Feasibility of transoral roboticassisted supraglottic laryngectomy

ORIGINAL ARTICLE
FEASIBILITY OF TRANSORAL ROBOTIC-ASSISTED
SUPRAGLOTTIC LARYNGECTOMY
Eran E. Alon, MD, Jan L. Kasperbauer, MD, Kerry D. Olsen, MD, Eric J. Moore, MD
Department of Otorhinolaryngology, Mayo Clinic, Rochester, Minnesota. E-mail: moore.eric@mayo.edu
Accepted 13 December 2010
Published online 15 April 2011 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/hed.21719
Abstract: Background. We aimed to describe our experience
with transoral robotic-assisted supraglottic laryngectomy.
Methods. We retrospectively reviewed the records of
patients who underwent transoral robotic-assisted supraglottic
laryngectomy at our institution between May 2007 and November
2008.
Results. During the study period, 7 patients with malignancy
underwent the procedure (4 men, 3 women; average
age, 61 years). All tumors were completely resected, with clear
margins on pathologic analysis. Six patients underwent neck
dissection at the time of transoral surgery. One intraoperative
complication occurred: thermal injury to the anterior cervical
skin. Four patients underwent primary tracheotomy tube placement,
3 of whom were decannulated without difficulty. Two
patients required long-term gastrostomy tubes while receiving
adjuvant radiotherapy.
Conclusions. Supraglottic malignancies can be successfully
resected transorally with robotic assistance. The potential
benefits of this method are improved access and visualization.
Further long-term follow-up is needed to compare oncologic
and functional outcomes with those of current approaches.
VC 2011 Wiley Periodicals, Inc. Head Neck 34: 225–229, 2012
Keywords: supraglottic laryngectomy; transoral robotic surgery
Transoral laser microsurgery was initially described
by Vaughan et al 1,2 and further popularized by
Steiner 3 for resection of malignant tumors of the
upper aerodigestive tract. Numerous studies have
since been published describing transoral resection of
malignancies in the supraglottic larynx. 4–12 Recently,
Ambrosch 13 reviewed the literature on laser microsurgery
for the treatment of laryngeal cancer. The 5-year
survival rates for early supraglottic carcinomas (T1
and T2) achieved with laser microsurgery were comparable
to the rates reported for open supraglottic laryngectomy.
Radiotherapy for T1 and T2 cancers was
shown to have comparable tumor control rates; how-
Correspondence to: E. J. Moore
The Mayo Clinic does not endorse the products mentioned in this
article.
This work was presented at Combined Otolaryngology Spring Meeting
in Phoenix, Arizona, May 28–31, 2009.
VC 2011 Wiley Periodicals, Inc.
ever, for patients with local recurrence, 14% to 31% of
patients required total laryngectomy. Only a few
reports in the literature describe transoral treatment
outcomes for moderately advanced (T3) cancers.
These studies show significantly better control and
organ preservation with laser microsurgery or open
approaches than those with radiotherapy. 13 Furthermore,
treatment by transoral approaches is associated
with better swallowing outcomes, shorter durations of
feeding tube placement, and decreased need for tracheotomy
tube compared with open approaches. 13
Transoral robotic surgery was introduced by Weinstein
et al 14 in 2005. Previous work from the University
of Pennsylvania has shown the feasibility and
safety of this approach to the larynx. 15,16 Furthermore,
Solares and Strome 17 demonstrated on a cadaveric
model the feasibility of the daVinci Surgical
System (Intuitive Surgical Inc, Sunnyvale, CA) for
accessing the supraglottic larynx. The advantages
cited for using the daVinci robotic system in transoral
surgery include movable, high-definition, 3-dimensional
imaging, not necessarily requiring line of sight;
natural hand movement translated to the robotic
instrument; and a shorter learning curve compared
with that of traditional transoral techniques. 18
At our institution, more than 100 transoral
approaches to tumors in the oropharynx, tongue base,
and larynx have been performed. Here, we describe
our experience with transoral robotic-assisted resection
of supraglottic malignancies.
MATERIALS AND METHODS
This study was approved by the Mayo Clinic Institutional
Review Board. We retrospectively searched our
patient database for records of patients who underwent
transoral robotic-assisted resection of supraglottic
malignancies between May 2007 and November
2008. Information obtained from the medical records
included surgical procedure, tumor type and stage,
postoperative recovery, and any complications.
Operative Technique. The patients were placed in a
supine position and intubated with a laser-protected
endotracheal tube. Paralysis was induced to assist in
Robotic Transoral Supraglottic Laryngectomy HEAD & NECK—DOI 10.1002/hed February 2012 225

FIGURE 1. Feyh-Kastenbauer oral retractor. [Color figure can be
viewed in the online issue, which is available at wileyonlinelibrary.
com.]
transoral exposure. A Feyh-Kastenbauer oral retractor
(Gyrus ACMI, Bartlett, TN) was used for transoral exposure
(see Figure 1). This retractor includes several
adjustable blades; for supraglottic exposure, the laryngeal
blade (Wollenberg Laryngeal Blade; Gyrus ACMI)
(see Figure 2) was found to be most beneficial because
it reached deep into the vallecula. The laryngoscope
holder and chest support were used to suspend the
retractor. The retractor allowed the surgeon to advance
the blade and to pivot the angle of the blade to obtain
maximal exposure. Slim cheek retractors can be
mounted to help secure the endotracheal tube to the
side, and suction may be attached to the frame of the
retractor, although we did not find this efficacious.
Once we achieved adequate exposure, the daVinci
Surgical System was brought into the surgical field,
alongside the operating table. Three robotic arms
were used: 1 arm held the camera at midline; the
other 2 arms held the various 5-mm instruments. In
most cases, the Schertel grasper (Intuitive Surgical)
(see Figure 3) was found to be most useful in handling
the tissue, and a spatula tip cautery (Intuitive
Surgical) was placed in the other arm (see Figure 4).
A30 upward-facing, binocular, rigid endoscope was
FIGURE 3. Operative photograph. Operative exposure with
assistant at head of bed and robot in position. [Color figure can be
viewed in the online issue, which is available at wileyonlinelibrary.
com.]
used in all cases. The 30 lens allowed for placement
of the camera in the oropharynx, keeping it out of the
way of the other instruments. The grasping instrument
and cautery were brought in at an angle and
the trocars supporting these instruments were positioned
at cheek level to maximize the range of motion
and to avoid collision of the instruments. The primary
surgeon operated the daVinci system from the console.
An assistant was positioned at the head of the
patient with 2 suction instruments, assisting in
smoke evacuation, retraction, and hemostasis.
The approach to the tumors depended on their
location and extent. If the tumors were small enough
to be visualized in their entirety, an attempt was
made to resect them en bloc. For large, deep, infiltrating
tumors, dissection was carried through the
tumors to establish depth and orientation, and the
tumors were resected piecemeal. Margins were submitted
separately for frozen section pathologic analysis
in all cases. All frozen section margins were
obtained using the robotic system. If the epiglottis
was resected, the branch of the superior laryngeal artery
passing in the pharyngoepiglottic fold was identified
and ligated with a surgical clip (see Figure 5). A
suction cautery was also available for hemostasis.
FIGURE 2. Wollenberg laryngeal blade retractor. [Color figure
can be viewed in the online issue, which is available at
wileyonlinelibrary.com.]
FIGURE 4. Monopolar spatula cautery. (Adapted from Intuitive
Surgical, Inc. EndoWrist Instrument and Accessory Catalog
September 2010; p. 12 [Internet]. Sunnyvale (CA). Available at:
http://www.intuitivesurgical.com/products/endowrist_instruments/
871145_L_I-and-A_Catalog_2010_Public_small.pdf. Used with
permission.)
226 Robotic Transoral Supraglottic Laryngectomy HEAD & NECK—DOI 10.1002/hed February 2012

FIGURE 5. Supraglottic resection with clips on a branch of the
left superior laryngeal artery. [Color figure can be viewed in the
online issue, which is available at wileyonlinelibrary.com.]
RESULTS
Patients. Search of the database identified 7
patients who underwent transoral robotic-assisted
resection of supraglottic malignancies during the
study period. The cohort included 4 men and 3
women, with an average age of 61 years (range, 45–
72 years) (Table 1). In all patients, biopsy of the tumor
indicated a diagnosis of squamous cell carcinoma.
On the basis of the 2003 American Joint Committee
on Cancer (AJCC) TNM classification system, 2
patients had T1 tumors, 4 patients had T2 tumors,
and 1 patient had a T3 tumor. One patient had stage
I disease, 2 patients had stage II disease, 2 patients
had stage III disease, and 2 patients had stage IVA
disease. Once hemostasis and clear margins were
achieved, all patients underwent neck dissection at
the time of their initial surgery, except 1 patient who
was undergoing surgery for a previously treated recurrence.
Tracheotomy tubes were placed in 4 of the 7
patients at the time of surgery because of concomitant
bilateral neck dissections and immediate concern for
airway obstruction. Nasogastric feeding tubes were
placed in 5 patients.
Surgical Outcome. Adequate exposure was achieved
in all cases, with visualization of the tumor and the
ability to manipulate the robotic arms to allow resection
(see Figure 3). In fact, as compared with our experience
with transoral laser microsurgery, transoral
robotic surgery allowed for (1) a wider field of visualization,
without the need to readjust the laryngoscope;
(2) access to larger and bulkier tumors, which
in other circumstances might have been resected with
a traditional open approach; and (3) the ability to use
2 surgeons, thereby allowing for a more efficient
resection. Furthermore, transoral robotic surgery
allowed us to gain access to various areas that would
have been hidden with traditional line-of-sight microlaryngoscopy
and bronchoscopy, especially in the anterior
structures of the supraglottis. The extent of
infrahyoid versus suprahyoid involvement and anterior
vs posterior involvement was not a limiting factor
in the resections. No procedures were converted to
open traditional partial laryngectomy. Negative surgical
margins were achieved in all cases. The average
blood loss for the entire procedure (transoral surgery
and neck dissections) was 82 mL (range, 30–125 mL),
and the average hospital stay was 5 days (range, 4–8
days).
One immediate intraoperative complication was
identified at the end of the procedure. The patient
had a T3 tumor extending into the pre-epiglottic
space and adjacent to the thyroid cartilage. For
improved exposure, the patient’s larynx was taped
down to the operative table. This resulted in a thermal
injury due to the proximity of the electrocautery
to the skin. The skin involved was excised at the time
of the neck dissection without difficulty. The same
patient also had a late complication of supraglottic
stenosis, most likely attributable to the extent of her
surgery and disease. She subsequently required a
supraglottoplasty with stenting of her airway and is
currently decannulated.
Three of the 4 patients with tracheotomy tubes
were decannulated between postoperative days 4 and
45. One patient with supraglottic stenosis required
replacement of a tracheotomy tube, and 1 patient who
Table 1. Patient clinical data.
Patient/age, y
TNM
classification Procedure RT Trach † NG tube ‡ Outcome
1/72 T2N1M0 TORS, Rt ND N — N ALF
2/51 T1N0M0 TORS, Rt ND N — 56 days ALF
3/45 T3N0M0 TORS, Trach Bilat ND N 4 days 38 days ALF
4/57 T2N0M0 TORS, Trach Bilat ND N 45 days 45 days ALF
5/67 T2N2bM0 TORS, Trach Y Trach dependent G tube during RT Death, unknown
cause
6/67 T1N1M0 TORS N — N ALF
7/71 T2N2cM0 TORS, Trach Bilat ND Y 21 days G tube during RT ALF
Abbreviations: ALF, alive at last follow-up; Bilat, bilateral; G tube, gastrostomy tube; N, none; ND, neck dissection; NG, nasogastric feeding tube; Rt, right; RT, radiotherapy;
TORS, transoral robotic surgery; Trach, tracheotomy tube; Y, yes.
† Duration of tracheotomy tube use.
‡ Duration of nasogastric feeding tube use.
Robotic Transoral Supraglottic Laryngectomy HEAD & NECK—DOI 10.1002/hed February 2012 227

equired postoperative radiotherapy was kept with a
tracheotomy tube for airway protection and pulmonary
hygiene ascribed to aspiration. Three of the 5
patients who required nasogastric feeding tubes had
the tubes removed between postoperative days 38 and
56, and the other 2 patients, who received adjuvant
radiotherapy, required a gastrostomy tube. Only 2
patients required adjuvant radiotherapy for extensive
nodal disease. Although the follow-up period was
brief, no recurrence has been identified in any patient
since the surgery.
One patient in our cohort died of unknown causes
6 months after his surgery. He had completed adjuvant
radiotherapy and was dependent on tracheotomy
and gastrostomy tubes, without clinical evidence of
recurrent disease at the time of death.
DISCUSSION
Early reports on the use of transoral endoscopic
approaches limited the role of these approaches to biopsy
of suspicious lesions. 13 With the pioneering work
of Steiner and others, transoral endoscopic laser surgery
has evolved to be a sound oncologic approach to
early supraglottic cancers and, in certain circumstances,
to advanced cancers. 18 The main advantages of
this approach compared with the traditional open
approaches are preservation of organ structure and
function. Fewer patients require tracheotomy tubes,
rehabilitation of swallowing and vocal function is
quicker, and the incidence of aspiration pneumonia is
lower. 19 Furthermore, this approach allows for additional
treatment, and the transoral approach can be
converted to an open approach at any time. 20
There is general consensus that success is dependent
on an experienced surgeon with sound knowledge
of the surgical technique, the understanding of piecemeal
resection techniques, and endoscopic understanding
of the anatomy. 20 The experience of the
surgeon may be reflected in the number of complications
encountered. 21 The traditional endoscopic transoral
approach has several technical limitations. It
uses a microscope that is limited by ‘‘line of sight,’’
which may limit the surgeon’s view of the surgical
field and require frequent repositioning of the microscope
and/or the laryngoscope. Furthermore, this
approach allows for only 1 surgeon to operate at a
given time.
Robotic surgery has gained wide acceptance in the
urologic field and has since been implemented in cardiac,
gynecologic, and general surgery. In endoscopic
transoral approaches, the robotic system allows for 2
surgeons to participate in the procedure; the primary
surgeon operates the arms from a remote console,
while the assistant at the head of the patient can
assist with suctioning, retraction, and hemostasis.
The primary surgeon maintains a 3-dimensional view
and can reposition the camera at will. Another
advantage of the robotic system is the elimination of
the ‘‘fulcrum effect’’; the surgeon no longer uses long
instruments but controls the distal end of the robotic
instruments with 7 degrees of freedom, with scaling
of movement, increased precision, and tremor
filtration.
The current robotic system, however, does have
some limitations. The robotic system lacks haptic
feedback; the surgeon cannot sense the pressure
placed on the tissue or the firmness of the tissue.
This creates a limitation when attempting to assess
extent and depth of disease. The current system is
also restricted by the size of the instruments.
Although we were able to expose all the tumors and
resect them with negative margins, the 5-mm robotic
arms were cumbersome in a narrow surgical field.
In our patient group, 1 intraoperative complication
occurred: a monopolar cautery burn. Most likely,
the use of a cautery instrument in this area is suboptimal
because of the dissemination of heat and the
char that is created on the margin edges of the specimen,
which can make it difficult to evaluate by frozen
section pathologic analysis. The use of lasers, such as
thulium lasers, integrated into the robotic system
may solve this problem.
Further tailoring of the robotic systems to our surgical
needs may offer patients safe and oncologically
sound transoral procedures with a shorter hospital
stay, quicker return to an oral diet, and limited need
for a tracheotomy tube.
CONCLUSIONS
Supraglottic malignancy can be successfully resected
transorally with robotic assistance. As experience
grows, many malignancies that have been traditionally
approached with open partial laryngectomy may
be candidates for a more minimally invasive
approach. The potential benefits of this method are
improved access and visualization. Further long-term
follow-up is needed to compare oncologic and functional
outcomes with those of current approaches.
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