OT
Otolaryngology

Transoral robotic surgery

February 21, 2012.
Steven J. Wang, MD,

Educational Objectives

The goal of this program is to improve the management of patients with head and neck cancer. After hearing and assimilating this program, the clinician will be better able to:

1. Evaluate the technique, advantages, and disadvantages of transoral robotic surgery for oropharyngeal cancer.

2. Perform transoral robotic surgery for radical tonsillectomy and tongue base resection.

Summary

Principles of surgical approaches: obtain negative margins; liberal use of complex reconstructive techniques; use of postoperative radiation therapy for high-risk cases; local control and good functional rehabilitation possible; 1990s — organ preservation strategies through combined chemotherapy and radiation therapy; similar oncologic outcomes achieved as with primary surgery and irradiation; early 21st century — lesser role of surgery due to increased use of CRT; oral cavity remains primarily surgical disease; primary open surgery less common in oropharynx and larynx; primary CRT more common

Oropharyngeal cancer: study — ³80% control rates for stage III and IV cancers treated with concurrent CRT; better than historically achieved with surgery and irradiation; however, many patients in recent series younger; ³50% of new cases related to human papillomavirus (HPV; more favorable prognosis)

Limitations to CRT: cure rates >85% suggest some patients overtreated; organ preservation does not always equal function preservation; long-term consequences of high-intensity chemotherapy and radiation therapy — swallowing dysfunction (permanent gastrostomy tube dependence); pharyngeal stricture; debilitating xerostomia; chronic pain; osteoradionecrosis; with high survival rates expected with CRT, difficult to convince patients to undergo conventional radical surgery and reconstruction

Surgery for oropharyngeal cancer: must provide equal or better local control rates as CRT and offer better functional outcomes; to improve conventional open surgery — achieve more accurate and precise margins; transoral approach to minimize disruption of extrinsic pharyngeal muscles, avoid tracheostomy, achieve more rapid recovery

Transoral robotic surgery (TORS): addresses limitations of standard transoral surgery (eg, restricted surgical access, long instrumentation with limited functionality, limited line of sight); approved by Food and Drug Administration for treatment of benign and malignant disease of head and neck

Da Vinci surgical system: surgeon sits at console located at distance from patient; robotic cart at patient’s bedside; not programmable (all controlled by surgeon); 2 laterally placed instrument arms and central video camera (high-definition 3-dimensional imaging); tumor removed en bloc; cut with cautery or flexible CO₂ laser; most defects heal by secondary intention (no flaps)

Benefits: improved 3-dimensional visualization; wristed instruments enable high degree of freedom in angulation of instruments; motion scaling increases precision and eliminates surgeon tremor and fatigue

Drawbacks: lack of haptic or tactile feedback; current instrumentation not designed for head and neck surgery

Radical tonsillectomy: contraindications to TORS — most T4 tumors; tumor adjacent to carotid artery; invasion lateral to constrictor muscles or prevertebral fascia; presence of retropharyngeal internal carotid artery; technique —exposure with Crowe-Davis retractor; use grasping instrument, then monopolar cautery; bedside assistant for suctioning smoke and bleeding; palpate before starting; initial incision lateral to anterior tonsillar pillar at pterygomandibular raphe; in “off” position, tip of monopolar Bovie used as blunt dissecting tool; go through lateral constrictor muscles; can extend resection if tumor involves tongue base

Tongue base resection: contraindications to TORS — most T4 tumors; bulky tumors involving >50% of base of tongue; technique — FK-WO retractor; tongue blades to selectively expose either right or left base of tongue; retractors to further open oral opening; nasal intubation gets endotracheal tube out of way; midline incision to establish depth of resection; ligate lingual artery with hemoclips

Supraglottic laryngectomy: current instrumentation not suited to lesions of glottic larynx; technique similar to that used with transoral laser microsurgery

Issues: cost — expensive, but used for other procedures; aside from capital cost, additional »$500 per case; no additional fees because no CPT codes; shorter hospital stay after TORS; postoperative radiation therapy — often indicated for patients with oropharyngeal cancers who have neck disease (particularly patients with HPV); risk for swallowing dysfunction; however, after tumor removed with TORS, volume of treatment reduced and dose intensity lowered; can result in better preservation of swallowing; postoperative chemotherapy — indicated for positive margins and extracapsular extension in lymph nodes; study — for oropharyngeal cancers treated surgically with transoral resection and neck dissection, extracapsular extension not independent predictor of poor outcome; suggests chemotherapy possibly not needed for patients who undergo comprehensive neck dissection with TORS, even those with extracapsular spread

Clinical trial data: study — nonrandomized; compared TORS and CRT; 75% of patients avoided chemotherapy; similar locoregional control in both groups; 2-yr G-tube dependency rate, 0 for TORS patients; average cost for TORS-treated patients less

Readings

Disclosures

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning committe reported nothing to disclose.

Acknowledgements

Dr. Wang was recorded at UCSF Otolaryngology Update 2011, held November 10-12, 2011, in San Francisco, CA, and sponsored by University of California, San Francisco, School of Medicine, Office of Continuing Medical. For information about future events from University of California, San Francisco, School of Medicine, please visit medschool2.ucsf.edu. The Audio-Digest Foundation thanks the speaker and the sponsor for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0 CE contact hours.

Lecture ID:

OT450402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation