Application of a computer-assisted flexible endoscope system for transoral surgery of the hypopharynx and upper esophagus.

Zenker's diverticulum is a common pathology in the transition zone of the posterior hypopharynx and esophagus. Surgical treatment is routinely performed by ENT and general surgeons. Besides the traditional open transcervical diverticulectomy, the introduction of transoral rigid treatment led to a paradigm change and is now the preferred treatment option for patients who are fit for general anesthesia. The implementation of interventional flexible endoscopy has opened another new micro-invasive approach for patients with high morbidity. Here, we present the potential utilization of a flexible, single port, robot-assisted, and physician-controlled endoscope system to facilitate transoral surgical access to the hypopharynx and upper esophagus. Transoral surgery of the hypopharynx and upper esophagus was performed in human cadavers (n = 5) using the Flex System (Medrobotics, Raynham, USA). Anatomical landmarks were identified, and posterior cricothyroid myotomy was performed with compatible flexible instruments in all cases. The approach to the hypopharynx and upper esophagus using the Flex system is feasible in a cadaveric model. Myotomy with a flexible tool and needle knife (from the perspective of treatment of Zenker´s diverticulum) was successful in all cases. Visualization of the surgical site with the system's HD camera is suitable and the flexible instruments meet the special needs of a micro-invasive transoral approach. Zenker´s diverticulum can be potentially treated with a transoral minimally invasive approach using a computer-assisted flexible endoscope system. This setup could be of advantage in patients with reduced mobility of the cervical spine to prevent open transcervical surgery. In our study, the Flex system enabled advanced visualization of the surgical site and extended intervention options, compared to standard flexible endoscopic treatment. However, general anesthesia is mandatory for the presented approach. Application in live patients with actual pathologies of the hypopharynx and upper esophagus will have to prove suitability for the treatment of Zenker's diverticulum. Further development of the system could include improved instrumentation and an adoption by other disciplines with challenging anatomy such as colorectal surgery.

Potential Advantages of a Single-Port, Operator-Controlled Flexible Endoscope System for Transoral Surgery of the Larynx.

INTRODUCTION: Transoral surgery of the larynx is commonly performed with a rigid laryngoscope, a microscope, and a laser. We investigated the potential utility of a flexible, single-port, robot-assisted and physician-controlled endoscopic system to enable easy, transoral surgical access to the larynx. METHODS: Transoral laryngeal surgery was performed in human cadavers (n = 4) using the Flex System and compatible flexible instruments. Anatomical landmarks were identified, and mock surgical procedures were performed. RESULTS: Standard laryngeal surgical procedures were completed successfully in a human cadaver model. The built-in HD digital camera enabled high-quality visualization of the larynx. Epiglottectomy, as well as posterior cordectomy, were performed by laser and radio-frequency resection. The flexible design of the compatible tools enabled a nontraumatic approach. CONCLUSION: The Flex System has the potential to improve surgical access to the larynx, especially in patients with challenging anatomy. The associated flexible instruments enabled completion of surgical procedures in the larynx in a human cadaveric model. Further clinical studies, as well as the development of supplemental technology and tools, are recommended for future clinical applications.

Nasolacrimal duct stenosis-Surgery with a novel robotic endoscope positioning system.

BACKGROUND: Distal nasolacrimal duct stenosis is usually treated by head and neck surgeons with transnasal endoscopic dacryocystorhinostomy (DCR). The presented clinical study discusses advantages and drawbacks of a robot-assisted endoscope positioning system, which allows for hands-free visualization of the surgical field. MATERIAL AND METHODS: Two patients were treated by surgical DCR. The endoscopic positioning system (Medineering® ) features a mechatronic holding arm with four segments and seven degrees of freedom. It is driven by using a foot pedal. RESULTS: Visualization and instrumentation of the surgical field including the relevant anatomical landmarks were feasible. The endoscope position could be controlled with sufficient precision. The surgeon was able to maintain bimanual instrumentation. CONCLUSION: The endoscope positioning system allows for two-handed surgery, which facilitates the essential steps of the surgical procedure. If the benefit of the system is sufficient for the use in clinical routine, it has to be evaluated in repeated applications.

Setup and initial testing of an endoscope manipulator system for assistance in transoral endoscopic surgery.

Purpose For the treatment of malignant diseases of the oral cavity and the larynx, a total or partial resection is the standard therapy, while in special cases chemo- and/or external radiation therapy is considered. Transoral access reduces trauma and hospitalization time. Transoral surgery is usually executed using external microscopic imaging. Therefore, the microscope is placed in the visual line of the opening of the mouth and throat. However, specific anatomical structures like the posterior commissure (dorsal end of the vocal cords) are not visible in these procedures. An endoscopic approach can improve this problem. We introduce a new prototype system for endoscopic assisted transoral surgery. Methods Based on clinical observation and discussions with professional users and surgeons, the clinical need was identified and specified. A general concept or an endoscopic manipulator to assist microlaryngeal surgery was designed. For that a steerable rigid endoscope was combined with an actuator that allows translational and rotational movement. A quick release fastener was designed allowing for fast change of the endoscope and independence from its shape and type. The actuator was fixed on a commercially available, semi-active medical holding arm for easy positioning. The holder can be fixed to the standard rails of the surgical table. The piezoelectric drives integrated in the actuator are activated with a foot pedal. This allows easy and fast fine positioning, while the hands are free to perform the surgery with standard instruments for microlaryngeal surgery. Results A prototype of the system for endoscopic assisted transoral surgery was developed. The entire technical setup was tested in terms of usability and performance in a simulated surgical scenario. A basic phantom, representing the throat and vocal cords was created and placed on a surgical table. The system was installed on the table and the clinical workflow of a simulated endoscopic assisted surgery on the vocal cords was performed. The performance of the setup and the procedure success was evaluated by clinical users. Conclusion Fixture of the system on the surgical table is fast and easy due to its low weight and compact design. The medical holder allows a fast initial positioning of the system in front of the phantom patient. An easy insertion and removal of the endoscope was realized using the quick release fastener. The developed endoscope fixation is universally adaptable and not limited to a single type of endoscope. The piezoelectric drives, combined with the foot pedal, allow a precise placement and readjustment of the endoscope during surgery. The use of a multi view endoscope enables a variable view on the surgical situs. The size and shape of the whole setup offer excellent access to the targeted structures. The development was classified beneficial by the clinical users.

Features of haptic and tactile feedback in TORS-a comparison of available surgical systems.

Sustained interest and an increase of possible indications endorse the role of robot-assisted surgery of the head and neck region. However, broad clinical application is impeded by substantial extra cost, time exposure and a supposed deficit of haptic and tactile feedback. The role of haptic feedback has barely been examined in this context, and literature provides only limited objective validation. This point of criticism applies to all commercially available systems. We created an experimental setup to evaluate, quantify and compare the performance of surgical systems. The daVinci system (Intuitive Surgical), the Flex system (Medrobotics) and standard rigid instruments (23 cm laryngoscopic grasper, Karl Storz) were compared with the human hand by head and neck surgeons (n = 15), performing a variety of surgical tasks. Specific samples with different rigidity were sorted with all devices, and the resulting orders were analyzed by permutation analysis, indicating differences in precision and accuracy of haptic and tactile feedback. The human hand was superior in all trials, acting as reference modality. The flexible instruments of the Flex system performed better than the electro-mechanically decoupled instruments of the daVinci system for the majority of measures recorded, suggesting a benefit in terms of haptic and tactile feedback in this context. While not all aspects of haptic and tactile feedback were accessible, this first objective comparison endorses the inferiority of robot-assisted surgery in terms of haptic and tactile feedback, compared to the human sense or standard surgical tools. Furthermore, the immediate force transmission of the Flex system seems to be superior to the electro-mechanical transformation of the daVinci system, indicating an advantage in terms of haptic and tactile feedback in immediate comparison. This study is providing a basis for further experiments and the development of robotic surgery towards an implementation in clinical routine.

Recent advances in robot-assisted head and neck surgery.

OBJECTIVE: This article reviews current clinical applications and experimental developments for robotic surgery in the head and neck with special focus on financial challenges, current clinical trials, and the controversial aspect of haptic and tactile feedback. DATA SOURCES: Literature was screened using the pubmed library. Information on clinical trials was excerpted from the National Institute of Health database. Additional data on experimental developments were gathered by personal communication. RESULTS: A steep increase in clinical applications for robotic surgery in the head and neck is determined as possible indications extend. Clinical trials are mostly non-randomized. A wide range of new robotic systems are expected to come into clinical use in the near future. CONCLUSION: As head and neck surgeons become more familiar with robotic surgery some patients evidently benefit from new technologies. Increased competition between the systems will certainly drive technological improvement and decrease the financial burden. Copyright © 2016 John Wiley & Sons, Ltd.

Hybrid procedure for total laryngectomy with a flexible robot-assisted surgical system.

INTRODUCTION: Total laryngectomy is a standard procedure in head-and-neck surgery for the treatment of cancer patients. Recent clinical experiences have indicated a clinical benefit for patients undergoing transoral robot-assisted total laryngectomy (TORS-TL) with commercially available systems. Here, a new hybrid procedure for total laryngectomy is presented. METHODS: TORS-TL was performed in human cadavers (n = 3) using a transoral-transcervical hybrid procedure. The transoral approach was performed with a robotic flexible robot-assisted surgical system (Flex®) and compatible flexible instruments. Transoral access and visualization of anatomical landmarks were studied in detail. RESULTS: Total laryngectomy is feasible with a combined transoral-transcervical approach using the flexible robot-assisted surgical system. Transoral visualization of all anatomical structures is sufficient. The flexible design of the robot is advantageous for transoral surgery of the laryngeal structures. CONCLUSION: Transoral robot assisted surgery has the potential to reduce morbidity, hospital time and fistula rates in a selected group of patients. Initial clinical studies and further development of supplemental tools are in progress. Copyright © 2016 John Wiley & Sons, Ltd.

First use of a computer-assisted operator-controlled flexible endoscope for transoral surgery.

Transoral robotic surgery (TORS) has become an accepted treatment option for head and neck cancer. However, anatomical limitations and a relevant financial burden require alternative developments in this field. To this end, a patient presenting with a T2 squamous cell carcinoma of the lower lateral oropharyngeal wall was effectively treated with a new Conformité Européene-certified, computer-assisted, operator-controlled flexible endoscope (Flex). Intraoperative visualization and tissue handling were acceptable and safe. Transoral surgery with the flexible endoscope was safely conducted in a clinical setting. The introduction of alternative TORS systems will increase competition, drive scientific improvement, and reduce financial expenses.