Preoperative predictors of difficult hypopharyngeal exposure by retractor for transoral robotic surgery.

INTRODUCTION: Transoral endoscopic surgeries provide excellent oncologic outcomes while preserving speech and swallowing ability. However, feasibility has been a major concern about transoral surgery. Therefore, ensuring visualization of the surgical field and sufficient working space is required. The aim of this study was to evaluate the parameters in the preoperative assessment that affect hypopharyngeal exposure. METHODS: Before transoral surgery, parameters regarding the patient's neck and face such as modified Mallampati index, thyroid-mental distance (TMD), and ability to fully open the mouth were evaluated. Cephalometry and cervical spine radiography were performed preoperatively to evaluate the size of the mandible bone, mouth opening, and cervical spine extension. Mandibular bone parameters such as intergonion distance, mental-gonion distance, articulare-gonion distance, and aperture angle were measured. According to hypopharyngeal exposure using FKWO retractor, patients were divided into difficult hypopharyngeal exposure group (DHE) and non-difficult hypopharyngeal exposure group (non-DHE). Parameters were enrolled to evaluate the relationship between these parameters and DHE status. RESULTS: This study included 51 patients, 37 in the non-DHE group and 14 in the DHE group. On radiographic evaluation, there was a significant difference in the degree of cervical lordosis between non-DHE and DHE patients. A significantly higher proportion of DHE patients had a history of radiotherapy compared with non-DHE patients. CONCLUSION: Patients with limited cervical extension and a history of previous radiotherapy might have difficult hypopharyngeal exposure during transoral surgery. This is the first report to suggest a classification system for hypopharyngeal exposure during transoral surgery.

Evolution of robotic systems for transoral head and neck surgery.

Oropharyngeal tumor is traditionally resected from an open approach, often necessitating the need of a midline mandibulotomy in order to remove tumor safely with oncologic margins. The limitations imposed by a transoral route include poor visualization of the inferior extent of the oropharynx, rigid instrumentation, and inability to resect tumor that extends caudally into the supraglottis. While visualization with angled endoscopes, coupled with flexible laser development and microscopic magnification may overcome some of these limitations, this technique suffers from linear trajectory of the instruments which hampers expedient surgical resection in a 3-dimensional fashion. With development of the Da Vinci Surgical System, the safety and oncologic feasibility of removing oropharyngeal tumors are made possible because it provides a 3-dimensional magnification of the surgical field and wristed maneuverability of the surgical instruments which enable surgeons to operate around tight anatomical confines. Nevertheless, this first-generation robot is continually being modified with more flexibility and maneuverability through the development of robots like the FLEX Robotic System and more recently the Da Vinci Single Port System (SP). In this review, we will discuss the historic developments of robots for transoral applications, present the current approved robotic systems, and highlight the upcoming robots for transoral robotic surgery (TORS). Finally, we will also propose an ideal TORS surgical robot by highlighting the engineering technologies to accomplish these challenges.

Salvage endoscopic nasopharyngectomy for local recurrent or residual nasopharyngeal carcinoma: a 10-year experience.

BACKGROUND: Our aim was to review the outcomes of endoscopic nasopharyngectomy performed on a large series of patients with residual or recurrent nasopharyngeal carcinomas and to identify the prognostic factors. METHODS: Ninety-one patients with residual (10) and recurrent (81) nasopharyngeal carcinomas who underwent endoscopic nasopharyngectomy were enrolled in our study. Clinical information including gender, age, medical history, symptoms, radiographic findings, tumor stage, treatment, recurrence time, postoperative pathological examination, complications, and outcomes at last follow-up visit was collected. The survival curves and multivariate survival analysis were analyzed using the Kaplan-Meier and Cox proportional hazards model. RESULTS: Our study included 71 men and 20 women with a median age of 51 years. The lesions were staged as follows: rT1, 30; rT2, 13; rT3, 29; and rT4, 19. No serious operative or postoperative complication was observed. The median follow-up period was 23 months (range, 4-109 months). Tumor necrosis was identified in 40 of 91 patients. At the last follow-up, 42 patients were free of disease, 10 were alive with disease, and 39 had died. At 2- and 5-year follow-up, the overall survival rates were 64.8% and 38.3%, respectively; the disease-free survival rates were 57.5% and 30.2%, respectively, for the two periods. Multivariate analysis showed that T classification (P = 0.02) and tumor necrosis (P = 0.024) were independent risk factors. CONCLUSIONS: Endoscopic nasopharyngectomy is a feasible and effective surgical treatment for recurrent and residual nasopharyngeal carcinomas.

Transoral endoscopic nasopharyngectomy with a flexible next-generation robotic surgical system.

OBJECTIVES/HYPOTHESIS: To determine the feasibility of transoral endoscopic nasopharyngectomy without division of the soft plate using a flexible, next-generation robotic surgical system. STUDY DESIGN: Preclinical anatomic study using four human cadavers. METHODS: Transoral resection of the nasopharyngeal wall with en-bloc resection of the cartilaginous Eustachian tube and dissection of the parapharyngeal fat space. RESULTS: The first flexible robotic surgical system has recently been described. We performed a series of laboratory experiments to determine whether this flexible system could be used to perform transoral robotic nasopharyngectomy. This novel system allowed docking of the patient-side cart at the side of the operating table. The cannula tip was placed approximately 12 cm from the edge of the retractor pointing superiorly toward the nasopharynx (NP). Retraction of the soft palate anteriorly and tonsillar pillars laterally with stay sutures expanded the velopharyngeal inlet, providing adequate space to deploy all four instruments (three surgical instruments and a camera) into the NP for dissection. All instruments could be deployed into the NP, without collision or restriction of joint movement in this cadaver model. Using this position and docking location, the new flexible surgical robot provided sufficient access, reach, and visualization to complete robotic nasopharyngectomy with en-bloc resection of the cartilaginous Eustachian tube. CONCLUSION: This feasibility study showed that transoral endoscopic nasopharyngectomy could be performed without compromising the integrity of the soft palate using a novel flexible robotic surgical system. LEVEL OF EVIDENCE: N/A. Laryngoscope, 126:2257-2262, 2016.

Transoral robotic surgery (TORS) for laryngeal and hypopharyngeal cancers.

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

Transoral palate-sparing nasopharyngectomy with the Flex® System: preclinical study.

OBJECTIVES/HYPOTHESIS: The nasopharynx remains one of the most challenging areas to surgically access given its deep location, narrow confines, and surrounding critical neurovascular anatomy. Various open and endoscopic approaches have been developed, all of which have been limited to some degree in their ability to bimanually instrument and visualize in this area. STUDY DESIGN: Cadaveric dissection. METHODS: Study using one fresh human cadaver. A novel, highly articulated endoscope with flexible instrumentation, the Flex System, was placed in the oral cavity and advanced around the soft palate into the nasopharynx to perform a nasopharyngectomy. RESULTS: A complete nasopharyngectomy was accomplished with the Flex System without palatal incisions or extended-access approaches. CONCLUSIONS: The Flex System is a novel computer-assisted flexible endoscope with a highly articulated scope and flexible instruments that was successfully used to perform a nasopharyngectomy while avoiding any additional incisions. This system holds promise in minimally invasive skull base surgery. LEVEL OF EVIDENCE: NA.

[Total laryngopharyngectomy and reconstruction with a jejunum speech siphon : A case report]. / Totale Laryngopharyngektomie und Rekonstruktion mit Jejunumsprechsiphon : Fallbericht.

Advanced laryngeal and hypopharyngeal carcinomas are associated with a poor prognosis and a pronounced loss of quality of life due to impairment of the swallowing and voice function. The fundamental therapeutic challenge is successful tumor control with concomitant rehabilitation of swallowing and voice functions. Further objectives are a low complications rate (fistula, aspiration) and prompt transfer to the adjuvant radio-oncologic therapy. With these factors in mind, the microvascular anastomosed jejunum speech siphon with a biventer rein has proven to be an effective method of reconstruction following extensive circular laryngopharyngeal resections. In this case report, a typical operative and postoperative course is presented, as are the functional results.

A clinical study of transoral pharyngectomies to treat superficial hypopharyngeal cancers.

BACKGROUND: For years, it has been a major interest for surgeons and oncologists to develop a novel technique to detect hypopharyngeal cancers at an early stage and to treat the lesions in a less invasive manner. The advent of the narrow band imaging system combined endoscopy and various endoscopic approaches shed light on the new era of the minimum invasive management of superficial cancers in hypopharyngeal regions. METHODS: Three endoscopic approaches, endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic laryngopharyngeal surgery, were chronologically introduced at our institute. In this study, we focused on the clinical outcomes, advantages and limitations of each procedure. RESULTS: A total of 30 patients (42 procedures) received transoral pharyngectomies between June 2006 and May 2012. Tracheotomy was performed in 9 of 42 (21%) patients. Three patients developed local recurrence and were subsequently controlled by additional transoral pharyngectomies. The 2- and 5-year local control rates were 92.8 and 83.5%. The 2- and 5-year overall survival rates were 82.1%. CONCLUSIONS: Endoscopic mucosal resection, endoscopic submucosal dissection and endoscopic laryngopharyngeal surgery-transoral pharyngectomies are useful procedures for treating superficial hypopharyngeal cancers. Endoscopic mucosal resection manifested the least invasiveness and may be beneficial for resecting small superficial lesions, endoscopic submucosal dissection may be advantageous for patients with difficult laryngopharyngeal exposure and endoscopic laryngopharyngeal surgery has shown the optimal effectiveness and minimal complications and can be applied to most of the hypopharyngeal sub-sites. All three procedures require a high level of technical skill and close collaboration between otolaryngologists and gastroenterologists.

Transoral robotic surgery for hypopharyngeal squamous cell carcinoma: 3-year oncologic and functional analysis.

The recent trend in treatment of hypopharyngeal cancer is organ preservation in order to maintain swallowing and speech function as well as improve quality of life. Transoral robotic surgery (TORS) can remove hypopharyngeal lesions successfully without an external incision, preserving physiologic functions of affected organs. However, studies have yet to assess the oncologic and functional results of TORS for the treatment of hypopharyngeal cancer. This prospective study evaluated the oncologic and functional results of TORS for the treatment of hypopharyngeal cancer obtained at our institution over a period of 3 years and confirmed the validity of TORS as a surgical organ-preserving strategy. Between April 2008 and September 2011, 23 patients who were diagnosed with hypopharyngeal cancer underwent TORS for removal of a primary lesion. The da Vinci Robotic system (Intuitive Surgical Inc., Sunnyvale, California) was used to remove the lesion. The Kaplan-Meier method was used to analyze overall survival and disease-free survival. Videopharyngogram study (VEF) was performed and functional outcome swallowing scale (FOSS) was utilized to measure and evaluate swallowing function. Acoustic wave form analysis was conducted to evaluate voice status. Overall survival at 3 years was 89% and disease-free survival was 84%. On the VEF study, serious aspiration or delay of swallowing was not observed during the pharyngeal stage of the swallowing process. Overall, 96% of the patients showed favorable swallowing abilities with an FOSS score ranging from 0 to 2. The fundamental frequency variation (vF0) and jitter were increased upon acoustic waveform analysis (vF0=2.71 ± 0.063, Jitter=2.01 ± 0.034), but the harmonic-to-noise ratio (HNR) and shimmer were maintained close to the normal range (HNR=1.28 ± 0.001, Shim=1.74 ± 0.036). The oncologic and functional results of TORS were quite acceptable for the treatment of hypopharyngeal cancer. TORS is a valid treatment option as a surgical, organ-preserving strategy for select patients with hypopharyngeal cancer.

Endoscopic transoral oropharyngectomy using laparoscopic surgical instruments.

BACKGROUND: Recently, several transoral approaches for minimally invasive surgery have been developed for oropharyngeal cancer. However, all approaches have certain disadvantages. Therefore, we built and examined new surgical environments for improving the situation. METHODS: Endoscopic transoral resection using a pharyngeal retractor or distending laryngoscope, rigid videoendoscope, and laparoscopic surgical instruments was performed in 17 patients with oropharyngeal squamous cell carcinoma. Postoperative results regarding oncology and function as well as complications were documented. RESULTS: The 2-year relapse-free survival rate was 100%. Postoperative swallowing and speech function were satisfactory: 94.1% of cases scored ≤1 on the functional outcome swallowing scale (FOSS) and ≤1 on the communication score. Further, no perioperative mortality occurred. CONCLUSIONS: The improved surgical environment made it possible to perform a safe and reliable en bloc resection with a wide field of view and sufficient working space. Our system can be useful, although further studies on additional cases are required.

The role of reconstruction for transoral robotic pharyngectomy and concomitant neck dissection.

OBJECTIVE: To evaluate the impact of primary reconstruction of postablative defects following transoral robotic surgery on function and the risk of orocutaneous fistula. DESIGN: Prospective nonrandomized clinical trial. SETTING: Tertiary academic medical center. PATIENTS: Thirty-one patients treated with transoral robotic pharyngectomy for malignant disease. Each case was analyzed for patient age, sex, primary site of the tumor, pathologic characteristics, stage of disease, complications, fistula rate, and functional outcomes. Functional outcomes were assessed using the Performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale. INTERVENTIONS: In 25 patients, the primary treatment was with transoral robotic pharyngectomy, and 6 cases were salvage procedures performed for recurrent disease following radiation (3 patients) or chemoradiation (3 patients). Twenty-six patients underwent a concomitant unilateral selective neck dissection, and 3 patients underwent concomitant bilateral selective neck dissections; 2 patients did not require a neck dissection for treatment of the primary malignant tumor. MAIN OUTCOME MEASURES: Complication rate, fistula rate, and oral function. RESULTS: Primary intraoral reconstruction was performed in all 31 patients. Musculomucosal advancement flap pharyngoplasty was performed in 25 patients with a concomitant velopharyngopasty (6 patients), and radial forearm free flap reconstruction was performed in 6 patients. There were no intraoperative complications; however, postoperatively, 1 patient developed a neck hematoma that was treated with bedside drainage and 4 patients sustained minor musculomucosal flap necrosis of the superior aspect of the flap. None of the patients developed a neck infection of salivary fistula. Endoscopic evaluation of swallowing demonstrated that none of the patients experienced aspiration or velopharyngeal reflux, and the performance Status Scale for Head and Neck Cancer Patients and the Functional Oral Intake Scale at 2 weeks, 2 months, 6 months, 9 months, and 1 year demonstrated a progressive improvement in diet, swallowing, and oral function. CONCLUSIONS: Primary transoral robotic reconstruction may provide a benefit by decreasing the fistula rate in patients undergoing concomitant neck dissection. Patients regain excellent function following surgery and adjuvant therapy.

Feasibility of transoral lateral oropharyngectomy using a robotic surgical system for tonsillar cancer.

Conventional surgical approaches for tonsillar carcinomas have a great risk for developing treatment-related morbidity. To minimize this morbidity, transoral lateral oropharyngectomy (TLO) using the robotic surgical system was performed, and the efficacy and feasibility of this procedure was evaluated. TLO was performed using the da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA). It consists of a surgeon's console and a manipulator cart equipped with three robotic arms. The surgeon is provided with three-dimensional magnified images from the endoscopic arm and can control two instrument arms for delicate operations from the console. Safe resection of tonsillar carcinoma was possible with the three-dimensional magnified images. When proceeding with resection of the buccopharyngeal fascia, we could prevent damage to the carotid artery, which is located posterolateral to the tonsillar fossa, since the joint at the distal part of the robotic arm can be bent freely from side to side. By using the 30 degrees endoscope, we can achieve a better surgical view of the base of the tongue area. TLO was performed successfully in all five patients without surgical complications. The mean operating time was 44 min, and an average of 19 min was required for setting up the robotic system. TLO using the robotic system will be a good option for organ preservation therapy in the treatment of carcinomas of the tonsil and the tonsillar fossa in the future.

Harmonic scalpel in pharyngolaryngectomy with radical neck dissection.

OBJECTIVE: The aim of this study was to verify the efficacy and applicability of the Ultracision Harmonic Scalpel (Ethicon Endo-Surgery, Cincinnati, OH) in pharyngolaryngectomy with radical neck dissection. DESIGN: This work evaluated the use of the Harmonic Scalpel in otolaryngology as a new and alternative method to overcome some complications of traditional surgery. SETTING: The study was conducted with 20 patients in the ENT Department of the University of Genoa (Italy) between January 1, 2005, and December 31, 2006. METHODS: A prospective, randomized study was undertaken on 20 pharyngolaryngectomies with radical neck dissection performed using a Harmonic Scalpel (10 patients) or traditional surgery (10 patients). MAIN OUTCOME MEASURES: The evaluation included operation time, intraoperative blood loss, postoperative seroma formation, and pattern of wound healing. RESULTS: In patients treated with Harmonic Scalpel, the mean operation time was significantly shorter, the blood loss was less, laryngeal and neck drainage on the first and second postoperative days was significantly smaller, and no postoperative complications were noted. CONCLUSIONS: The use of the Harmonic Scalpel during pharyngolaryngectomy and radical neck dissection led to diminished bleeding, shorter operative time, less seroma formation, and better wound healing in the postoperative period.

[Laparoscopy-assisted harvesting of free small intestine transplants for reconstruction of voice and deglutition after total laryngopharyngectomy--an animal experiment study]. / Laparoskopisch assistierte Entnahme freier Dünndarmtransplantate zur Rekonstruktion von Stimm- und Schluckfunktion nach totaler Laryngopharyngektomie--Eine tierexperimentelle Untersuchung.

Based on animal trials the presented study results describe a laparoscopic assisted removal of an extra-long free jejunal graft to reconstruct voice and swallowing after a total laryngo-pharyngectomy in cases with advanced malignancies of the larynx including invasion in the upper oesophagus. With a microvascular anastomosed small bowel segment, we have been able to reconstruct parts of the pharynx and to create a speaking syphon as devised by Ehrenberger in an one-stage procedure. The concept of avoidance of an extensive laparotomy may result in an decreased morbidity of this surgical procedure. Therefore it represents a challenging single indication of minimally invasive surgery of the oesophagus. A well established interdisciplinary teamwork is the key for success in this extensive procedure.

Laparoscopic harvesting of jejunal free flaps for esophageal reconstruction.

Endoscopic harvest of the jejunum is indicated for the reconstruction of complex defects of the head and neck and specifically the reconstruction of circumferential defects of the esophagus. However, open laparotomies are associated with systemic and local morbidity and are often seen as prohibitively invasive procedures. Laparoscopy for intra-abdominal procedures is a proven technique that yields less morbidity and provides an anatomical exposure similar to that of the open approach. We report on 11 consecutive clinical cases of free jejunal flap harvesting with the laparoscopic technique and show that the procedure is feasible.

Use of surgical stapling device in excision of pharyngeal diverticulum.

Pharyngeal diverticulum (Zenker's diverticulum, hypopharyngeal pouch) is an outpouching of pharyngeal mucosa through a triangular area of weakness between the lower oblique fibres of the inferior constrictor muscle and cricopharyngeus called Killian's dehiscence. Prescribed treatment in large pouches is excision of the diverticulum with or without cricopharyngeal myotomy. Experience of closure of the oesophageal defect with an automatic stapling device is presented in nine cases of pharyngeal diverticula. Previous reports describing this technique have included substantial delays in the resumption of oral intake and prolonged hospitalization. It is shown that these delays are unnecessary.

A simple instrument for endoscopic laryngeal and pharyngeal surgery.

A simple suture instrument for endoscopic microlaryngeal surgery is presented. It is made from a common sewing machine needle that is soldered in a 25 cm pipe-like holder and is slightly bent near the point. The needle tip is so threaded that the thread can pierce through both edges of a wound following placement with an endoscopic tube. The thread is held by a forceps, the instrument withdrawn and the suture knotted. In practice, wounds can be sutured very quickly, easily and comfortable. An example of its application is use of the instrument to shorten significantly and simplify the performance of endoscopic arytenoidectomy.

[Use of polyglactin 910 mesh with collagen in the prevention of pharyngostomes]. / Utilisation du filet de polyglactine 910 avec collagène dans la prévention des pharyngostomes.

The use of the collagen-coated Polyglactine 910 mesh is proposed as a preventive treatment of pharyngostomes in extensive pharyngolaryngectomies for necrotized hypopharyngeal tumors. The good results obtained in this series of 12 cases may be explained by a distribution of stress in the pharyngeal sutures, associated to a decrease in the stress exerted on the tight mucosal suture, as well as a sliding-rotating effect of the pharyngeal muscular suture, which is thus displaced relative to the plane of the mucosal suture. This original technique seems to be fully effective during the first two postoperative weeks, and may greatly help in the prevention of the dangerous pharyngostomes during the postoperative period following extensive pharyngeal resections.