26% of the cases. Six of the 130 patients needed conversion to an open approach. There were 15 postoperative hemorrhages and 2 deaths due to posthemorrhage complications in patients with significant comorbidities at 9 and 18 days after the surgery. The median setup and procedure times were 52 +/- 46 and 90 +/- 92 minutes, respectively. The learning curve was characterized by better selection and management of potential patients.Conclusion. The visualization offered by the robotic assistance allowed transoral resections of tumors that were difficult to resect or unresectable by laser surgery. Self-assessment of surgical exposure and a decrease in the need to convert to an open procedure over time suggested improvement in TORS-related surgical skills. Nevertheless, strict patient selection is essential. Even with a minimally invasive approach, some patients will need a tracheostomy for safety reasons.
Vural, E., O. E. Tulunay-Ugur, et al. (2012). “Transoral robotic supracricoid partial laryngectomy with cartilaginous framework preservation.” Journal of Robotic Surgery: 1-4.
To report the technical feasibility of performing transoral robotic supracricoid partial laryngectomy with preservation of the thyroid cartilage. This is a case report from a tertiary-care academic institution. A patient with recurrent T2 glottic squamous cell carcinoma of the larynx underwent supracricoid partial laryngectomy with negative margins and preservation of the laryngeal framework using transoral robotic surgery, where an adequate exposure to the endolarynx was obtained by using a Feyh-Kastenbauer retractor. The patient was successfully decannulated in postoperative week 4, and his gastrostomy tube was removed in postoperative week 6. Transoral robotic surgery may be feasible in select glottic/subglottic laryngeal lesions, if adequate exposure is obtained. © 2012 Springer-Verlag London Ltd.
Pediatric (1)
Loveland, J., A. Numanoglu, et al. (2012). “Pediatric minimally invasive surgery in Africa: limitations and current situation.” Seminars in Pediatric Surgery 21(2): 160-163.
The second largest and most populous continent, with an exploding pediatric population, Africa has an overwhelming burden on its very limited pediatric surgical services. In an international environment of progressively advancing endoscopic and robotic surgical techniques, the authors focus on the current role of endoscopic surgery on the continent and explore the potential reasons for its delayed acceptance and implementation. They proceed to document the spectrum of what is available and, using their “African experience,” expand on financially viable models of further rolling out these techniques, including discussion around suitable training models for surgeons and their teams.
Wang, M. H., B. Chen, et al. (2012). “Pediatric urology fellowship training: Are we teaching what they need to learn?” Journal of Pediatric Urology.
Objective: Pediatric urology training has traditionally been based on an apprenticeship model. As part of our curriculum re-development, we surveyed recent graduates (2007-2009) regarding the teaching of clinical/surgical skills and medical knowledge during their training. Methods: 44 pediatric urologists who completed 2 years of ACGME (Accreditation Council for Graduate Medical Education)-accredited programs and had been practicing for at least 18 months were anonymously surveyed. An IRB-approved survey was developed by a team of educators at the Johns Hopkins School of Medicine and Bloomberg School of Public Health. Results: 31 of 44 responded to 100% of the questions; 90% of the respondents felt their fellowship successfully prepared them for discussing surgical options and performing the procedures that they are now doing; 74% felt well trained to manage perioperative complications and 65% felt well trained to manage non-surgical problems. Faculty feedback/supervision, independent reading, and conferences were rated as a very effective method of teaching (87%). Top three procedures they wished they had learned: laparoscopic/robotic surgery, hypospadias repair, and augmentation/Mitrofanoff. Top three non-surgical topics: urinary tract infection, voiding dysfunction, and billing/coding. Conclusion: It is reassuring that ACGME fellowship-trained pediatric urologists feel prepared in commonly performed procedures and perioperative care. Faculty supervision/feedback is highly valued. © 2012 Journal of Pediatric Urology Company.