Transoral robotic surgery

TransOral Robotic Surgery (TORS) is a modern surgical technique used to treat tumors of the mouth and throat via direct access through the mouth. TransOral Robotic Sleep Apnea (TORSA) surgery utilizes the same approach to open the upper airway of patients with obstructive sleep apnea. In TORS and TORSA procedures, the surgeon uses a surgical robot to view and access structures in the oral cavity (mouth) and pharynx (back of the throat) without any incisions through the neck, chin or lip (these incisions are necessary in traditional, non-robotic approaches). Current TORS techniques include radical tonsillectomy, resection of palate and base of skull tumors, hemiglossectomy and resection of tumors above and involving the larynx. The TORSA technique is used for uvulopalatopharyngoplasty, hemiglossectomy, and other airway procedures.

Transoral robotic surgery
Specialtyotolaryngology

History

The TORS technique was first developed in 2004-2005 by Drs. Gregory Weinstein and Bert O'Malley Jr. at the University of Pennsylvania.[1][2] At the time, surgical robots, in particular the da Vinci Surgical System, were already being used in urologic, thoracic and abdominal procedures. They realized the potential value of the surgical robot for otolaryngological procedures.[3] Over the next several years, Drs. Weinstein and O'Malley conducted research to demonstrate the efficacy and safety of the TORS technique.[4][5][6][7][8][9][10][11][12] They proved the efficacy of the TORS procedures for cancer cure, without the potentially disastrous complications of the established otolaryngological techniques of open surgical resection and conventional endoscopic surgery. TORS afforded cancer cure with less operating time, blood loss, and complication frequency. In light of this data, the FDA approved the da Vinci system to perform TORS procedures in 2009.[13][14][15]

Dr. Erica Thaler, also at the University of Pennsylvania, researched the applications of the TORS approach to patients with obstructive sleep apnea, and published her work in 2016. She found that a multilevel approach, including tongue resection and uvulopalatopharyngoplasty, increased airway space and oxygen levels in most cases. The newly minted procedure was found especially beneficial for patients without prior pharyngeal surgery.[16]

Procedural Details

To begin a TORS/TORSA procedure, the patient is anesthetized in the supine position. A retractor is used to open the mouth to create room for the robotic camera and surgical instruments. The da Vinci patient-side cart is then brought to the bedside and the robotic instruments and camera are guided into the patient's mouth. Once the operation begins, the surgeon sits at the surgeon's console and views the patient's throat through a 3-dimensional view finder. As the surgeon manipulates the instrument controls, the robotic instruments move deep inside the patient's mouth, and the operation is performed. Resection of tissue and suturing are accomplished with the advantages of the surgical robot at the back of the pharynx.

The defining aspects of the TORS technique are:

  1. The operation is performed with the technology of the surgical robot.
  2. The robotic instruments are placed in the patient's mouth, rather than through an external incision.

Variations in the TORS technique are due to location of the cancer or obstruction and to the surgeon's preference.

Indications

Cancerous or benign tumors

TORS provides an excellent alternative to chemoradiation and traditional open surgeries for some cancers of the mouth, throat, larynx and base of skull. Chemotherapy and radiation therapy are associated with long-term, potentially harmful toxicities, and open surgeries are highly invasive and prone to serious complications and extended hospital stays. TORS avoids these issues by avoiding the external incisions and reducing surgical time, both of which are associated with increased blood loss and infection.[6] There are ongoing clinical trials collecting data on TORS, but numerous studies have repeatedly shown it to be both safe and effective in treating malignant and benign tumors of the head and neck.[17]

Figure 1: This diagram shows how TORSA increases the airway size when the lingual tonsils are too large.
Figure 2: This diagram shows how TORSA increases the airway size when the mouth is too small or the tongue is too large.

Obstructive sleep apnea (TORSA)

The objective of TORSA (TransORal Sleep Apnea) surgery is to increase the size of the air space leading from the mouth to the trachea. This can include removal of the tonsils, adenoids, uvula and edge of the palate, and/or part of the base of the tongue. When removal of the base of the tongue is necessary, it can be removed in one of two ways. If the lingual tonsil tissue is large along the back of the tongue, it is shaved in a side-to-side direction [Figure 1]. If the tongue is exceedingly large compared to the size of the throat, it is reduced by resecting tissue in the midline [Figure 2]. Quantitative studies of patient outcomes are not yet available.

Outcomes

TORS procedures offer many advantages to the alternative surgical techniques of open surgical resection and conventional endoscopic surgery. The current literature indicates that the TORS technique results in less blood loss, shorter hospital stays, and lower complication rates than open surgery.[18]

TORS as a cancer treatment

To date, the largest study of TORS as a cancer treatment included data from 410 patients. This study demonstrated 91.8% 2-year locoregional control of the cancer, and 94.5% 2-year disease-specific survival. These numbers are similar to those of other head and neck cancer treatment options.[17] A separate study of 62 patients found that 69% resumed oral intake prior to discharge, and 83% within two weeks.[19]

TORS/TORSA as an obstructive sleep apnea treatment

The Apnea-Hypopnea Index (AHI), the number of breathing obstructions or near-obstructions per hour of sleep, is one common way to measure the degree of a patient's sleep apnea. The higher the number, the worse the breathing during sleep. In a 2016 study of 75 patients, the average decrease in AHI post-TORS was 45%.[16] Another 2016 study found an average AHI reduction of 51% in 11 patients.[20] Researchers have also investigated the effect of TORS surgery for obstructive sleep apnea on swallowing function. A 2015 study of 78 patients found that oral feeding was resumed on average 1.05 days post-operatively, and not a single patient complained of long-term swallowing difficulty.[21]

Complications

Many studies have evaluated TORS patient outcomes and have found complications in 10-25% of cases. Most of these are minor, including dehydration, tooth injury, bleeding, dysphagia, dysgeusia, and uncontrolled pain. Fewer patients develop major complications, which include hemorrhage, deep venous thrombosis, pneumonia, pulmonary embolism, or death.[22][23][24]

References
  1. Weinstein, Gregory S.; O'Malley, Bert W. Jr. (2011). TransOral robotic surgery. Plural Publishing. ISBN 978-1597560740.
  2. "Penn Medicine TransOral Robotic Surgery Program". Penn Medicine.
  3. Hockstein, Neil G.; O'Malley, Bert W. Jr. (2008). "Transoral robotic surgery". Operative Techniques in Otolaryngology. 19 (1): 67–71. doi:10.1016/j.otot.2008.03.005.
  4. Weinstein, Gregory S.; O'Malley, Bert W. Jr; Hockstein, Neil G. (2005). "Transoral Robotic Surgery: Supraglottic Laryngectomy in a Canine Model". The Laryngoscope. 115 (7): 1315–1319. doi:10.1097/01.MLG.0000170848.76045.47. PMID 15995528. S2CID 30860198.
  5. Hockstein, Neil G.; Weinstein, Gregory S.; O'Malley, Bert W. Jr (2005). "Maintenance of Hemostasis in Transoral Robotic Surgery". ORL. 67 (4): 220–224. doi:10.1159/000088012. PMID 16145284. S2CID 46748839.
  6. O'Malley, Bert W. Jr; Weinstein, Gregory S.; Snyder, Wendy; Hockstein, Neil G. (2006). "Transoral Robotic Surgery (TORS) for Base of Tongue Neoplasms". The Laryngoscope. 116 (8): 1465–1472. doi:10.1097/01.mlg.0000227184.90514.1a. PMID 16885755. S2CID 6816969.
  7. O'Malley, Bert W. Jr; Weinstein, Gregory S.; Hockstein, Neil G. (2006). "Transoral Robotic Surgery (TORS): Glottic Microsurgery in a Canine Model". Journal of Voice. 20 (2): 263–268. doi:10.1016/j.jvoice.2005.10.004. PMID 16472973.
  8. Hockstein, Neil G.; O'Malley, Bert W. Jr; Weinstein, Gregory S. (2006). "Assessment of Intraoperative Safety in Transoral Robotic Surgery". The Laryngoscope. 116 (2): 165–168. doi:10.1097/01.mlg.0000199899.00479.75. PMID 16467698. S2CID 30810422.
  9. Weinstein, Gregory S.; O'Malley, Bert W. Jr; Snyder, Wendy; Sherman, Eric; Quon, Harry (2007). "Transoral robotic surgery: radical tonsillectomy". Archives of Otolaryngology–Head & Neck Surgery. 133 (12): 1220–1226. doi:10.1001/archotol.133.12.1220. PMID 18086963.
  10. O'Malley, Bert W. Jr; Weinstein, Gregory S. (2007). "Robotic skull base surgery: Preclinical investigations to human clinical application". Archives of Otolaryngology–Head & Neck Surgery. 133 (12): 1215–1219. doi:10.1001/archotol.133.12.1215. PMID 18086962.
  11. Solares, C Arturo; Strome, Marshall (2007). "Transoral Robot-Assisted CO2 Laser Supraglottic Laryngectomy: Experimental and Clinical Data". The Laryngoscope. 117 (5): 817–820. doi:10.1097/MLG.0b013e31803330b7. PMID 17473675. S2CID 33544525.
  12. Weinstein, Gregory S.; O'Malley, Bert W. Jr; Snyder, Wendy; Hockstein, Neil G. (2007). "Transoral Robotic Surgery: Supraglottic Partial Laryngectomy". Annals of Otology, Rhinology, and Laryngology. 116 (1): 19–23. doi:10.1177/000348940711600104. PMID 17305273. S2CID 43831955.
  13. "TransOral Robotic Surgery". Penn Medicine Department of Otorhinolaryngology - Head and Neck Surgery.
  14. Justin, Grant A.; Chang, Edward T.; Camacho, Macario; Brietzke, Scott E. (2016). "Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis". Otolaryngology–Head and Neck Surgery. 154 (5): 835–846. doi:10.1177/0194599816630962. PMID 26932967. S2CID 13739656.
  15. Vicini, C.; Dallan, I.; Canzi, P.; Frassineti, S.; La Pietra, M.G.; Montevecchi, F. (2016). "Transoral robotic tongue base resection in obstructive sleep apnoea-hypopnoea syndrome: A preliminary report". ORL. 72 (1): 22–27. doi:10.1159/000284352. PMID 20173358. S2CID 207655554.
  16. Thaler, Erica R.; Rassekh, Christopher H.; Lee, Jonathon M.; Weinstein, Gregory S.; O'Malley, Bert W. Jr. (2016). "Outcomes for multilevel surgery for sleep apnea: Obstructive sleep apnea, transoral robotic surgery, and uvulopalatopharyngoplasty". The Laryngoscope. 126 (1): 266–269. doi:10.1002/lary.25353. PMID 26153069. S2CID 206202769.
  17. Byrd, J. Kenneth; Ferris, Robert L. (2016). "Is There a Role for Robotic Surgery in the Treatment of Head and Neck Cancer?". Current Treatment Options in Oncology. 17 (6): 1–12. doi:10.1007/s11864-016-0405-5. PMC 5423354. PMID 27117980.
  18. Weinstein, Gregory S.; O'Malley, Bert W. Jr.; Desai, Shaun C.; Quon, Harry (2009). "Transoral robotic surgery: does the ends justify the means?". Current Opinion in Otolaryngology & Head and Neck Surgery. 17 (2): 126–131. doi:10.1097/MOO.0b013e32832924f5. PMID 19342953. S2CID 17900923.
  19. Iseli, Tim A.; Kulbersh, Brian D.; Iseli, Claire E.; Carroll, William R.; Rosenthal, Eben L.; Magnuson, J. Scott (2009). "Functional outcomes after transoral robotic surgery for head and neck cancer". Otolaryngology–Head and Neck Surgery. 141 (2): 166–171. doi:10.1016/j.otohns.2009.05.014. PMID 19643246. S2CID 31522196.
  20. Arora, Asit; Chaidas, Konstantinos; Garas, George; Amlani, Ashik; Darzi, Ara; Kotecha, Bhik; Tolley, Neil S. (2016). "Outcome of TORS to tongue base and epiglottis in patients with OSA intolerant of conventional treatment". Sleep and Breathing. 20 (2): 739–747. doi:10.1007/s11325-015-1293-9. hdl:10044/1/51660. PMID 26669877. S2CID 8939908.
  21. Eesa, Mohamed; Montevecchi, Filippo; Hendawy, Ehsan; D'Agostino, Giovanni; Meccariello, Giuseppe; Vicini, Claudio (2015). "Swallowing outcome after TORS for sleep apnea: short- and long-term evaluation". European Archives of Oto-Rhino-Laryngology. 272 (6): 1537–1541. doi:10.1007/s00405-014-3480-x. PMID 25557003. S2CID 116036.
  22. Justin, Grant A.; Chang, Edward T.; Camacho, Macario; Brietzke, Scott E. (2016). "Transoral Robotic Surgery for Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis". Otolaryngology–Head and Neck Surgery. 154 (5): 835–846. doi:10.1177/0194599816630962. PMID 26932967. S2CID 13739656.
  23. Glazer, Tiffany A.; Hoff, Paul T.; Spector, Matthew E. (2014). "Transoral Robotic Surgery for Obstructive Sleep Apnea: Perioperative Management and Postoperative Complications". JAMA Otolaryngology–Head & Neck Surgery. 140 (12): 1207–1212. doi:10.1001/jamaoto.2014.2299. PMID 25275670.
  24. Chia, Stanley H.; Gross, Neil D.; Richmon, Jeremy D. (2013). "Surgeon Experience and Complications with Transoral Robotic Surgery (TORS)". Otolaryngology–Head and Neck Surgery. 149 (6): 885–892. doi:10.1177/0194599813503446. PMID 24013139. S2CID 3339804.
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