TECHNICAL STRATEGY
Transoral Robotic Supraglottic Partial Laryngectomy Fatma Tu¨lin Kayhan, MD, Kamil Hakan Kaya, MD, Ahmet Altintas, MD, and Ibrahim Sayin, MD Objective: Transoral robotic supraglottic laryngectomy is a new surgical way to perform endolaryngeal resection of supraglottic laryngeal carcinoma. The aim of this report was to present our initial experience about transoral robotic supraglottic laryngectomy for early supraglottic cancer. Methods: Subjects with early squamous cell carcinoma (T1YT2) of supraglottic region who managed using transoral robotic surgery in a tertiary referral center were included in the study. The technique of robot-assisted resection, intraoperative blood loss, mean robotic operating time, pathologic margin status, postoperative extubation, need for a tracheotomy, and length of hospitalization, complications, duration of oral nutrition, and neck dissection and radiotherapy needs were evaluated. Results: Thirteen subjects (12 men, 1 woman) with T1YT2 supraglottic carcinoma were successfully operated on with transoral robotic surgery. In all subjects, negative margins were obtained. The mean total robotic surgery time was 31.6 (SD, 16.2) minutes (range, 20Y80 minutes). Mean total blood loss was less than 40 mL. Subjects started oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4Y30 days) postoperatively. The mean hospitalization was 15.4 (SD, 10.4) days (range, 7Y42 days). Conclusions and Relevance: Transoral robotic supraglottic laryngectomy with the da Vinci robotic system can be regarded as a feasible, safe, and effective technique. Although short-term results seem discouraging, long-term results are needed to evaluate the oncologic safety. Key Words: Supraglottic cancer, early, robotic surgery, da Vinci Surgical System
tracheotomy, early swallowing function, and decreased hospital stay. Besides, when completed successfully with negative surgical margins, oncologic results are comparable with open surgery.1,2 The initial technique to perform endolaryngeal surgery is transoral laser surgery, which uses rigid laryngoscopes and devices.3 This will be sometimes technically demanding because of the limited area and limited visualization and manipulation in supraglottic region. When a handpiece for laser fiber did not exist, the surgeon has to use one hand for micromanipulator and the other for tissue grasping. Even if a handpiece exists; the rigidity of the devices did not let an additional instrument. Although not proven, oncologic safety is argued by some practitioners because the technique will need the piecemeal resection of the tissue, which is opposite to en bloc resection philosophy.4 Supraglottic carcinoma (T1, T2, T3) can be treated by surgery or radiotherapy (RT). Supraglottic partial laryngectomy with open surgery has high local control rates, which is 90% for T1 and T2 carcinomas and 70% to 90% for T3 carcinomas. The other favored method, transoral laser supraglottic laryngectomy, has comparable local control rates, which is 80% to 90% for T1, 80% to 93% for T2, and 67% to 83% for T3 supraglottic carcinomas.1 The transoral approach with robotic surgery (TORS) was introduced in 2005. In January 2010, the Food and Drug Administration approved TORS for use in benign and malignant disease of the tonsils, pharynx, and larynx. To date, various endolaryngeal procedures including supraglottic partial laryngectomy, radical tonsillectomy, tongue base resection, and vocal cord surgery have been performed successfully with the TORS approach.5 Previous reports also proved the safety and efficacy of the procedure.6Y10 This study presents early supraglottic laryngeal SCC subjects treated with transoral robotic supraglottic laryngectomy with the da Vinci robotic surgical system.
(J Craniofac Surg 2014;25: 1422Y1426)
MATERIALS AND METHODS
T
he ideal approach to supraglottic carcinoma of the larynx (SGL) is to preserve the larynx, and it functions with negative surgical margins.1 Endolaryngeal surgery for supraglottic laryngeal squamous cell carcinoma (SCC) has advantages over the open surgical techniques with decreasing the operative morbidity, the need of
From the Department of Otolaryngology Head and Neck Surgery, Bakirko¨y Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey. Received September 3, 2013. Accepted for publication November 14, 2013. Address correspondence and reprint requests to Ibrahim Sayin, MD, Department of Otolaryngology Head and Neck Surgery, Bakirko¨y Dr. Sadi Konuk Education And Research Hospital, Tevfik Sa?lam Caddesi, No. 11. 34147, Bakirko¨y, Istanbul, Turkey; E-mail: [email protected] I.S. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000572
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From January 2010 to January 2013, subjects who underwent transoral robotic supraglottic laryngectomy were included in the study. The study was approved by the local ethics board. Subjects who were diagnosed with T1 and T2 supraglottic carcinoma were visited. Subjects who were at T3 stage or more were not operated on during the study period with TORS. Therapeutic alternatives including RT, transoral laser microsurgery (TLM), TORS, and open surgery were offered to subjects. Subjects who accepted TORS were operated on. The age, sex, pathologic diagnosis, smoking habit, operation time, anesthesia time, the robotic setup time, robotic surgery time, estimated blood loss, surgical margin status, the need of tracheotomy, prolonged intubation time, oral feeding time, additional therapies, follow-up period, and early and late complications were recorded. Preoperatively, subjects were evaluated for conditions that will complicate the placement of the F-K retractor such as rigid short neck, retrusive mandible, prominent teeth, peripheral soft tissue, and so on. All surgeries were performed under general anesthesia. Transnasal intubation, with a laser-resistant tube (no. 5.5Y6), was done in all subjects. The subjects underwent reverse Trendelenburg position,
The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
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The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
and the eyes were protected. The da Vinci robotic system setup was completed, and the subject card was docked as described previously.5 An F-K retractor (Gyrus Medical, Maple Grove MN) was used to expose vallecula and epiglottis. The 8-mm 0-degree da Vinci three-dimensional robotic camera was introduced into the oral cavity, and the operation field was visualized. Than 2 lateral arms were replaced. For the TORS-supraglottic laryngectomy, 5-mm EndoWrists monopolar cautery was placed on the first arm, and a Maryland dissector or a 5-mm EndoWrists Schertel grasper was placed on the second arm. The surgery was performed with the robotic supraglottic laryngectomy technique, which was previously described by Weinstein et al.6 In first step, the epiglottis was caught with the Schertel grasper. It is divided into 2 pieces with monopolar cautery until the level of petioles. In the second step, the mucosa of vallecula was transected, and the pre-epiglottic tissue was dissected to the level of the hyoid bone. In the third step, the thyroid cartilage was identified at the superior aspect, and dissection was made downward from the inner perichondrium of the cartilage. In the fourth step, the superior laryngeal artery and vein were identified in the pharyngoepiglottic fold. These arteries and veins were clipped with at least 4 hemoclips. Then, the artery and vein were transected and coagulated with monopolar cautery. In the fifth step, dissection was made in the paraglottic region to the level of the anterior commissure on both sides. In the last step, the supraglottic laryngeal mucosa was cut over the vocal cords, and en bloc resection was completed (Figs. 1AYD). This surgery was a type 3b excision according to endoscopic supraglottic laryngectomy dissection classification of the European Laryngological Society.11 Control biopsies were taken from vocal cords, pre-epiglottic and paraglottic areas, and arytenoid mucosa and other resection borders. The further hemostasis was made with monopolar cautery. If there was bleeding from a major vessel, the bleeding was stopped with hemoclips. At the end of the operation, a nasogastric tube was replaced. After the operation, the patients were kept intubated for 24 o 36 hours. The patients were extubated in the intensive care unit, and after a
FIGURE 1. A, Preoperative view of the supraglottic lesion: The lesion is limited in supraglottic region and did not extend to the glottic region and did not affect the vocal cord mobility. B, The lesion was excised from the pre-epiglottic region: epiglottis was caught with Schertel grasper, and the excision was made with cautery. The console surgeon aspirates the area and stopped bleeding with hemoclips. C, The appearance of the larynx after completion of the procedure: After this stage, surgical margins were controlled, and control biopsies were taken. D, The appearance of larynx immediately after surgery: Both vocal cords are mobile, and there is no sign of residual tumor.
Transoral robotic supraglottic partial laryngectomy
4-hour follow-up, patients were taken to service. They kept antibiotics for 1 week after surgery. The subjects’ nasogastric tubes were removed at the time the oral feeding started. The patients underwent bilateral functional neck dissection 2 to 3 weeks after the operation. The subjects who have positive neck nodes underwent RT. The subjects were followed up weekly in the first month, monthly in the remaining first year, and bimonthly in the following year. During surgery, dissection of the tissue and coagulation were performed with monopolar cautery. The grasping and dissection were performed with the Schertel grasper or Maryland dissector. The suction was performed by an assistant surgeon on the subject card during the surgery. At the end of the operation, biopsies were taken from all surgical margins. All reported data were expressed as mean (SD).
RESULTS Thirteen subjects were evaluated. Twelve (92.3%) of 13 subjects were male, whereas the remaining 1 subject (7.7%) was female. The subjects’ ages ranged from 45 to 68 years with an average of 60 (SD, 6.7) years. Twelve (92.3%) of 13 subjects had a history of smoking with an average of 50.46 (SD, 34.30) pack-years. The mean follow-up was 14.5 (SD, 10.3) months (range, 2Y31 months). The subjects’ data are summarized in Table 1. In all subjects, the exposure of the laryngeal region with the F-K retractor was adequate. In all subjects, the surgeon can complete the procedure. In all subjects, 2 pieces of supraglottic laryngectomy specimen were removed en bloc. The mean anesthetic time is 85.3 (SD, 33.4) minutes (range, 60Y165 minutes). The mean setup and exposure time was 35.7 (SD, 16.3) minutes (range, 20Y65 minutes). Mean robotic surgical time was 31.6 (SD, 16.2) minutes (range, 20Y80 minutes). In all cases, the estimated total blood loss was less than 40 mL. In all cases, negative margins were obtained. The operative and postoperative data are summarized in Tables 2 and 3. No tracheotomy was required for surgery. During the follow-up, 3 subjects needed tracheotomy. Two subjects needed tracheotomy when they were receiving RT. Two subjects experienced pneumonia, and 1 subject developed a laryngeal stenosis. Subjects with laryngeal stenosis underwent an additional procedure; the tracheotomy was done, and the stenosis was reoperated with transoral laser surgery. The subjects’ oral feeding started at the time of nasogastric tube removal. They were started on oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4Y30 days) postoperatively. The mean hospitalization period was 15.4 (SD, 10.4) days (range, 7Y42 days). The postoperative data are summarized in Table 3. We treated all subjects’ neck with a neck dissection 2 to 3 weeks after surgery even if they were clinically N0. In the final pathologic evaluation, 4 neck dissection specimens showed lymph node metastasis. One subject developed distant pulmonary metastasis. These subjects received further RT and/or chemotherapy protocols (Table 4). No local or regional recurrence was observed during the follow-up period. Preoperative, intraoperative, and postoperative views of some subjects are shown in Figures 1AY1D.
DISCUSSION In all subjects, who had a diagnosis of supraglottic laryngeal carcinoma and agreed to operate, the surgery can be successfully performed. There were no oropharyngeal and neck anatomical problems that will complicate the TORS. We commonly performed Type 3b resection according to the endoscopic supraglottic laryngectomy dissection classification of European Laryngological Society.11 In type 3 resection, a medial supraglottic laryngectomy with resection
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Subject Data Subject
Age, y
Sex
Diagnosis
68 61 64 61 51 66 45 60 56 64 55 65 60
M M M M M M F M M M M M M
SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC
1 2 3 4 5 6 7 8 9 10 11 12 13
T Classification T1 T1 T1 T1 T1 T1 T1 T1 T1 T1 T1 T1 T1
N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0
M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0
Smoker, Pack-Years
Follow-up, mo
20 80 60 60 None 150 30 60 35 40 32 45 44
31 29 25 25 18 16 13 10 8 4 4 4 2
laryngoscope is restricted, and surgical instruments are rigid and limited. Learning curve also exists for endolaryngeal surgery. The robotic da Vinci Surgical System is a new way to perform endolaryngeal surgery. Series of cases undergoing cordectomy, radical tonsillectomy, tongue base resection, and partial pharyngectomy with TORS have been reported.5 In addition, robotic microlaryngeal surgery for supraglottic carcinoma has been reported recently. Early results are encouraging, although long-term results are needed to establish its efficacy.6Y10 In general, the advantages of the system include an improved three-dimensional magnified (40 magnification) visualization, the 540-degree motion capacity of the robotic arms, and simultaneous resection and coagulation functions. The system also filters tremors both in the use of the instruments and the view. These advantages enable a more precise surgery in terms of better assessment of surgical margins and better protection of anatomical structures. Postoperative pain will decrease, the healing process is more rapid, and the return of the patients to their normal diet is shorter than with other methods. In TORS SGL, preservation of suprahyoid and infrahyoid muscles and preservation of superior laryngeal nerve resulted in early return of swallowing function. A shorter recovery period, shorter return to normal diet, and shorter hospital stay are other significant advantages. The da Vinci system also allows the surgeon to perform surgery in a more comfortable position.5 Robotic surgery for SGL carcinoma has been reported recently. In the first report, Weinstein et al6 operated on 3 subjects with SGL carcinoma. The report mainly focused on the feasibility of the procedure,
of the pre-epiglottic space was done. This excision also extended to the ventricular fold. In any oncologic surgery, the surgical margin negativity is an important issue. Positive surgical margin is related with high local recurrence, distant metastasis, and decreased survival rate.1 In our cases, all surgical margins were controlled with biopsies, and the surgical margins were all negative at the end of the operation. In TORS-SL, a tracheotomy can be avoided. For early postoperative respiration problems, a prolonged intubation was done for all subjects. In our cases, the duration of prolonged intubation varied from 24 to 36 hours. Transoral approach with robotic surgery SGL intubation prolonged to 48 hours as reported previously. This time is only for caution and will decrease with enough experience. Among our subjects, no reintubation was needed, and none of the subjects received steroids when they were extubated. None of our subjects needed tracheotomy in the preoperative period. Two subjects needed tracheotomy when they were receiving RT. One subject needed a temporary tracheotomy for laryngeal stenosis during follow-up. Grant et al3 reported that a temporary tracheostomy is needed in 32% of the subjects during the TLM. In treatment of SGL carcinoma, TLM is an alternative to RT and open surgery. Endolaryngeal surgery is preferable, because it has several advantages such as avoiding skin incision and avoiding tracheotomy. Overall, the surgery decreases postoperative morbidity. However, endolaryngeal surgery has some challenges that will complicate the manipulation of this area. The area of the tongue base and pharynx are limited; the view of the surgical area through the
TABLE 2. Operative Data of the Subjects
Subject 1 2 3 4 5 6 7 8 9 10 11 12 13
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Anesthetic Time, min
Setup and Exposure Time, min
Robotic Surgical Time, min
Surgical Margin Status
Estimated Blood Loss, mL
Perioperative Complication
125 165 120 110 75 65 65 65 60 65 70 60 65
65 65 55 45 35 30 20 25 20 30 25 25 25
40 80 40 35 30 20 27 22 20 20 30 22 25
Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative
G40 G40 G40 G40 G40 G40 G40 G40 G40 G40 G40 G40 G40
No No No NO No No No No No No No No No
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
Transoral robotic supraglottic partial laryngectomy
TABLE 3. Postoperative Data of the Subjects Subject
Prolonged Intubation Time, hrs
Tracheotomy
Nasogastric Tube Removal, d
Hospitalization Time, d
Postoperative Complication
24 24 36 36 24 24 24 24 24 24 24 24 24
No No Post-RT Post-RT No No No yes No No No No No
28 4 15 30 15 5 7 10 4 6 8 4 5
20 7 20 42 15 30 14 10 9 8 7 9 10
Pneumonia None Laryngeal stenosis Pneumonia None None None None None None None None None
1 2 3 4 5 6 7 8 9 10 11 12 13 d, days; hrs, hours.
and all 3 subjects were successfully operated on with robotic surgery without any complications. In this first report, the total time for robotic procedure was 120 minutes (range, 62Y178 minutes). Mean exposure and robotic positioning were reported as 18 minutes (range, 6Y39 minutes). In 2007, Solares and Strome7 reported 1 subject they had operated on. Although they attempted to perform the procedure in 3 subjects, only in 1 case did they achieve adequate exposure, and the remaining 2 cases could not be operated on. The subjects started oral feeding on the fifth postoperative day, and in the first month, control showed no residual tumor. In 2012, Alon et al8 reported 7 subjects (4 male and 3 female subjects with an average age of 61 years). They successfully completed all procedures with clear surgical margins. They had noted 1 intraoperative complication, which is thermal injury to the anterior cervical skin. In 4 subjects, a tracheostomy was needed, and 3 of these 4 subjects can be decannulated successfully. One subject needed long-term tracheotomy, and 2 subjects needed long-term gastrostomy tube replacement in this study. For treatment of neck in 6 subjects, they had performed the neck dissection at the time of robotic resection. Ozer et al9 also reported 13 subjects in the same year. They achieved negative surgical margins in all subjects. Average robotic operative time and blood loss were 25.3 minutes and 15.4 mL, respectively. Return to normal diet was within the first 24 hours in 11 subjects. Adjuvant RT was needed in 2 subjects. There is only 1 report that evaluated the swallowing and voice function on 16 subjects.10 Swallowing function was evaluated with
videopharyngogram and the functional outcome swallowing scale. Complete recovery of swallowing ability was observed at an average of 8.3 days after surgery. Aspiration occurred only in 1 subject. In this study, 91% of the subjects reported favorable swallowing and voice function. Mendehlson et al4 reported 18 subjects who underwent TORS-SL with at least 12 months follow-up. In all subjects, they achieved negative surgical margins. They treated the neck at the same time with TORS if clinically positive lymph node exists. If the neck is N0, they performed a sentinel lymph node biopsy. If the result of the biopsy was positive, the subjects underwent a selective neck dissection 2 to 3 weeks after surgery. Among these subjects, 3 recurrences (16.7%) from the neck were seen. Four subjects (22.2%) developed distant metastasis during follow-up. Our results are comparable with previous studies. Although the majority of the studies reported adequate access to surgical area, some conditions such as retrusive mandible, peripheral soft tissue, rigid short neck, and prominent teeth will result in inadequate access. These points should be properly evaluated preoperatively. In all subjects, we had achieved adequate exposure and could perform the procedure with negative surgical margins. The total operation time as well as setup/exposure/robotic surgical times varies among studies. The mean anesthetic time was 85, 3 (SD, 33.4) minutes (range, 60Y165 minutes). The mean setup and exposure time was 35.7 (SD, 16.3) minutes (range, 20Y65 minutes). Mean robotic surgical time was 31.6 (SD, 16.2) minutes (range,
TABLE 4. Pathologic Examination Results of the Supraglottic Tumor and Neck Dissection Specimen Subject 1 2 3 4 5 6 7 8 9 10 11 12 13
T Stage T2 T2 T1 T2 T1 T2 T1 T2 T2 T2 T1 T2 T2
pN
Stage
N3 N0 N0 N0 N0 N0 N0 N0 N2C N2C N0 N2C N0
Stage
Tumor Differentiation
Cartilage Invasion
Perineural Invasion
Lymphatic Invasion
Vascular Invasion
Postoperative CRT
IVC II I II I II I II IV IV I IV II
Grade 2 Grade 2 Grade 2 Grade 2 Grade 1 Grade 2 Grade 2 Grade 3 Grade 3 Grade 1 Grade 1 Grade 2 Grade 3
Negative Negative Negative Negative Negative Negative Negative Positive Negative Negative Negative Negative Negative
Negative Negative Negative Negative Negative Positive Negative Positive Negative Negative Negative Positive Negative
Positive Negative Negative Negative Negative Negative Negative No Positive Positive Negative Positive Negative
Positive Positive Negative Negative Negative Positive Negative No Positive No Negative Positive Negative
Yes Yes No No No No No No Yes Yes No Yes No
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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20Y80 minutes). These times were reduced with further learning of the procedure. Other reports also noted the importance of experience in decreasing the surgical time in TORS.12 In all cases, the estimated total blood loss was less than 40 mL. No major bleeding was observed. In any endolaryngeal surgery, bleeding is an important problem. In TORS, additional to hemostasis capacity of cautery and laser, hemoclips can be used under a magnified area, and a more effective hemostasis can be achieved. For postoperative complications, 2 subjects had pneumonia, and 1 subject developed a laryngeal stenosis during follow-up. The subjects’ oral feeding started at the time of nasogastric tube removal. They were started on oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4Y30 days) postoperatively. The mean hospitalization period was 15.4 (SD, 10.4) days (range, 7Y42 days). Because the procedure is relatively new, we prefer to observe our subjects a few days more in the hospital. With the establishment of the procedure, this time will shorten. Also, subjects who had pneumonia also had increased mean hospital stay. Because SGL of the larynx has a high occult metastasis potential, we treated all subjects’ neck with a neck dissection 2 to 3 weeks after surgery if they were clinically N0. Indications for chemoradiotherapy (CRT) were N2+ stage and extracapsular spread. Four subjects received CRT for advanced neck disease and one for distant metastasis. Our mean follow-up was 14.5 (SD, 10.3) months (range, 2Y31 months). No local or regional recurrence was observed during the follow-up period. We think our period is not long enough to make a decision for oncologic safety. The oncologic safety has to be assessed in other large series that also have longer follow-up periods. As mentioned during our follow-up, only 1 distant metastasis occurred. A doubt always arises for the additional expenditures of the robotic system. Robotic instruments and surgery is more expensive than other surgeries. We believe that cost-effectiveness is a multifactorial subject, and benefits in surgical teams’ comfort, the effect on overall morbidity, and its future potentials must be taken into consideration when evaluating this issue.
CONCLUSIONS We found that TORS SGL was feasible, safe, and effective. Transoral approach with robotic surgery provided better exposure, visualization, and access than standard endolaryngeal surgery. Subjects return to normal diet earlier, and reduced morbidity was an advantage
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of this operation. For oncologic safety, additional series with long follow-up is needed.
ACKNOWLEDGMENT Ibrahim Sayin, MD, had full access to all of the data in the study had takes responsibility for the integrity of the data and the accuracy of the data analysis.
REFERENCES 1. Rodrigo JP, Sua´rez C, Silver CE, et al. Transoral laser surgery for supraglottic cancer [review]. Head Neck 2008;30:658Y666 2. Silver CE, Beitler JJ, Shaha AR, et al. Current trends in initial management of laryngeal cancer: the declining use of open surgery. Eur Arch Otorhinolaryngol 2009;266:1333Y1352 3. Grant DG, Salassa JR, Hinni ML, et al. Transoral laser microsurgery for carcinoma of the supraglottic larynx. Otolaryngol Head Neck Surg 2007;136:900Y906 4. Mendehlson AH, Remacle M, van der Vorst S, et al. Outcomes following transoral robotic surgery: supraglottic laryngectomy. Laryngoscope 2013;123:208Y214 5. Kayhan FT, Kaya KH, Sayin I. Transoral robotic cordectomy for early glottic carcinoma. Ann Otol Rhinol Laryngol 2012;121:497Y502 6. Weinstein GS, O’Malley BW Jr, Snyder W, et al. Transoral robotic surgery: supraglottic partial laryngectomy. Ann Otol Rhinol Laryngol 2007;116:19Y23 7. Solares CA, Strome M. Transoral robot-assisted CO2 laser supraglottic laryngectomy: experimental and clinical data. Laryngoscope 2007;117:817Y820 8. Alon EE, Kasperbauer JL, Olsen KD, et al. Feasibility of transoral robotic-assisted supraglottic laryngectomy. Head Neck 2012;34:225Y229 9. Ozer E, Alvarez B, Kakarala K, et al. Clinical outcomes of transoral robotic supraglottic laryngectomy. Head Neck 2013;35:1158Y1161 10. Park YM, Kim WS, Byeon HK, et al. Surgical techniques and treatment outcomes of transoral robotic supraglottic partial laryngectomy. Laryngoscope 2013;123:670Y677 11. Remacle M, Hantzakos A, Eckel H, et al. Endoscopic supraglottic laryngectomy: a proposal for a classification by the working committee on nomenclature. European Laryngological Society. Eur Arch Otorhinolaryngol 2009;266:993Y998 12. Lawson G, Matar N, Remacle M, et al. Transoral robotic surgery for the management of head and neck tumors: learning curve. Eur Arch Otorhinolaryngol 2011;268:1795Y1801
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Transoral Robotic Supraglottic Partial Laryngectomy Fatma Tu¨lin Kayhan, MD, Kamil Hakan Kaya, MD, Ahmet Altintas, MD, and Ibrahim Sayin, MD Objective: Transoral robotic supraglottic laryngectomy is a new surgical way to perform endolaryngeal resection of supraglottic laryngeal carcinoma. The aim of this report was to present our initial experience about transoral robotic supraglottic laryngectomy for early supraglottic cancer. Methods: Subjects with early squamous cell carcinoma (T1YT2) of supraglottic region who managed using transoral robotic surgery in a tertiary referral center were included in the study. The technique of robot-assisted resection, intraoperative blood loss, mean robotic operating time, pathologic margin status, postoperative extubation, need for a tracheotomy, and length of hospitalization, complications, duration of oral nutrition, and neck dissection and radiotherapy needs were evaluated. Results: Thirteen subjects (12 men, 1 woman) with T1YT2 supraglottic carcinoma were successfully operated on with transoral robotic surgery. In all subjects, negative margins were obtained. The mean total robotic surgery time was 31.6 (SD, 16.2) minutes (range, 20Y80 minutes). Mean total blood loss was less than 40 mL. Subjects started oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4Y30 days) postoperatively. The mean hospitalization was 15.4 (SD, 10.4) days (range, 7Y42 days). Conclusions and Relevance: Transoral robotic supraglottic laryngectomy with the da Vinci robotic system can be regarded as a feasible, safe, and effective technique. Although short-term results seem discouraging, long-term results are needed to evaluate the oncologic safety. Key Words: Supraglottic cancer, early, robotic surgery, da Vinci Surgical System
tracheotomy, early swallowing function, and decreased hospital stay. Besides, when completed successfully with negative surgical margins, oncologic results are comparable with open surgery.1,2 The initial technique to perform endolaryngeal surgery is transoral laser surgery, which uses rigid laryngoscopes and devices.3 This will be sometimes technically demanding because of the limited area and limited visualization and manipulation in supraglottic region. When a handpiece for laser fiber did not exist, the surgeon has to use one hand for micromanipulator and the other for tissue grasping. Even if a handpiece exists; the rigidity of the devices did not let an additional instrument. Although not proven, oncologic safety is argued by some practitioners because the technique will need the piecemeal resection of the tissue, which is opposite to en bloc resection philosophy.4 Supraglottic carcinoma (T1, T2, T3) can be treated by surgery or radiotherapy (RT). Supraglottic partial laryngectomy with open surgery has high local control rates, which is 90% for T1 and T2 carcinomas and 70% to 90% for T3 carcinomas. The other favored method, transoral laser supraglottic laryngectomy, has comparable local control rates, which is 80% to 90% for T1, 80% to 93% for T2, and 67% to 83% for T3 supraglottic carcinomas.1 The transoral approach with robotic surgery (TORS) was introduced in 2005. In January 2010, the Food and Drug Administration approved TORS for use in benign and malignant disease of the tonsils, pharynx, and larynx. To date, various endolaryngeal procedures including supraglottic partial laryngectomy, radical tonsillectomy, tongue base resection, and vocal cord surgery have been performed successfully with the TORS approach.5 Previous reports also proved the safety and efficacy of the procedure.6Y10 This study presents early supraglottic laryngeal SCC subjects treated with transoral robotic supraglottic laryngectomy with the da Vinci robotic surgical system.
(J Craniofac Surg 2014;25: 1422Y1426)
MATERIALS AND METHODS
T
he ideal approach to supraglottic carcinoma of the larynx (SGL) is to preserve the larynx, and it functions with negative surgical margins.1 Endolaryngeal surgery for supraglottic laryngeal squamous cell carcinoma (SCC) has advantages over the open surgical techniques with decreasing the operative morbidity, the need of
From the Department of Otolaryngology Head and Neck Surgery, Bakirko¨y Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey. Received September 3, 2013. Accepted for publication November 14, 2013. Address correspondence and reprint requests to Ibrahim Sayin, MD, Department of Otolaryngology Head and Neck Surgery, Bakirko¨y Dr. Sadi Konuk Education And Research Hospital, Tevfik Sa?lam Caddesi, No. 11. 34147, Bakirko¨y, Istanbul, Turkey; E-mail: [email protected] I.S. had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. The authors report no conflicts of interest. Copyright * 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000572
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From January 2010 to January 2013, subjects who underwent transoral robotic supraglottic laryngectomy were included in the study. The study was approved by the local ethics board. Subjects who were diagnosed with T1 and T2 supraglottic carcinoma were visited. Subjects who were at T3 stage or more were not operated on during the study period with TORS. Therapeutic alternatives including RT, transoral laser microsurgery (TLM), TORS, and open surgery were offered to subjects. Subjects who accepted TORS were operated on. The age, sex, pathologic diagnosis, smoking habit, operation time, anesthesia time, the robotic setup time, robotic surgery time, estimated blood loss, surgical margin status, the need of tracheotomy, prolonged intubation time, oral feeding time, additional therapies, follow-up period, and early and late complications were recorded. Preoperatively, subjects were evaluated for conditions that will complicate the placement of the F-K retractor such as rigid short neck, retrusive mandible, prominent teeth, peripheral soft tissue, and so on. All surgeries were performed under general anesthesia. Transnasal intubation, with a laser-resistant tube (no. 5.5Y6), was done in all subjects. The subjects underwent reverse Trendelenburg position,
The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
and the eyes were protected. The da Vinci robotic system setup was completed, and the subject card was docked as described previously.5 An F-K retractor (Gyrus Medical, Maple Grove MN) was used to expose vallecula and epiglottis. The 8-mm 0-degree da Vinci three-dimensional robotic camera was introduced into the oral cavity, and the operation field was visualized. Than 2 lateral arms were replaced. For the TORS-supraglottic laryngectomy, 5-mm EndoWrists monopolar cautery was placed on the first arm, and a Maryland dissector or a 5-mm EndoWrists Schertel grasper was placed on the second arm. The surgery was performed with the robotic supraglottic laryngectomy technique, which was previously described by Weinstein et al.6 In first step, the epiglottis was caught with the Schertel grasper. It is divided into 2 pieces with monopolar cautery until the level of petioles. In the second step, the mucosa of vallecula was transected, and the pre-epiglottic tissue was dissected to the level of the hyoid bone. In the third step, the thyroid cartilage was identified at the superior aspect, and dissection was made downward from the inner perichondrium of the cartilage. In the fourth step, the superior laryngeal artery and vein were identified in the pharyngoepiglottic fold. These arteries and veins were clipped with at least 4 hemoclips. Then, the artery and vein were transected and coagulated with monopolar cautery. In the fifth step, dissection was made in the paraglottic region to the level of the anterior commissure on both sides. In the last step, the supraglottic laryngeal mucosa was cut over the vocal cords, and en bloc resection was completed (Figs. 1AYD). This surgery was a type 3b excision according to endoscopic supraglottic laryngectomy dissection classification of the European Laryngological Society.11 Control biopsies were taken from vocal cords, pre-epiglottic and paraglottic areas, and arytenoid mucosa and other resection borders. The further hemostasis was made with monopolar cautery. If there was bleeding from a major vessel, the bleeding was stopped with hemoclips. At the end of the operation, a nasogastric tube was replaced. After the operation, the patients were kept intubated for 24 o 36 hours. The patients were extubated in the intensive care unit, and after a
FIGURE 1. A, Preoperative view of the supraglottic lesion: The lesion is limited in supraglottic region and did not extend to the glottic region and did not affect the vocal cord mobility. B, The lesion was excised from the pre-epiglottic region: epiglottis was caught with Schertel grasper, and the excision was made with cautery. The console surgeon aspirates the area and stopped bleeding with hemoclips. C, The appearance of the larynx after completion of the procedure: After this stage, surgical margins were controlled, and control biopsies were taken. D, The appearance of larynx immediately after surgery: Both vocal cords are mobile, and there is no sign of residual tumor.
Transoral robotic supraglottic partial laryngectomy
4-hour follow-up, patients were taken to service. They kept antibiotics for 1 week after surgery. The subjects’ nasogastric tubes were removed at the time the oral feeding started. The patients underwent bilateral functional neck dissection 2 to 3 weeks after the operation. The subjects who have positive neck nodes underwent RT. The subjects were followed up weekly in the first month, monthly in the remaining first year, and bimonthly in the following year. During surgery, dissection of the tissue and coagulation were performed with monopolar cautery. The grasping and dissection were performed with the Schertel grasper or Maryland dissector. The suction was performed by an assistant surgeon on the subject card during the surgery. At the end of the operation, biopsies were taken from all surgical margins. All reported data were expressed as mean (SD).
RESULTS Thirteen subjects were evaluated. Twelve (92.3%) of 13 subjects were male, whereas the remaining 1 subject (7.7%) was female. The subjects’ ages ranged from 45 to 68 years with an average of 60 (SD, 6.7) years. Twelve (92.3%) of 13 subjects had a history of smoking with an average of 50.46 (SD, 34.30) pack-years. The mean follow-up was 14.5 (SD, 10.3) months (range, 2Y31 months). The subjects’ data are summarized in Table 1. In all subjects, the exposure of the laryngeal region with the F-K retractor was adequate. In all subjects, the surgeon can complete the procedure. In all subjects, 2 pieces of supraglottic laryngectomy specimen were removed en bloc. The mean anesthetic time is 85.3 (SD, 33.4) minutes (range, 60Y165 minutes). The mean setup and exposure time was 35.7 (SD, 16.3) minutes (range, 20Y65 minutes). Mean robotic surgical time was 31.6 (SD, 16.2) minutes (range, 20Y80 minutes). In all cases, the estimated total blood loss was less than 40 mL. In all cases, negative margins were obtained. The operative and postoperative data are summarized in Tables 2 and 3. No tracheotomy was required for surgery. During the follow-up, 3 subjects needed tracheotomy. Two subjects needed tracheotomy when they were receiving RT. Two subjects experienced pneumonia, and 1 subject developed a laryngeal stenosis. Subjects with laryngeal stenosis underwent an additional procedure; the tracheotomy was done, and the stenosis was reoperated with transoral laser surgery. The subjects’ oral feeding started at the time of nasogastric tube removal. They were started on oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4Y30 days) postoperatively. The mean hospitalization period was 15.4 (SD, 10.4) days (range, 7Y42 days). The postoperative data are summarized in Table 3. We treated all subjects’ neck with a neck dissection 2 to 3 weeks after surgery even if they were clinically N0. In the final pathologic evaluation, 4 neck dissection specimens showed lymph node metastasis. One subject developed distant pulmonary metastasis. These subjects received further RT and/or chemotherapy protocols (Table 4). No local or regional recurrence was observed during the follow-up period. Preoperative, intraoperative, and postoperative views of some subjects are shown in Figures 1AY1D.
DISCUSSION In all subjects, who had a diagnosis of supraglottic laryngeal carcinoma and agreed to operate, the surgery can be successfully performed. There were no oropharyngeal and neck anatomical problems that will complicate the TORS. We commonly performed Type 3b resection according to the endoscopic supraglottic laryngectomy dissection classification of European Laryngological Society.11 In type 3 resection, a medial supraglottic laryngectomy with resection
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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TABLE 1. Subject Data Subject
Age, y
Sex
Diagnosis
68 61 64 61 51 66 45 60 56 64 55 65 60
M M M M M M F M M M M M M
SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC SCC
1 2 3 4 5 6 7 8 9 10 11 12 13
T Classification T1 T1 T1 T1 T1 T1 T1 T1 T1 T1 T1 T1 T1
N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0 N0
M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0
Smoker, Pack-Years
Follow-up, mo
20 80 60 60 None 150 30 60 35 40 32 45 44
31 29 25 25 18 16 13 10 8 4 4 4 2
laryngoscope is restricted, and surgical instruments are rigid and limited. Learning curve also exists for endolaryngeal surgery. The robotic da Vinci Surgical System is a new way to perform endolaryngeal surgery. Series of cases undergoing cordectomy, radical tonsillectomy, tongue base resection, and partial pharyngectomy with TORS have been reported.5 In addition, robotic microlaryngeal surgery for supraglottic carcinoma has been reported recently. Early results are encouraging, although long-term results are needed to establish its efficacy.6Y10 In general, the advantages of the system include an improved three-dimensional magnified (40 magnification) visualization, the 540-degree motion capacity of the robotic arms, and simultaneous resection and coagulation functions. The system also filters tremors both in the use of the instruments and the view. These advantages enable a more precise surgery in terms of better assessment of surgical margins and better protection of anatomical structures. Postoperative pain will decrease, the healing process is more rapid, and the return of the patients to their normal diet is shorter than with other methods. In TORS SGL, preservation of suprahyoid and infrahyoid muscles and preservation of superior laryngeal nerve resulted in early return of swallowing function. A shorter recovery period, shorter return to normal diet, and shorter hospital stay are other significant advantages. The da Vinci system also allows the surgeon to perform surgery in a more comfortable position.5 Robotic surgery for SGL carcinoma has been reported recently. In the first report, Weinstein et al6 operated on 3 subjects with SGL carcinoma. The report mainly focused on the feasibility of the procedure,
of the pre-epiglottic space was done. This excision also extended to the ventricular fold. In any oncologic surgery, the surgical margin negativity is an important issue. Positive surgical margin is related with high local recurrence, distant metastasis, and decreased survival rate.1 In our cases, all surgical margins were controlled with biopsies, and the surgical margins were all negative at the end of the operation. In TORS-SL, a tracheotomy can be avoided. For early postoperative respiration problems, a prolonged intubation was done for all subjects. In our cases, the duration of prolonged intubation varied from 24 to 36 hours. Transoral approach with robotic surgery SGL intubation prolonged to 48 hours as reported previously. This time is only for caution and will decrease with enough experience. Among our subjects, no reintubation was needed, and none of the subjects received steroids when they were extubated. None of our subjects needed tracheotomy in the preoperative period. Two subjects needed tracheotomy when they were receiving RT. One subject needed a temporary tracheotomy for laryngeal stenosis during follow-up. Grant et al3 reported that a temporary tracheostomy is needed in 32% of the subjects during the TLM. In treatment of SGL carcinoma, TLM is an alternative to RT and open surgery. Endolaryngeal surgery is preferable, because it has several advantages such as avoiding skin incision and avoiding tracheotomy. Overall, the surgery decreases postoperative morbidity. However, endolaryngeal surgery has some challenges that will complicate the manipulation of this area. The area of the tongue base and pharynx are limited; the view of the surgical area through the
TABLE 2. Operative Data of the Subjects
Subject 1 2 3 4 5 6 7 8 9 10 11 12 13
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Anesthetic Time, min
Setup and Exposure Time, min
Robotic Surgical Time, min
Surgical Margin Status
Estimated Blood Loss, mL
Perioperative Complication
125 165 120 110 75 65 65 65 60 65 70 60 65
65 65 55 45 35 30 20 25 20 30 25 25 25
40 80 40 35 30 20 27 22 20 20 30 22 25
Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative Negative
G40 G40 G40 G40 G40 G40 G40 G40 G40 G40 G40 G40 G40
No No No NO No No No No No No No No No
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery
& Volume 25, Number 4, July 2014
Transoral robotic supraglottic partial laryngectomy
TABLE 3. Postoperative Data of the Subjects Subject
Prolonged Intubation Time, hrs
Tracheotomy
Nasogastric Tube Removal, d
Hospitalization Time, d
Postoperative Complication
24 24 36 36 24 24 24 24 24 24 24 24 24
No No Post-RT Post-RT No No No yes No No No No No
28 4 15 30 15 5 7 10 4 6 8 4 5
20 7 20 42 15 30 14 10 9 8 7 9 10
Pneumonia None Laryngeal stenosis Pneumonia None None None None None None None None None
1 2 3 4 5 6 7 8 9 10 11 12 13 d, days; hrs, hours.
and all 3 subjects were successfully operated on with robotic surgery without any complications. In this first report, the total time for robotic procedure was 120 minutes (range, 62Y178 minutes). Mean exposure and robotic positioning were reported as 18 minutes (range, 6Y39 minutes). In 2007, Solares and Strome7 reported 1 subject they had operated on. Although they attempted to perform the procedure in 3 subjects, only in 1 case did they achieve adequate exposure, and the remaining 2 cases could not be operated on. The subjects started oral feeding on the fifth postoperative day, and in the first month, control showed no residual tumor. In 2012, Alon et al8 reported 7 subjects (4 male and 3 female subjects with an average age of 61 years). They successfully completed all procedures with clear surgical margins. They had noted 1 intraoperative complication, which is thermal injury to the anterior cervical skin. In 4 subjects, a tracheostomy was needed, and 3 of these 4 subjects can be decannulated successfully. One subject needed long-term tracheotomy, and 2 subjects needed long-term gastrostomy tube replacement in this study. For treatment of neck in 6 subjects, they had performed the neck dissection at the time of robotic resection. Ozer et al9 also reported 13 subjects in the same year. They achieved negative surgical margins in all subjects. Average robotic operative time and blood loss were 25.3 minutes and 15.4 mL, respectively. Return to normal diet was within the first 24 hours in 11 subjects. Adjuvant RT was needed in 2 subjects. There is only 1 report that evaluated the swallowing and voice function on 16 subjects.10 Swallowing function was evaluated with
videopharyngogram and the functional outcome swallowing scale. Complete recovery of swallowing ability was observed at an average of 8.3 days after surgery. Aspiration occurred only in 1 subject. In this study, 91% of the subjects reported favorable swallowing and voice function. Mendehlson et al4 reported 18 subjects who underwent TORS-SL with at least 12 months follow-up. In all subjects, they achieved negative surgical margins. They treated the neck at the same time with TORS if clinically positive lymph node exists. If the neck is N0, they performed a sentinel lymph node biopsy. If the result of the biopsy was positive, the subjects underwent a selective neck dissection 2 to 3 weeks after surgery. Among these subjects, 3 recurrences (16.7%) from the neck were seen. Four subjects (22.2%) developed distant metastasis during follow-up. Our results are comparable with previous studies. Although the majority of the studies reported adequate access to surgical area, some conditions such as retrusive mandible, peripheral soft tissue, rigid short neck, and prominent teeth will result in inadequate access. These points should be properly evaluated preoperatively. In all subjects, we had achieved adequate exposure and could perform the procedure with negative surgical margins. The total operation time as well as setup/exposure/robotic surgical times varies among studies. The mean anesthetic time was 85, 3 (SD, 33.4) minutes (range, 60Y165 minutes). The mean setup and exposure time was 35.7 (SD, 16.3) minutes (range, 20Y65 minutes). Mean robotic surgical time was 31.6 (SD, 16.2) minutes (range,
TABLE 4. Pathologic Examination Results of the Supraglottic Tumor and Neck Dissection Specimen Subject 1 2 3 4 5 6 7 8 9 10 11 12 13
T Stage T2 T2 T1 T2 T1 T2 T1 T2 T2 T2 T1 T2 T2
pN
Stage
N3 N0 N0 N0 N0 N0 N0 N0 N2C N2C N0 N2C N0
Stage
Tumor Differentiation
Cartilage Invasion
Perineural Invasion
Lymphatic Invasion
Vascular Invasion
Postoperative CRT
IVC II I II I II I II IV IV I IV II
Grade 2 Grade 2 Grade 2 Grade 2 Grade 1 Grade 2 Grade 2 Grade 3 Grade 3 Grade 1 Grade 1 Grade 2 Grade 3
Negative Negative Negative Negative Negative Negative Negative Positive Negative Negative Negative Negative Negative
Negative Negative Negative Negative Negative Positive Negative Positive Negative Negative Negative Positive Negative
Positive Negative Negative Negative Negative Negative Negative No Positive Positive Negative Positive Negative
Positive Positive Negative Negative Negative Positive Negative No Positive No Negative Positive Negative
Yes Yes No No No No No No Yes Yes No Yes No
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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20Y80 minutes). These times were reduced with further learning of the procedure. Other reports also noted the importance of experience in decreasing the surgical time in TORS.12 In all cases, the estimated total blood loss was less than 40 mL. No major bleeding was observed. In any endolaryngeal surgery, bleeding is an important problem. In TORS, additional to hemostasis capacity of cautery and laser, hemoclips can be used under a magnified area, and a more effective hemostasis can be achieved. For postoperative complications, 2 subjects had pneumonia, and 1 subject developed a laryngeal stenosis during follow-up. The subjects’ oral feeding started at the time of nasogastric tube removal. They were started on oral nutrition with a mean of 10.8 (SD, 8.9) days (range, 4Y30 days) postoperatively. The mean hospitalization period was 15.4 (SD, 10.4) days (range, 7Y42 days). Because the procedure is relatively new, we prefer to observe our subjects a few days more in the hospital. With the establishment of the procedure, this time will shorten. Also, subjects who had pneumonia also had increased mean hospital stay. Because SGL of the larynx has a high occult metastasis potential, we treated all subjects’ neck with a neck dissection 2 to 3 weeks after surgery if they were clinically N0. Indications for chemoradiotherapy (CRT) were N2+ stage and extracapsular spread. Four subjects received CRT for advanced neck disease and one for distant metastasis. Our mean follow-up was 14.5 (SD, 10.3) months (range, 2Y31 months). No local or regional recurrence was observed during the follow-up period. We think our period is not long enough to make a decision for oncologic safety. The oncologic safety has to be assessed in other large series that also have longer follow-up periods. As mentioned during our follow-up, only 1 distant metastasis occurred. A doubt always arises for the additional expenditures of the robotic system. Robotic instruments and surgery is more expensive than other surgeries. We believe that cost-effectiveness is a multifactorial subject, and benefits in surgical teams’ comfort, the effect on overall morbidity, and its future potentials must be taken into consideration when evaluating this issue.
CONCLUSIONS We found that TORS SGL was feasible, safe, and effective. Transoral approach with robotic surgery provided better exposure, visualization, and access than standard endolaryngeal surgery. Subjects return to normal diet earlier, and reduced morbidity was an advantage
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of this operation. For oncologic safety, additional series with long follow-up is needed.
ACKNOWLEDGMENT Ibrahim Sayin, MD, had full access to all of the data in the study had takes responsibility for the integrity of the data and the accuracy of the data analysis.
REFERENCES 1. Rodrigo JP, Sua´rez C, Silver CE, et al. Transoral laser surgery for supraglottic cancer [review]. Head Neck 2008;30:658Y666 2. Silver CE, Beitler JJ, Shaha AR, et al. Current trends in initial management of laryngeal cancer: the declining use of open surgery. Eur Arch Otorhinolaryngol 2009;266:1333Y1352 3. Grant DG, Salassa JR, Hinni ML, et al. Transoral laser microsurgery for carcinoma of the supraglottic larynx. Otolaryngol Head Neck Surg 2007;136:900Y906 4. Mendehlson AH, Remacle M, van der Vorst S, et al. Outcomes following transoral robotic surgery: supraglottic laryngectomy. Laryngoscope 2013;123:208Y214 5. Kayhan FT, Kaya KH, Sayin I. Transoral robotic cordectomy for early glottic carcinoma. Ann Otol Rhinol Laryngol 2012;121:497Y502 6. Weinstein GS, O’Malley BW Jr, Snyder W, et al. Transoral robotic surgery: supraglottic partial laryngectomy. Ann Otol Rhinol Laryngol 2007;116:19Y23 7. Solares CA, Strome M. Transoral robot-assisted CO2 laser supraglottic laryngectomy: experimental and clinical data. Laryngoscope 2007;117:817Y820 8. Alon EE, Kasperbauer JL, Olsen KD, et al. Feasibility of transoral robotic-assisted supraglottic laryngectomy. Head Neck 2012;34:225Y229 9. Ozer E, Alvarez B, Kakarala K, et al. Clinical outcomes of transoral robotic supraglottic laryngectomy. Head Neck 2013;35:1158Y1161 10. Park YM, Kim WS, Byeon HK, et al. Surgical techniques and treatment outcomes of transoral robotic supraglottic partial laryngectomy. Laryngoscope 2013;123:670Y677 11. Remacle M, Hantzakos A, Eckel H, et al. Endoscopic supraglottic laryngectomy: a proposal for a classification by the working committee on nomenclature. European Laryngological Society. Eur Arch Otorhinolaryngol 2009;266:993Y998 12. Lawson G, Matar N, Remacle M, et al. Transoral robotic surgery for the management of head and neck tumors: learning curve. Eur Arch Otorhinolaryngol 2011;268:1795Y1801
* 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
