Intraoral anastomosis for primary microsurgical reconstruction in patients of oral cavity malignancies: Retrospective analysis of 30 cases from a tertiary care center in India.

INTRODUCTION: In patients undergoing either robotic neck dissection or no neck dissection, the neck recipient vessels for the free flaps remain unexposed. Intraoral vessels have been successfully used as microvascular recipients but their use in intraoral malignancies is uncommon. We describe our initial experience of using intraoral recipients in 30 patients with oral cavity malignancies. METHODS: For this retrospective observational study, the hospital records of all patients who underwent microvascular reconstruction using intraoral recipient vessels over a 14-month period at a tertiary care hospital in India were studied. Patient demographics, disease profile, details of oncosurgical resection, reconstructive procedure details, and postoperative recovery data were analyzed. RESULTS: Intraoral anastomosis was successfully performed in 30 patients. The average patient was middle-aged (mean age 54 years) and male (26/30). Location of the postexcision defect was the buccal mucosa in 16/30 and the tongue in 12/30 patients. Anterolateral thigh flap (ALT) was used in 28/30 patients. Recipient vessels were facial vessels in 24/30 patients and lingual vessels in 6/30 patients. Venous anastomotic coupler was used in 27/30 patients. Three patients underwent re-exploration for flap congestion with loss of flap in 2/30 patients. CONCLUSION: The intraoral approach offers consistent vascular anatomy and can be performed without any external incision and oro-cervical tunneling. Being technically challenging, it has an initial learning phase. Adequate mouth opening and preservation of recipient vessels during excision and neck dissection are important prerequisites. This approach can offer a scarless reconstruction, which can improve the psycho-social rehabilitation of the patients.

Transoral Robotic surgery - excision of Tongue base Tumour with the Entire Hyoid bone in a Salvage Setting.

Objectives - Transoral robotic surgery (TORS) is an already well established modality of treatment for early stage oropharyngeal cancer. This case report will throw light on the role of TORS as a treatment option for oropharyngeal cancer in a salvage setting. Methods - This is a case of a 69 year old patient who was a follow up case of carcinoma base of tongue, status - post concurrent chemoradiation who presented with residual disease at the primary site. Results - TORS was used as a successful treatment modality for base of tongue carcinoma in a salvage setting. The surgical procedure included removal of the entire hyoid bone in toto along with the tumour which is not reported in literature. The procedure also helped us in achieving an R0 resection. Conclusion - TORS should be considered as an important management modality for tongue base tumours in upfront as well as salvage setting.

Technical and anatomic considerations of skin flap elevation in bilateral axillo-breast insufflation robotic-assisted neck dissection.

We have divided the chest and neck flap elevation for neck dissection into four steps. The flaps are divided into three zones corresponding to the vascular structures, which can be injured in this area. Our modifications outline safe techniques of flap elevation for robotic neck dissection.

Clinical Robotic Surgery Association (India Chapter) and Indian rectal cancer expert group's practical consensus statements for surgical management of localized and locally advanced rectal cancer.

Introduction: There are standard treatment guidelines for the surgical management of rectal cancer, that are advocated by recognized physician societies. But, owing to disparities in access and affordability of various treatment options, there remains an unmet need for personalizing these international guidelines to Indian settings. Methods: Clinical Robotic Surgery Association (CRSA) set up the Indian rectal cancer expert group, with a pre-defined selection criterion and comprised of the leading surgical oncologists and gastrointestinal surgeons managing rectal cancer in India. Following the constitution of the expert Group, members identified three areas of focus and 12 clinical questions. A thorough review of the literature was performed, and the evidence was graded as per the levels of evidence by Oxford Centre for Evidence-Based Medicine. The consensus was built using the modified Delphi methodology of consensus development. A consensus statement was accepted only if ≥75% of the experts were in agreement. Results: Using the results of the review of the literature and experts' opinions; the expert group members drafted and agreed on the final consensus statements, and these were classified as "strong or weak", based on the GRADE framework. Conclusion: The expert group adapted international guidelines for the surgical management of localized and locally advanced rectal cancer to Indian settings. It will be vital to disseminate these to the wider surgical oncologists and gastrointestinal surgeons' community in India.

Transoral Robotic Surgery for Recurrent Tumors of the Upper Aerodigestive Tract (RECUT): An International Cohort Study.

BACKGROUND: Transoral robotic surgery (TORS) is an emerging minimally invasive surgical treatment for residual, recurrent, and new primary head and neck cancers in previously irradiated fields, with limited evidence for its oncological effectiveness. METHODS: A retrospective observational cohort study of consecutive cases performed in 16 high-volume international centers before August 2018 was conducted (registered at clinicaltrials.gov [NCT04673929] as the RECUT study). Overall survival (OS), disease-free survival, disease-specific survivals (DSS), and local control (LC) were calculated using Kaplan-Meier estimates, with subgroups compared using log-rank tests and Cox proportional hazards modeling for multivariable analysis. Maximally selected rank statistics determined the cut point for closest surgical resection margin based on LC. RESULTS: Data for 278 eligible patients were analyzed, with median follow-up of 38.5 months. Two-year and 5-year outcomes were 69.0% and 62.2% for LC, 71.8% and 49.8% for OS, 47.2% and 35.7% for disease-free survival, and 78.7% and 59.1% for disease-specific survivals. The most discriminating margin cut point was 1.0 mm; the 2-year LC was 80.9% above and 54.2% below or equal to 1.0 mm. Increasing age, current smoking, primary tumor classification, and narrow surgical margins (≤1.0 mm) were statistically significantly associated with lower OS. Hemorrhage with return to theater was seen in 8.1% (n = 22 of 272), and 30-day mortality was 1.8% (n = 5 of 272). At 1 year, 10.8% (n = 21 of 195) used tracheostomies, 33.8% (n = 66 of 195) used gastrostomies, and 66.3% (n = 53 of 80) had maintained or improved normalcy of diet scores. CONCLUSIONS: Data from international centers show TORS to treat head and neck cancers in previously irradiated fields yields favorable outcomes for LC and survival. Where feasible, TORS should be considered the preferred surgical treatment in the salvage setting.

Robotic transoral approach for salvage retropharyngeal node dissection: an analysis of functional and oncological outcomes.

Presence of metastatic tumour in the retropharyngeal node has a negative impact on the prognosis. We present here our 5-year experience and the outcomes of transoral robotic retropharyngeal node dissection (RPND) in salvage settings. Hospital database was accessed to extract details of patients with head and neck cancer who developed retropharyngeal (RP) node metastasis. Patients who underwent transoral robotic surgery (TORS) for RPND in salvage settings were included for the study. Patients were first followed-up after 10 days of discharge and then on a monthly basis after completion of treatment. At each follow-up, swallow functions and disease status were recorded. A total of 10 patients met the inclusion criteria and underwent salvage transoral robotic RPND. The total number of lymph nodes removed from these patients were 11, with all having malignant tumour deposits. The median follow-up was 20 months. Four patients developed distant metastasis. There were no major procedure-related complications. Our experience suggests that TORS as treatment modality is oncologically sound and feasible for salvage RP node dissection.Level of evidence Retrospective Study (3).

Modified Preauricular Cervico-facial Approach for Oral Cancers: an Analysis of Oncological and Functional Outcomes.

The quest for a more cosmetic and functionally better approach to oral cancer continues unabated. The modified facelift and preauricular approaches have been a common approach in trauma and cosmetic surgery. In the current study, we evaluate the feasibility and functional outcomes of a preauricular cervico-facial approach for compartmental resection of complex gingiva-buccal complex tumours with concurrent neck dissection. This was a prospective single-centre study and recruited patients of biopsy-proven operable advanced oral cavity tumours. These patients underwent compartmental tumour resections with neck dissection using the modified preauricular approach. Patients were followed up and advised adjuvant treatment when mandated. At 3rd month and 6th month follow-up, QoL was assessed using the self-administered University of Washington Quality of Life scale (UW-QOL). A total of 20 patients met the inclusion criteria and were recruited for the approach. All patients had surgically clear margins on histopathological analysis. Oral swallow was initiated on the 10th postoperative day and the average duration of nasogastric tube dependence was 13 days. All patients had reasonably good oral commissure competence and none had drooling of saliva at 6th month follow-up. Modified preauricular cervico-facial approach to locally advanced gingiva-buccal complex tumours is a safe and holds the possibility of a functionally superior approach.

Oncological outcome following initiation of treatment for stage III and IV HPV negative oropharyngeal cancers with transoral robotic surgery (TORS).

OBJECTIVE: To report long-term oncological and functional outcome of Transoral Robotic Surgery escalated treatment including radiotherapy or chemoradiotherapy for Stage III-IV HPV negative oropharyngeal malignancies. METHOD: From March 2013 to September 2015, 153 patients with oropharyngeal carcinoma were included in the study. Patients were evaluated for disease free survival, overall survival and post-treatment functional outcomes. RESULTS: 153 patients (96 males and 57 females) underwent TORS for oropharyngeal carcinoma. 142 patients on final histopathology had stage III and IV disease and received adjuvant treatment based on final histopathology. One hundred and sixteen (81.7%) patients were disease free on average follow-up of 48 months with an overall survival of 91.5% at mean follow-up of 48 months. CONCLUSION: TORS can be used to intensify treatment of Stage III/IV oropharyngeal carcinoma and avoid early and late toxicities due to higher doses of upfront RT/CTRT and achieve better oncological outcome.

Oncological outcome following TORS in HPV negative supraglottic carcinoma.

OBJECTIVE: The aim of this study was to determine the oncological and functional outcomes following transoral robotic surgery (TORS) in human papilloma virus negative supraglottic cancers. STUDY DESIGN: A prospective observational study at a tertiary cancer care center, New Delhi, India. MATERIALS AND METHODS: From February, 2013 to December, 2015, 45 patients with supraglottic lesions underwent TORS using the da Vinci® surgical system. RESULTS: Forty-five patients underwent TORS for supraglottic laryngectomy (SGL), with all patients undergoing bilateral neck dissection. The most common site was Ary-epiglottic fold. 47.9% were cT1 and 52.1% were cT2. Average robotic set-up time was 8.8 min and average robotic operative time was 42.9 min. A positive or close margin was seen in 12 patients (26.7%) on frozen, which were revised intraoperatively. On final histology, 3 (6.7%) patients had a margin of <5 mm. The average closest margin was 5.7 mm. Patients tolerated oral feeds within 2 weeks of procedure. All patients were HPV negative. Postoperatively, all patients had adequate swallowing and speech. Follow-up ranged from 24 to 58 months. Thirty-eight (84.4%) patients were alive and disease free. CONCLUSION: TORS is a safe, feasible, minimally invasive, and oncologically safe procedure in patients with early HPV supraglottic cancers. It has less morbidity and offers benefits in terms of early airway and feeding rehabilitation and avoids complications resulting from radiation therapy for these patients.

Feasibility, Safety, and Surgical Outcome of Robotic Hemithyroidectomy Via Transaxillary and Retroauricular Approach: an Institutional Experience.

The aim of this observational prospective study was to determine the technical feasibility, safety, and adequacy of robotic hemithyroidectomy. From April 2015 to May 2016, 16 patients with solitary thyroid lesion underwent robotic hemithyroidectomy using the Da Vinci® Si Surgical system. Patients were observed and data were recorded on surgical time, blood loss, complications, and functional outcome of the patients. A total of 16 patients (3 males and 13 females; mean age 39.9 years) underwent robotic hemithyroidectomy after evaluation for solitary thyroid nodule with a mean nodule size of 2.2 ± 0.3 cm. Fiber-optic laryngoscopy (FOL) was normal in all cases pre-operatively. Five patients were operated by transaxillary approach, the rest by retroauricular (facelift) approach. Mean pocket dissection time was 42 min for transaxillary and 40 min for retroauricular approach. Mean operative console time was 59.4 min for transaxillary and 52.6 min for retroauricular approach. Average blood loss was 45 ml. Mean hospital stay was 1.5 days. None of the patients had any post-operative complication on follow-up. One patient had restricted left vocal cord mobility which improved in 3 months. Mean pain score was 0.25 ± 0.4 and average speech score was 0.5 ± 0.2 at 3 months. Post-operatively, all patients had adequate swallowing with no episode of aspiration. Robotic hemithyroidectomy is a safe, feasible, and oncologically safe procedure. It has benefits in terms of better scar cosmesis than open surgery.

Robotic retroauricular thyroidectomy: initial experience from India.

Robotic thyroidectomy is getting accepted worldwide, but, majority of the literature is from South Korea. The purpose of this paper is to review the early experiences with robotic retroauricular (RA) thyroidectomy from India. The rationale for robotic thyroidectomy, its advantages and disadvantages are reviewed. The reasons for selecting the RA approach and the criteria used for selecting the patients are discussed. The early experience and outcomes of 29 patients, from three centres across India is presented. Robotic approaches score above endoscopic methods. RA approach may have some technical advantages for the head and neck surgeons. Sufficient cadaver and preclinical training should be undertaken. Standardized and formal teaching for robotic surgical skill is necessary. Case selection is important especially in the initial phases of the learning curve. Our early experience with robotic thyroidectomy was encouraging.

Oncological outcome following de-intensification of treatment for stage I and II HPV negative oropharyngeal cancers with transoral robotic surgery (TORS): A prospective trial.

OBJECTIVE: This prospective study aimed to see long-term oncological outcome of Transoral Robotic Surgery as single modality treatment for cT1-T2 N0 HPV negative oropharyngeal malignancies. METHOD: From March 2013 to October 2015, 57 patients with early stage oropharyngeal carcinoma underwent Transoral robotic surgery (TORS) with neck dissection using daVinci® Surgical system. Patients were evaluated for disease free survival, overall survival, locoregional and distant metastasis. RESULTS: 57 patients (48 males and 9 females) underwent TORS for early stage oropharyngeal carcinoma. All patients underwent ipsilateral neck dissection and 12 patients underwent bilateral neck dissection. 49 patients with final histopathology suggestive of stage I and II disease did not received any adjuvant treatment. Mean age at presentation was 59.4years (37-88years). Most common site of involvement was the base of tongue (BOT) in 31 (54.8%) patients. Twenty-four (42.1%) patients were cT1 and 33 (57.9%) were cT2 at presentation. During follow-up, 2 (4.2%) patients recurred locoreginally and 1 (2.1%) patient had distant metastasis. Two patients expired due to causes other than malignancy. Forty-three (89.6%) patients were disease free on an average follow-up of 29months with an overall survival of 93.8% at mean follow-up of 29months. CONCLUSION: Transoral Robotic Surgery as a single modality treatment is a good option for cure in HPV negative early resectable oropharyngeal malignancies which are relatively unresponsive to radiation. TORS can be used to de-intensify the treatment of early stage oropharyngeal carcinoma and thus avoid the early and late toxicities associated with Radiotherapy/Chemoradiotherapy.

Salvage Transoral Robotic Surgery for Recurrent or Residual Head and Neck Squamous Cell Carcinoma: A Single Institution Experience.

BACKGROUND: The present study was conducted to evaluate the technical feasibility, safety and adequacy of surgical margins with salvage transoral robotic surgery (TORS) for recurrent or residual head and neck squamous cell carcinoma patients. MATERIALS AND METHODS: Thirty patients who underwent salvage TORS using the 'DaVinci' robot were enrolled in the study and data related to their surgical time, complications and functional outcome were recorded. RESULTS: The feasibility of salvage TORS in our study was observed to be 100%. Positive margins were encountered in only 6.7% of patients. Mean blood loss was 23.3 ml with no patient requiring blood transfusion. Postoperative complications in the form of primary haemorrhage requiring active surgical intervention occurred in 13.3%. Oral feeding could be started as early as the 3rd postoperative day in a few patients, with nasogastric tubes being removed on the 12th postoperative day. Long term gastrostomy tube dependency was seen in 10% cases. Median survival of patients was 19 months. CONCLUSIONS: Salvage TORS is a safe, effective and feasible option in the management of treatment failure cases. It offers an alternative surgical approach with unexpected benefits in terms of tracheostomy tube use, Ryle's tube and gastrostomy dependence.

Transoral robotic surgery in management of oropharyngeal cancers: a preliminary experience at a tertiary cancer centre in India.

BACKGROUND: The aim of this observational prospective study was to determine the technical feasibility, safety and adequacy of surgical margins for transoral robotic surgery (TORS) in oropharyngeal cancers. METHODS: From March 2013 to May 2014, 60 patients with oropharyngeal lesions underwent TORS with or without neck dissection using the 'DaVinci' robot. Patients were observed and data recorded on surgical time, blood loss, complications and functional outcome of patients. RESULTS: All 60 patients underwent TORS, with neck dissection performed in 45 of the patients. A positive margin was seen in two patients (3.3 %). Intent to treatment was radical in 42 patients and salvage in 18 patients. None of the patients required tracheostomy, and one patient (1.66 %) died postoperatively. Postoperative complications in the form of primary haemorrhage required active intervention in three patients. Average estimated blood loss was 26.5 ± 31.1 ml. Postoperatively, all patients had adequate swallowing and speech function with nasal twang reported in three patients on long-term follow up. Patients started tolerating oral feeds within a week of procedure (mean 3.96 days), with the nasogastric tube removed on the ninth postoperative day (mean 9.19 days). No long-term gastrostomy tube dependency was reported. CONCLUSION: TORS is a safe, feasible, minimally invasive procedure in patients with oropharyngeal cancers. It has the least morbidity and offers benefits in terms of avoidance of tracheostomy tube, prolonged Ryle's tube and gastrostomy dependency.

Squamous cell carcinoma of the superior gingivobuccal sulcus: an 11-year institutional experience of 203 cases.

OBJECTIVE: The report presents an 11-year Institutional experience of 203 cases with superior gingivobuccal sulcus tumours receiving surgical intervention at a comprehensive tertiary cancer care centre. METHODS: A retrospective chart review of patients with a confirmed diagnosis of squamous cell carcinoma of superior gingivobuccal sulcus was done and data related to patient demographic profile; details of surgical procedure, follow-up and survival were collected. RESULTS: Infratemporal fossa clearance was performed in 56 patients. The 10-year overall survival and disease-free survival was observed to be 39 and 52%, respectively, with a median follow-up of 15 months. The overall survival was 40 and 36%, respectively, in cases with and without infratemporal fossa clearance. Similarly, the disease-free survival was found to be 58 and 49%, respectively, in cases with and without infratemporal fossa clearance. CONCLUSION: Patients with higher stage tumours who underwent infratemporal fossa clearance showed better overall and disease-free survival than those who did not undergo infratemporal fossa clearance.