MUSC ENT E-Update: Transoral Robotic Sugery

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Dear Colleague,

In our June ENT E-Update, Dr. Terry A. Day describes how the advancing role of robotic technology in head and neck surgery continues to drastically transform how routine and complex operations are performed worldwide.

You can read more about Dr. Day below and on our website. Please feel free to contact us with your feedback or questions about our E-Udate articles, your patients, or any other ENT issue at entupdate@musc.edu.

Paul R. Lambert, MD

Professor and Chair

Transoral Robotic Surgery

Robert J. Yawn, MD

Terry A. Day, MD

Figure 1. Patient with nasogastric tube and tracheotomy tube following open head and neck cancer operation

Traditionally, surgical extirpation of head and neck tumors required radical approaches that often leave patients with visible scars, facial deformities, and difficulty chewing or swallowing. In addition, feeding tubes and neck breathing tubes(trach) are commonly required, necessitating a lengthy hospital stay and recovery. (Figure 1) Fortunately, more minimally invasive techniques are becoming increasingly available due to progressive advances in technology. Today, through the use of surgical robots, surgeons can now remove tumors from difficult to access areas deep in the head and neck without making any incisions in the face, neck or cheek area - often avoiding scars, feeding tubes, and breathing(trach) tubes. (Figure 2)

Figure 2. Patient after transoral robotic surgery and separate right neck dissection without nasogastric tube or tracheotomy, and small neck dissection scar

Telepresence robotic surgery was initially developed in the early 1980's by NASA researchers in collaboration with the Stanford Research Institute. The US military took an early interest in these efforts as well, hoping that surgeons may eventually be able to stabilize critically wounded soldiers on the battlefield from remote sites. Although telepresence surgery has yet to become reality, medical robots continue to drastically transform the way that routine and complex operations are performed throughout the world.

Most robotic surgery in 2012 is performed using the da Vinci� Surgical System (Figure 3) (Intuitive Surgical Inc., Sunnyvale, CA). In this system, a 3D endoscope and two robotic surgical arms are placed transorally and manipulated by the surgeon at a separate patient-side console. The magnified three-dimensional image is displayed just above the surgeon's hands, giving the illusion that the instrument tips extend directly from the control grips. Compared to traditional endoscopy, robotic techniques offer superior visualization, tremor reduction, and greater dexterity due to the surgical arms' six degrees of freedom. In essence, tumors of deep head and neck structures can now be precisely extirpated without any external incisions. This transoral robotic surgical procedure performed for tumors of the oropharynx and larynx has been referred to as TORS.

Figure 3. da Vinci surgical robot with three arms and one 3D camera (however, only two surgical arms are utilized in transoral surgery)

TABLE 1: GOALS OF TORS

Shorter surgery time
Less blood loss
Faster recovery
Shorter hospital stay
Earlier return to work and play
Reduced pain
Avoid feeding tubes
Avoid tracheotomy tubes

Figure 4. Dr. Joshua Hornig

Figure 4 depicts Dr. Joshua Hornig at the robotic console performing surgery. Separately, at the patient, the da Vinci system is remotely performing the surgery under Dr. Hornig's guidance. This system was initially FDA approved for thyroid operations through the axilla or under the arm. More recently FDA approval was obtained for removal of tumors of the oropharynx. At MUSC, Drs. Joshua Hornig and Terry Day are experienced in removal of oropharynx and larynx tumors using robotic technology in addition to transoral laser microsurgery, transoral and transcervical combined approaches, and complex reconstructive techniques. The MUSC Head & Neck Robotic Team is coordinated by Betty F. Lopez, RN, ADN and Monica Dunn, RN.

The MUSC Multidisciplinary Head and Neck Tumor Center evaluates patients with complex tumors of the mouth, throat, skin, voice box, thyroid, and salivary glands. Evaluations are provided by surgeons, radiation oncologists medical oncologists, speech therapists, and maxillofacial prosthodontists, often all in one day. The patients are then discussed prospectively at the Head & Neck and Thyroid, Parathyroid Tumor Board where a treatment and rehabilitation plan is developed to optimize treatment, cure and quality of life. The group includes head and neck surgeons Barry Malin, Eric Lentsch, Judith Skoner, Joshua Hornig, Boyd Gillespie, and Terry Day, but the interprofessional group including research and survivorship is crucial to comprehensive care. Click here for the complete list of MUSC Head and Neck Tumor Center team members.

HPV and Oropharyngeal Cancer and TORS

With the emerging evidence that human papillomavirus-associated cancers of the tonsil and base of tongue are increasing in incidence, more and more patients are requesting less invasive procedures to treat these malignancies. In fact, oropharyngeal cancer was the second most common HPV associated cancer behind cervical cancer, with an average of 11,726 cases annually (2,370 among females and 9,356 among males). The rate of oropharyngeal cancer among males (6.2) was four times that among females (1.4). (1) Most of these patients present with a tonsil or base of tongue mass and level IIa lymph nodes which are more commonly cystic than HPV(-) metastatic nodes.(2)

Treatment of Oropharyngeal Cancer with TORS

Studies are now available that have confirmed comparable or improved locoregional control and survival with TORS as the initial definitive nonsurgical therapy. Guidelines from the National Comprehensive Cancer Network(NCCN) show an option of surgical treatment or radiation treatment for stage 1 and 2 oropharyngeal cancer while combined modality treatment is indicated for stage 3 and 4 oropharyngeal cancers.(3) At MUSC, patients are evaluated and presented at the multidisciplinary head and neck tumor board and recommendations are made based upon the estimated cure rates, patient specific factors, tumor stage, site and histology, and quality of life related issues. For advanced stage oropharyngeal cancers, patients may be offered combinations of chemotherapy and radiation or surgery followed by radiation or chemoradiation to provide optimal cure and quality of life. Transoral Robotic Surgery may be performed in these scenarios but tumor free margins are critical to its success and transoral access requires adequate access for instrumentation, 3D cameras and visualization of the tumor and surrounding structures. When this is not possible, transoral surgery may not be an option and open surgery or nonsurgical options are presented to the patient.

Transoral robotic surgery is showing functional and locoregional control outcomes that rival radiation and chemoradiation results. In a study of 54 patients with oropharyngeal or laryngeal primaries, only 9% required tracheotomy and 83% were taking oral intake within two weeks of surgery.

Complications that occurred in this series included airway edema(9%), aspiration(6%), bleeding(6%) and salivary fistula(2%).(4)

In another group of 49 patients, local recurrence occurred in only one and regional recurrence in two, distant disease in four patients with a potential for downstaging reducing the need for adjuvant radiation and chemotherapy.(5) Another study of 89 patients with two year followup, there was 89.5% and 86.3% recurrence free survival at one and two years, respectively.(6)

An emerging area of interest that is now underway is robotic surgery for snoring and sleep apnea. Dr. Boyd Gillespie has extensive experience with sleep apnea treatment and surgery, and is one of the few surgeons in South Carolina and in the country who is board certified in Sleep Medicine. Dr. Gillespie has experience with transoral robotic sleep surgery aimed at treating snoring as well as sleep apnea without any external incisions or scars.

According to Dr. Joshua Hornig, "technological advances inherent to robotic surgery will expand the role of robotics in head and neck cancer treatment for years to come."

Terry A. Day, M.D.

Professor, Otolaryngology - Head & Neck Surgery

To contact any member of the MUSC Head & Neck Team

email headneck@musc.edu or call 843-792-8363

References:

CDC Morbidity & Mortality Weekly Report/MMWR: Human Papillomavirus-Associated Cancers in the United States, 2004-2008. April 20, 2012 / 61(15);258-261.
Gillespie MB, Rubinchik S, Hoel B, Sutkowski N. Human papillomavirus and oropharyngeal cancer: what you need to know in 2009. Curr Treat Options Oncol 2009;10:296-307.
http://www.nccn.org/professionals/physician_gls/pdf/head-and-neck.pdf
Iseli TA, Kulbersh BD, Iseli CE, Carroll WR, Rosenthal EL, Magnuson JS. Functional outcomes after transoral robotic surgery for head and neck cancer. Otolaryngol Head Neck Surg. 2009;141(2):166-171
Weinstein GS, O'Malley BW, Cohen MA and Quon H: Transoral robotic surgery for advanced oropharyngeal carcinoma. Archives of Otolaryngology-Head and Neck Surgery. 2010. 136(2): 1079-1085, 2010.
White HN, Moore EJ, Rosenthal EL, et al, Transoral robotic-assisted surgery for head and neck squamous cell carcinoma: one- and 2-year survival analysis. Archives of Otolaryngology-Head and Neck Surgery. 2010. 136(12:1248-1252.

About Dr. Day...

Terry A. Day, MD

Wendy and Keith Wellin Endowed Chair

in Head and Neck Surgery

Professor and Director,

Head & Neck Tumor Center

Vice Chair, Clinical Affairs

MD: University of Oklahoma

Residency: LSU-Shreveport

Fellowship: University of California, Davis

Special interest: Head and neck benign and malignant neoplasms, transoral robotic surgery