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  1. 1. TRANS ORAL ROBOTIC SURGERY Prof. S. Subbiah et al
  2. 2. 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. Prof. S. Subbiah et al
  3. 3. PUMA ARM Prof. S. Subbiah et al
  4. 4. 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. Prof. S. Subbiah et al
  6. 6. 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 Prof. S. Subbiah et al
  7. 7. Prof. S. Subbiah et al
  8. 8. 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). Prof. S. Subbiah et al
  9. 9. 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). Prof. S. Subbiah et al
  10. 10. 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). Prof. S. Subbiah et al
  11. 11. Feyh-Kastenbauer retractor Prof. S. Subbiah et al
  12. 12. laryngeal advanced retractor system Prof. S. Subbiah et al
  13. 13. Crowe-Davis retractor Prof. S. Subbiah et al
  14. 14. 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. Prof. S. Subbiah et al
  15. 15. APPLICATIONS • Lesions of the Palate • Palatine tonsils • Base of the tongue, • Posterior and lateral pharyngeal wall • Parapharyngeal space • Larynx and hypopharynx • Thyroid Prof. S. Subbiah et al
  16. 16. Oncological indications • TORS Tonsillectomy, • Tongue base resection,and • Supraglottic laryngectomy are the three most common robotic applications in the head and neck malignancy. Prof. S. Subbiah et al
  17. 17. PROCEDURE Prof. S. Subbiah et al
  18. 18. 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. Prof. S. Subbiah et al
  19. 19. 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. Prof. S. Subbiah et al
  20. 20. ROBOTIC MARYLAND Prof. S. Subbiah et al
  21. 21. 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. Prof. S. Subbiah et al
  22. 22. • The average set-up time after preliminary experience for TORS is about 30 minutes or less. Prof. S. Subbiah et al
  23. 23. Prof. S. Subbiah et al
  24. 24. Prof. S. Subbiah et al
  25. 25. 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 Prof. S. Subbiah et al
  26. 26. 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 Prof. S. Subbiah et al
  27. 27. • STEP 4 : Vallecular dissection • STEP 5 : Specimen orientation and frozen for margins • STEP 6 :Hemostasis. Prof. S. Subbiah et al
  28. 28. TONSILLAR AREA • Studies have shown that surgery is highly effective in treating tonsillar cancer and provides accurate staging information for adjuvant therapy. Prof. S. Subbiah et al
  29. 29. • Weinstein et al. described TORS for radical tonsillectomy in 27 patients with invasive squamous cell carcinoma of the tonsil. Prof. S. Subbiah et al
  30. 30. • 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. Prof. S. Subbiah et al
  31. 31. 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. Prof. S. Subbiah et al
  32. 32. 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. Prof. S. Subbiah et al
  33. 33. Prof. S. Subbiah et al
  34. 34. 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. Prof. S. Subbiah et al
  35. 35. 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. Prof. S. Subbiah et al
  36. 36. Prof. S. Subbiah et al
  37. 37. OTHERS • Infratemporal fossa Resection • Robotic-assisted microvascular anastomosis • First two cases of TORS-assisted free flap (radial forearm) reconstruction carried out successfully . Prof. S. Subbiah et al
  38. 38. 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. Prof. S. Subbiah et al
  39. 39. SHIFT OF PARADIGM Prof. S. Subbiah et al
  40. 40. • 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. Prof. S. Subbiah et al
  41. 41. 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. Prof. S. Subbiah et al
  42. 42. 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 . Prof. S. Subbiah et al
  43. 43. • 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. Prof. S. Subbiah et al
  44. 44. • 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. Prof. S. Subbiah et al
  45. 45. • 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. Prof. S. Subbiah et al
  46. 46. Prof. S. Subbiah et al
  47. 47. 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. Prof. S. Subbiah et al
  48. 48. 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. Prof. S. Subbiah et al
  49. 49. 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. Prof. S. Subbiah et al
  50. 50. COMPLICATIONS • Hemorrhage • Hematoma • Wound infection • Nerve palsy • Aspiration related infection • Rarely fistula. • complication rates are much less compared to open surgery or radiation therapy. Prof. S. Subbiah et al
  51. 51. Debatable • For comparing TORS with chemoradiation in terms of overall survival and disease free interval we need more RCT and worldwide adoption of TORS Prof. S. Subbiah et al
  52. 52. RECENT There are two techniques that are likely to improve margin control in TORS, Intelligent Knife technology. Narrow band imaging Intra-Operative Fluorescence Imaging. Prof. S. Subbiah et al
  53. 53. THANK YOU Prof. S. Subbiah et al