1.
TRANS ORAL ROBOTIC
SURGERY
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HISTORY
• In 1985 - stereotactic brain biopsy was taken
by PUMA SYSTEM.( Programmable universal
manipulation arm )
• In 1995 -Da vinci surgical system was
developed.
• In 2000 -FDA gave approval for first robotic
surgeries.
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PUMA ARM
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First otolaryngology application in
robotics kick started in 2002 -endoscopic neck
procedures
First application in humans was described
by mcloed in 2005 - documented excision of
vallecular cyst .
In 2009 FDA approved Da vinci surgical
system for TORS for lesions in pharnyx and
larynx.
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TORS
• DA VINCI ROBOTIC SYSTEM
• FLEX ROBOTICSYSTEM (MEDROBOTICS)
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DA VINCI (TORS)
The Da Vinci Surgical System consists of three components:
a surgeon’s console,
a patient-side robotic cart equipped with four arms,
a high-definition three-dimensional vision cart.
Typically, three robot arms are introduced into the oral
cavity:
an endoscope,
tissue forceps and a cutting tool,
usually a carbon dioxide laser or an electrocautery
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One to handle a 12-mm stereoscopic
endoscope at an angle of 0° or 30.
• The other two equipped with 5-mm endo
wrist (5 mm Maryland dissector and 5 mm
monopolar spatula).
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FLEX ROBOTIC SYSTEM
• The Flex robotic system from MedRobotics was FDA
approved for transoral use in July of 2015.
• This robotic system is unique as it is a flexible snake
like device that can be manipulated easily in oral
cavity compared to daVinci robot (rigid arms).
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EXPOSURE
• Transoral exposure of the tumor was
achieved using the
• Feyh-Kastenbauer retractor (Gyrus,
Tuttlingen, Germany)
• Crowe-Davis retractor,
• laryngeal advanced retractor system (Fentex,
Tuttlingen Germany).
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Feyh-Kastenbauer retractor
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laryngeal advanced retractor
system
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Crowe-Davis retractor
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STEPS OF DOCKING
• Position the patient and Operating table, including
table tilt.
• Position patient cart over patient.
• Set patient cart brakes.
• Docking the camera arm.
• Docking the instrument arms.
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APPLICATIONS
• Lesions of the Palate
• Palatine tonsils
• Base of the tongue,
• Posterior and lateral pharyngeal wall
• Parapharyngeal space
• Larynx and hypopharynx
• Thyroid
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Oncological indications
• TORS Tonsillectomy,
• Tongue base resection,and
• Supraglottic laryngectomy are the three most
common robotic applications in the head and neck
malignancy.
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PROCEDURE
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Patient positioning and preparation
• Universally the surgeons cart placed on the right
side patient ,and patient in supine position.
• Intubation may be done transorally or
transnasally.
Transnasal intubation is often advantageous in
Base of tongue tumours, whereas transoral intubation is
acceptable in tonsillar dissection
•. Secure the endotracheal tube with tape or a
suture.
• Place eye protection with durable eye shields.
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DOCKING
• Once adequate suspension and tumour
visualisation are achieved, the robot is docked
transorally.
• 0-degree cameras are generally best for tonsil
tumours and 30-degree for BOT.
• The Maryland dissector and monopolar cautery are
commonly used robotic instruments.
• The monopolar cautery is typically positioned
ipsilateral to the tumour.
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ROBOTIC MARYLAND
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ROLE OF ASSISTANT
• Should be positioned in a way to see the display on
the vision cart properly.
• Has an essential role to suctioning the smoke,
providing clear field by clearing blood and provide
tension/ counter tension and exposure.
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• The average set-up time after preliminary
experience for TORS is about 30 minutes or less.
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TONGUE BASE
• Early lesion involving base of tongue (T1/T2)
• Transoral robotic base of tongue resection has been
found to be useful in a diagnostic capacity in the
setting of unknown primary head and neck
malignancy.
• The angled scopes improves visualization and helps
the surgeon to navigate around corners, as is often
needed in tongue base surgery
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TONGUE BASE
STEP 1 : Anterior mucosal incision - jus behind the
retractor , not more than 1 cm depth
STEP 2 : Medial incision -Anterior to posterior till the
vallecula is reached.
STEP 3 : Lateral incision -proceed from lateral to
medial .Continue the mucosal incision across the
glossotonsillar sulcus then along the lateral
pharyngeal wall up to the vallecula
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• STEP 4 : Vallecular dissection
• STEP 5 : Specimen orientation and frozen for
margins
• STEP 6 :Hemostasis.
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TONSILLAR AREA
• Studies have shown that surgery is highly effective
in treating tonsillar cancer and provides accurate
staging information for adjuvant therapy.
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• Weinstein et al. described TORS for radical
tonsillectomy in 27 patients with invasive
squamous cell carcinoma of the tonsil.
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• Unresectable neck nodes
• Mandibular invasion,
• Involvement of >50% of the tongue base,
• Involvement of >50% of the posterior pharyngeal
wall,
• Carotid artery involvement.
• Fixation to prevertebral fascia.
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TORS SUPRAGLOTTIC
LARYNGECTOMY
1) Patients with adequate transoral exposure of
the surgical field;
2) T1 or T2 supraglottic carcinoma;
3) Selected T3 supraglottic carcinoma with mobile
vocal cords (with or without preepiglottic space
invasion); and
4) tumors with minimal pyriform sinus involvement.
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CONTRAINDICATIONS
• 1) Limited transoral exposure (ie, trismus, macroglossia,
micrognathia, or retrognathia);
• 2) Poor pulmonary reserve (FEV1/FVC <50%);
• 3) Tumor involvement of the thyroid cartilage or
anterior commissure;
• 4) Vocal cord fixation or paraglottic space invasion;
• 5) Bilateral arytenoid cartilage involvement;
• 6) Tumor extension into pyriform apex or postcricoid
mucosa.
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TORT ( TRANS ORAL ROBOTIC
THYROIDECTOMY)
• In 2009, Benhidjeb et al. reported the first series of
transoral thyroidectomy.
• The central camera was passed through a
sublingual incision.
• The two lateral working arms passed through
vestibular incisions anterior to the mandible.
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TOR/ETVA
In 2011, Richmon et al. modified this approach to
avoid the floor of mouth route.
All three ports were placed through the
vestibule anterior to the mandible to access the
subplatysmal space and the floor of mouth was not
violated.
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OTHERS
• Infratemporal fossa Resection
• Robotic-assisted microvascular anastomosis
• First two cases of TORS-assisted free flap (radial
forearm) reconstruction carried out successfully .
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NECK
• Positive neck nodes
• Patients with high risk (≥20%) for occult nodal
involvement.
• Neck dissections (uni- or bilateral) can be
performed immediately before or after the TORS
procedure or as a second-stage procedure.
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SHIFT OF PARADIGM
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• Cracchiolo et al discovered a steep rise of patients
with low T-status (T1–T2) OPSCC who underwent
primary surgical treatment.
• Total cases 3071
• TORS 846 (27.6%)
• In 2010 137 patients were treated with TORS,
• In 2013 280 patients were treated with TORS.
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ABSOLUTE CONTRAINDICATION
• Reduced mouth opening.
• Incomplete lesion visualisation.
• Mandible involvement.
• Tumours involving >50% of the base of the tongue.
• Internal carotid artery, or prevertebral fascia
involvement.
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BENEFITS
• Primary TORS- possible alternative to non-surgical
organ preservation regimen
• Up-front TORS - deintensification of adjuvant
therapy.
• Patients who would have received definitive RT as a
single modality treatment could avoid it with
primary TORS and possible complications of
radiation therapy .
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• swallowing outcomes
• More et al. compared functional
swallowing out-comes after TORS with outcomes
after primary chemoradiation therapy tonsillar
cancer. They found significantly better scores of the
MD Anderson Dysphagia Inventory (MDADI) at 6
and 12 months postoperatively for those patients
who underwent TORS.
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• 10x magnification results in improved
visualisation and the ability to resect lesions
en bloc in the oropharynx.
• Biology of disease and exact pathological
report can be obtained.
• TORS may avoid disfiguring surgeries.
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• Recent studies found out that surgical
staging alters clinical staging in 40% after
TORS
• The robotic arms also filter tremors,
allowing precision with microscopic
movements.
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ONCOLOGICAL OUTCOMES
Meta analysis.
Compared primary TORS with Open surgery.
TORS showed lower mortality rate , recurrence rate
and positive margin rates compared with open surgery.
But no significant statistical difference between two
groups.
Disease-free survival rate was significantly higher in
the TORS group than open surgery group.
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FUNCTIONAL OUTCOMES
• Park et al. evaluated prospectively the functional
outcomes of patients treated with TORS in comparison
with patients treated conventionally with transoral
approach or mandibulotomy during the same period of
the study.
• There was a significant difference in swallowing, time to
decannulation, and hospitalization period between the
two groups.
• In the TORS group, patients completely recovered the
ability to swallow after 6 days. In contrast, patients
undergoing conventional surgery did not completely
recover their swallowing until 12 days.
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DISADVANTAGES
• Ruptures during TORS are not unusual due to
manipulation by the Maryland forceps and could be
misinterpreted by the pathologist as being a
compromised margin.
• Cost effectiveness.
• Long learning curve.
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COMPLICATIONS
• Hemorrhage
• Hematoma
• Wound infection
• Nerve palsy
• Aspiration related infection
• Rarely fistula.
• complication rates are much less compared to
open surgery or radiation therapy.
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Debatable
• For comparing TORS with chemoradiation in terms of
overall survival and disease free interval we need more
RCT and worldwide adoption of TORS
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RECENT
There are two techniques that are likely to improve
margin control in TORS,
Intelligent Knife technology.
Narrow band imaging
Intra-Operative Fluorescence Imaging.
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53.
THANK YOU
Prof. S. Subbiah et al