RESUMEN
Transoral robotic surgery (TORS) provides a minimally invasive approach to address tumors in selected and challenging anatomical locations. Among the critical areas where TORS demonstrates its prowess is the oropharynx. Oropharyngeal tumors can invade parapharyngeal space (PPS) which contains vital structures such as the carotid artery, internal jugular vein, and cranial nerves IX-XII. A deeper understanding of the endoscopic anatomy of the parapharyngeal space could reduce the morbidity associated with tumor resection in this dense neurovascular area. This video-article provides a step-by-step cadaveric dissection of the lower PPS though a transoral robotic approach.
RESUMEN
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.
RESUMEN
Objective: Transoral robotic surgery (TORS) has evolved since its 2009 US Food and Drug Administration approval for use in local stage T1-T2 oropharyngeal carcinoma. The ability to resect increasingly larger and more complex lesions has led to the need to introduce reconstructive techniques through this route, avoiding the classic transmandibular or pull-through approach. Few studies have compared the safety, efficacy, and advantages of TORS versus classic open approaches in oropharyngeal salvage surgery with reconstruction using microanastomosed flaps. Here we retrospectively compare our center's experience with the open approach and TORS and describe the technical variations used. Methods: Between 2013 and 2021, 30 stage III-IV oropharyngeal cancer patients underwent salvage surgery with reconstruction in our center. From 2013 to 2017, 15 patients underwent surgery with the classic open approach, and from 2018 to 2021, an additional 15 patients underwent TORS. We have compared surgical outcomes, post-surgical results, and survival in the two groups. Results: Patient characteristics were similar in the two groups. TORS was associated with shorter surgical time (p < .001), fewer complications (p = .01), shorter hospital stay (p < .001), and lower feeding tube requirements (p = .003). No significant differences were observed between the two groups in the free margin rate or survival. Conclusion: Oropharyngeal salvage surgery with TORS with free flap reconstruction reduced associated morbidity compared to the open approach in a patient cohort with poor prognosis. Level of Evidence: 4.
RESUMEN
OBJECTIVE: Surgery is the standard treatment for most tumors in the prestyloid parapharyngeal space (PPS) but it can be a challenging procedure because of the anatomical complexity of the area. Prestyloid surgery can be performed with various lateral approaches or with a medial approach using transoral robotic surgery (TORS)-either alone or in combination with a transcervical incision. We have retrospectively compared our center's results with lateral and medial approaches. METHODS: Between 2015 and 2020, 28 patients with prestyloid PPS tumors underwent surgery at our center: 14 with lateral approaches, including transcervical, transcervical-parotid, and transcervical-mandibular, and 14 with medial approaches (12 with TORS and two with TORS plus a transcervical incision). We compared surgical time, postsurgical complications, length of hospital stay, need for feeding tube, and relapse-free survival in the two patient groups. RESULTS: Pleomorphic adenoma was the most frequent tumor and 60.7% of the tumors were benign. Tumor volume and maximum length were similar in the two groups of patients. Intraoperative image guidance and ultrasound were used in 33% of TORS. TORS was associated with less surgical time, fewer complications, and shorter hospital stays. Recurrence rates were similar in the two groups. CONCLUSION: The medial approach by TORS offers superior results in prestyloid tumors than the open lateral approach and can be refined by intraoperative guidance. Level of Evidence: 4.
RESUMEN
La cirugía transoral de la orofaringe ha presentado una importante evolución en los últimos años, al ampliarse las opciones quirúrgicas disponibles (TORS, TOUSS, TOLS), la capacidad de resecar lesiones cada vez más extensas y el número de pacientes que se beneficia de ellas. Este hecho ha provocado una evolución en la reconstrucción de los defectos quirúrgicos tras cirugía transoral. Este artículo tiene como objetivo la revisión de las posibles técnicas reconstructivas, las indicaciones y factores que tener en cuenta previamente a la cirugía, además de proponer un protocolo para valorar la necesidad de reconstrucción transoral sobre la base de la profundidad del defecto, la estadificación y el tratamiento previamente recibido
Transoral surgery of the oropharynx has seen an important evolution in recent years, expanding the surgical options available (TORS, TOUSS, TOLS). The capacity to resect increasingly extensive lesions and the number of patients who benefit from them. This fact has led to an evolution in the reconstruction of surgical defects after transoral surgery. This article aims to review the possible reconstructive techniques, indications and factors to be taken into account prior to surgery, proposing a protocol to assess the need for transoral reconstruction based on the depth of the defect, the staging, and previous treatment
Asunto(s)
Humanos , Neoplasias Orofaríngeas/cirugía , Colgajos Quirúrgicos , Complicaciones Posoperatorias/prevención & control , Procedimientos de Cirugía Plástica/métodos , Trasplante de PielRESUMEN
INTRODUCTION: Minimally invasive transoral surgery for oropharyngeal cancer is a challenge for head and neck surgeons because of the inside-out anatomic presentation and the confined workspace. This study was performed to describe the main neurovascular and muscular landmarks in a transoral approach. The authors propose an anatomic stratification for this surgery. MATERIALS AND METHODS: Lateral wall of the oropharynx and base of the tongue of 15 formalin-fixed heads (30 sides) and 5 fresh cadaveric heads (10 sides) sagittal sectioned were dissected from the inside outwards. Dissection of 7 fresh cadaveric heads via an endoscopic transoral approach was also performed. RESULTS: The lateral oropharyngeal wall was divided into 3 layers from medial to lateral, based in the styloid muscle diaphragm. The first layer, medial to styloid muscles, includes the tonsillar vascularization and the lingual branch of the glossopharyngeal nerve. The second layer, lateral to constrictor muscles, includes the pharyngeal venous plexus, the glossopharyngeal nerve, and the lingual artery. The third layer, lateral to styloid diaphragm, includes the parapharyngeal and submandibular spaces, the carotid vessels and lingual, vagus, glossopharyngeal and hypoglossal nerves. The base of the tongue was divided into central and lateral parts, which contain the lingual artery and lingual branches of the glossopharyngeal nerve. The main landmarks to find the neurovascular structures in each layer are described. CONCLUSION: The authors propose an anatomic division, which helps to plan oropharynx and base of the tongue surgery. This anatomic stratification is useful to surgeons when performing a reconstruction of the oropharynx with a transoral approach.
Asunto(s)
Nervio Glosofaríngeo/anatomía & histología , Nervio Hipogloso/anatomía & histología , Orofaringe , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Lengua , Puntos Anatómicos de Referencia , Arterias/anatomía & histología , Cadáver , Humanos , Modelos Anatómicos , Orofaringe/anatomía & histología , Orofaringe/inervación , Orofaringe/cirugía , Lengua/anatomía & histología , Lengua/inervación , Lengua/cirugíaRESUMEN
Transoral surgery of the oropharynx has seen an important evolution in recent years, expanding the surgical options available (TORS, TOUSS, TOLS). The capacity to resect increasingly extensive lesions and the number of patients who benefit from them. This fact has led to an evolution in the reconstruction of surgical defects after transoral surgery. This article aims to review the possible reconstructive techniques, indications and factors to be taken into account prior to surgery, proposing a protocol to assess the need for transoral reconstruction based on the depth of the defect, the staging, and previous treatment.
Asunto(s)
Neoplasias Orofaríngeas/cirugía , Colgajos Quirúrgicos , Humanos , Complicaciones Posoperatorias/prevención & control , Procedimientos de Cirugía Plástica/métodos , Procedimientos Quirúrgicos Robotizados/métodos , Trasplante de PielRESUMEN
Introducción y objetivos: La cirugía mínimamente invasiva ha presentado una expansión muy importante en la última década. Con el objetivo de aportar un lenguaje común tras cirugía transoral de la orofaringe, se ha creado un sistema de clasificación de las resecciones en esta zona, independientemente de la instrumentalización utilizada. Métodos: Desde el Grupo de Trabajo en Oncología de la Sociedad Catalana de Otorrinolaringología, se presenta una propuesta de clasificación basada en una división topográfica de las diferentes zonas de la orofaringe, así como en la afectación de las estructuras anexas según las vías anatómicas de extensión de estos tumores. Resultados: La clasificación se inicia utilizando la letra D o I según la lateralidad sea derecha (D) o izquierda (I). A continuación se coloca el número del área resecada. Esta numeración define las zonas iniciando a nivel craneal donde el área I sería el paladar blando, el área II lateral en la zona amigdalina, el área III en la base de lengua, el área IV en los repliegues glosoepiglóticos, la epiglotis y repliegues faringoepiglóticos, el área V pared orofaríngea posterior y VI el trígono retromolar. Se añade el sufijo p si la resección afecta profundamente al plano submucoso de la zona comprometida. Las diferentes áreas propuestas tendrían, de una forma teórica, diferentes implicaciones funcionales. Conclusiones: Propuesta de sistema de clasificación por áreas que permite definir diferentes tipos de cirugía transoral de la orofaringe así como compartir los resultados y ayudar en la docencia de este tipo de técnicas (AU)
Introduction and goals: There has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. Methods: From the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. Results: The classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone. The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. Conclusions: Proposal for a system of classification by area to define different types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique (AU)
Asunto(s)
Humanos , Neoplasias Orofaríngeas/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/clasificación , Procedimientos Quirúrgicos Otorrinolaringológicos/educación , Procedimientos Quirúrgicos Mínimamente Invasivos/clasificación , Procedimientos Quirúrgicos Robotizados/clasificación , Microcirugia/clasificación , Endoscopía/clasificaciónRESUMEN
INTRODUCTION AND GOALS: There has been a very significant increase in the use of minimally invasive surgery has in the last decade. In order to provide a common language after transoral surgery of the oropharynx, a system for classifying resections has been created in this area, regardless of the instrumentation used. METHODS: From the Oncology Working Group of the Catalan Society of Otorhinolaryngology, a proposal for classification based on a topographical division of the different areas of the oropharynx is presented, as also based on the invasion of the related structures according to the anatomical routes of extension of these tumours. RESULTS: The classification starts using the letter D or I according to laterality either right (D) or left (I). The number of the resected area is then placed. This numbering defines the zones beginning at the cranial level where area I would be the soft palate, lateral area II in the tonsillar area, area III in the tongue base, area IV in the glossoepiglottic folds, epiglottis and pharyngoepiglottic folds, area V posterior oropharyngeal wall and VI the retromolar trigone. The suffix p is added if the resection deeply affects the submucosal plane of the compromised area. The different proposed areas would, in theory, have different functional implications. CONCLUSIONS: Proposal for a system of classification by area to definedifferent types of transoral surgery of the oropharynx, and enable as sharing of results and helps in teaching this type of technique.
Asunto(s)
Neoplasias Orofaríngeas/cirugía , Procedimientos Quirúrgicos Otorrinolaringológicos/clasificación , Procedimientos Quirúrgicos Otorrinolaringológicos/métodos , Humanos , Procedimientos Quirúrgicos Mínimamente Invasivos/métodos , BocaRESUMEN
No disponible
Asunto(s)
Humanos , Femenino , Adulto , Músculo Masetero/patología , Músculo Masetero/cirugía , Músculo Masetero , Tumor de Células Granulares/complicaciones , Tumor de Células Granulares/patología , Tumor de Células Granulares/cirugía , Inmunohistoquímica/métodos , Tumor de Células Granulares , Espectroscopía de Resonancia Magnética/métodos , Biopsia con Aguja Fina/instrumentación , Biopsia con Aguja Fina/métodos , Microscopía , Glándula Parótida/citología , Glándula Parótida/patologíaAsunto(s)
Neoplasias Faciales/patología , Tumor de Células Granulares/patología , Músculo Masetero/patología , Neoplasias de los Músculos/patología , Neoplasias Faciales/diagnóstico por imagen , Neoplasias Faciales/cirugía , Femenino , Tumor de Células Granulares/diagnóstico por imagen , Tumor de Células Granulares/cirugía , Humanos , Imagen por Resonancia Magnética , Músculo Masetero/diagnóstico por imagen , Músculo Masetero/cirugía , Neoplasias de los Músculos/diagnóstico por imagen , Neoplasias de los Músculos/cirugía , Adulto JovenRESUMEN
Presentamos un caso de infección cervical profunda atípica con afectación principalmente muscular, cuyo agente causal fue Streptococcus pyogenes, y cuya clínica y evolución se caracterizaron por un brusco deterioro hemodinámico y fallo sistémico severo que hizo necesaria una exploración quirúrgica urgente y su posterior ingreso en la UCI. Tras el diagnóstico de miositis estreptocócica y el pertinente cambio de pauta antibiótica, el paciente presentó una mejoría progresiva hasta su restitución completa (AU)
An atypical case of deep neck infection is presented with muscular involvement as the main feature. Streptococcus pyogenes was the causal agent and abrupt haemodynamic impairment and severe systemic failure characterized its clinical course, requiring emergency surgical examination and subsequent admission to the critical care unit. After the diagnosis of Streptococcal Myositis was obtained and the antibiotic treatment adjusted, the patient progressively recovered completely (AU)
Asunto(s)
Humanos , Masculino , Anciano de 80 o más Años , Miositis/diagnóstico , Miositis/terapia , Penicilinas/uso terapéutico , Clindamicina/uso terapéutico , Miositis/fisiopatología , Miositis , Streptococcus pyogenes/aislamiento & purificaciónRESUMEN
An atypical case of deep neck infection is presented with muscular involvement as the main feature. Streptococcus pyogenes was the causal agent and abrupt haemodynamic impairment and severe systemic failure characterized its clinical course, requiring emergency surgical examination and subsequent admission to the critical care unit. After the diagnosis of streptococcal myositis was obtained and the antibiotic treatment adjusted, the patient progressively recovered completely.
Asunto(s)
Fascitis Necrotizante/etiología , Miositis/etiología , Músculos del Cuello/microbiología , Choque Séptico/etiología , Infecciones Estreptocócicas/complicaciones , Streptococcus pyogenes/aislamiento & purificación , Enfermedad Aguda , Anciano de 80 o más Años , Clindamicina/administración & dosificación , Clindamicina/uso terapéutico , Terapia Combinada , Desbridamiento , Drenaje , Quimioterapia Combinada , Urgencias Médicas , Fascitis Necrotizante/tratamiento farmacológico , Fascitis Necrotizante/cirugía , Humanos , Infusiones Intravenosas , Masculino , Meropenem , Miositis/tratamiento farmacológico , Miositis/cirugía , Músculos del Cuello/cirugía , Penicilinas/administración & dosificación , Penicilinas/uso terapéutico , Diálisis Renal , Choque Séptico/terapia , Infecciones Estreptocócicas/diagnóstico , Infecciones Estreptocócicas/tratamiento farmacológico , Infecciones Estreptocócicas/cirugía , Streptococcus pyogenes/efectos de los fármacos , Tienamicinas/uso terapéutico , Vancomicina/uso terapéuticoRESUMEN
Introducción: El divertículo de Zenker es una patología del esfínter esofágico superior susceptible de tratamiento quirúrgico en aquellos casos sintomáticos. Este tratamiento ha sufrido importantes cambios en los últimos años. Material y métodos: Se realizó un estudio retrospectivo de 16 pacientes tratados en nuestro servicio entre 2001 y 2008. Se utilizó el abordaje quirúrgico abierto y el abordaje endoscópico combinado mediante grapadora endoscópica y láser. Se analizó el tipo de tratamiento llevado a cabo, tamaño del divertículo, tiempo quirúrgico, tiempo hasta la ingesta oral, complicaciones quirúrgicas, estancia hospitalaria y la presencia de recidiva. Resultados: Se inició tratamiento endoscópico en 8 casos, siendo necesaria reconversión a técnica abierta en 2 casos. El tiempo operatorio fue de 90 min para el abordaje abierto y de 45 min en el endoscópico. La ingesta oral se reinició a las 36 horas en la abierta y a las 24h en la endoscópica, siendo el alta hospitalaria a los 3,8 días en la abierta y a los 2 días en la endoscópica. Aparecieron un 12,4% de complicaciones en relación con la cervicotomía. Se presentó recidiva de la patología en 2 pacientes que se habían sometido a tratamiento abierto, un caso fue tratado con abordaje endoscópico y otro con abierto. Conclusiones: El tratamiento endoscópico combinado parece ofrecer unos buenos resultados en aquellos enfermos con divertículo de Zenker sintomático que pueden ser sometidos a anestesia general. Si no es posible una buena exposición mediante el abordaje endoscópico se debe pasar a un abordaje mediante cervicotomía (AU)
Introduction: Zenker's diverticulum is a superior esophagus sphincter disease with a surgical management in symptomatic cases. This treatment has undergone important changes in recent years. Material and method: A retrospective review was carried out of 16 patients treated in our department between 2001 and 2008. Conventional open surgery was used as well as a combined endoscopic approach with stapler and CO2 laser. Type of treatment, diverticulum size, operating time, oral feeding time, surgical complications, hospital stay and occurrence of relapses were analyzed. Results: The endoscopic approach was used in 8 patients, with a conversion to conventional open surgery being necessary in 2 cases. Operating time was of 90min for the open approach and 45 in the endoscopic. Oral feeding could be reintroduced 36hours after open surgery and 24h after endoscopic treatment. The average discharge date was 3.8 days after the surgery in the open group and 2 days in the endoscopic group. Complications appeared in the 12.4% of the cases, all related to cervicotomy. There were 2 cases of relapse in the group treated with open surgery, one case was treated with the endoscopic approach and another with the open approach. Conclusions: The combined endoscopic approach offers good results in patients with symptomatic Zenker's diverticulum who can be under general anesthesia during the surgery. A conversion to open surgery with cervicotomy should be done when a good endoscopic exposure is not possible (AU)
Asunto(s)
Humanos , Masculino , Femenino , Adulto , Persona de Mediana Edad , Anciano , Anciano de 80 o más Años , Divertículo de Zenker/cirugía , Endoscopía Gastrointestinal/métodos , Laparoscopía/métodos , Terapia por Láser/métodos , Suturas , Grapado Quirúrgico/métodos , Estudios RetrospectivosRESUMEN
INTRODUCTION: Zenker's diverticulum is a superior esophagus sphincter disease with a surgical management in symptomatic cases. This treatment has undergone important changes in recent years. MATERIAL AND METHOD: A retrospective review was carried out of 16 patients treated in our department between 2001 and 2008. Conventional open surgery was used as well as a combined endoscopic approach with stapler and CO(2) laser. Type of treatment, diverticulum size, operating time, oral feeding time, surgical complications, hospital stay and occurrence of relapses were analyzed. RESULTS: The endoscopic approach was used in 8 patients, with a conversion to conventional open surgery being necessary in 2 cases. Operating time was of 90 min for the open approach and 45 in the endoscopic. Oral feeding could be reintroduced 36 hours after open surgery and 24h after endoscopic treatment. The average discharge date was 3.8 days after the surgery in the open group and 2 days in the endoscopic group. Complications appeared in the 12.4% of the cases, all related to cervicotomy. There were 2 cases of relapse in the group treated with open surgery, one case was treated with the endoscopic approach and another with the open approach. CONCLUSIONS: The combined endoscopic approach offers good results in patients with symptomatic Zenker's diverticulum who can be under general anesthesia during the surgery. A conversion to open surgery with cervicotomy should be done when a good endoscopic exposure is not possible.
Asunto(s)
Esofagoscopía/métodos , Laparoscopía/métodos , Terapia por Láser/métodos , Divertículo de Zenker/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Láseres de Gas/uso terapéutico , Masculino , Persona de Mediana Edad , Recurrencia , Reoperación , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
Sinusal mucoceles are expansive lesions related to ostium sinus obstruction and treatment is surgical. We present a case of frontal mucocele secondary to ostium drainage obstruction due to herniated orbital content. This entailed difficulties for intranasal surgical resolution so a combined approach was used. The different surgical options for treating such cases are discussed.
Asunto(s)
Hernia/complicaciones , Mucocele/etiología , Órbita/lesiones , Enfermedades Orbitales/complicaciones , Humanos , Masculino , Persona de Mediana EdadRESUMEN
Los mucoceles de senos paranasales son lesiones expansivas relacionadas con la obstrucción del ostium sinusal, cuyo tratamiento es quirúrgico. Presentamos un caso de un mucocele frontal secundario a una obstrucción del ostium de drenaje por contenido orbitario herniado. Este hecho conllevó dificultad para la resolución quirúrgica endonasal, por lo que se optó por una vía combinada. Para tratar este tipo de casos, se analizan las diferentes opciones quirúrgicas
Sinusal mucoceles are expansive lesions related to ostium sinus obstruction and treatment is surgical. We present a case of frontal mucocele secondary to ostium drainage obstruction due to herniated orbital content. This entailed difficulties for intranasal surgical resolution so a combined approach was used. The different surgical options for treating such cases are discussed
Asunto(s)
Humanos , Masculino , Persona de Mediana Edad , Mucocele/etiología , Hernia/complicaciones , Órbita/lesiones , Enfermedades Orbitales/complicacionesRESUMEN
INTRODUCTION: Oncological head and neck surgery has progressed with the possibility of adapting reconstruction to the surgery effected. In the last 30 years, two basic techniques have been developed: the pectoralis major myocutaneous flaps (PMMF) and microvascularized flaps. PMMF had a leading role in reconstruction surgery during the 1980s, but this has subsequently diminished in favour of microvascularized flaps. MATERIAL AND METHOD: A review was conducted on 351 reconstructive surgeries in 317 patients, of which 275 were PMMF and 76 free flaps. We analyzed age, gender, flap type, indication, and year of the surgery in all cases. RESULTS: 34 % of the revised flaps were used for reconstruction of the hypopharynx, 33 % for the oropharynx, 21 % for soft tissues, and 12 % for the repair of pharyngocutaneous fistulae. At our hospital, the introduction of the free flap technique from 2001 on has led to an increase in the use of reconstructive procedures as well as the replacement of PMMF by microvascularized flaps in a number of indications. CONCLUSIONS: In this age of microvascularized flaps, we believe that PMMF still has a privileged role in the repair of hypopharynx and cervical lesions. However, in such locations as the oral cavity or oropharynx and in facial soft- tissue reconstruction we prefer the use of microvascularized flaps.