Successful Application of Transoral Robotic Surgery in Failures of Traditional Transoral Laser Microsurgery: Critical Considerations

Abstract

Aims: To assess the role of transoral robotic surgery (TORS) in managing failures of conventional transoral laser microsurgery (TLM) in cases with difficult laryngeal exposure. Methods: Retrospective analysis of 3 patients with difficult laryngeal exposure treated with TORS. All 3 cases failed to be managed by conventional TLM after repeated attempts by experienced surgeons. In 2 cases, the initial disease was laryngeal cancer treated by a cricohyoidoepiglottopexy, with an obstructing residual epiglottis. The last case was a bilateral Reinke disease submitted to repeated TLM procedures, producing multiple supraglottic and glottic scars. In all cases, the difficult exposure was produced by a combination of concurrent elements including insufficient mouth opening, short and stiff neck, macroglossia and high-positioned larynx. Results: Two patients were exposed by means of a Davis Meyer mouth gag. The other patient was managed by a Feyh-Kastenbauer device. The key of the success was the possibility to work ‘around the corner' (30° angle view) where straight alignment of the larynx was impossible. Conclusions: Where possible, a TORS approach should be considered complementary to TLM in cases of very difficult or even impossible conventional transoral laryngoscopic approach.

Contemporary Surgical Management of Early Glottic Cancer

“…65 Exposure of the larynx may be facilitated with tongue retraction and partial epiglottectomy. 66,67 Another limiting factor, until recently, was the degree of thermal injury inflicted on the glottis by the monopolar cautery used with robotic surgery. Recently, this problem has been addressed by the development of a CO 2 laser fiber, which decreases the depth and width of thermal dissemination to adjacent tissues.…”

Transoral Robotic Surgery in Oropharyngeal Carcinoma

“…[43][44][45] This is accomplished with its binocular cameras, wristed instrumentation, and tremor reduction, which eliminates the ''fulcrum'' effect and ''line of sight'' difficulties. 46,47 Indeed, Vicini et al 48 praised this aspect of the TORS approach for being able to locate and work in areas not amenable to visualization using the TLM approach. 48 In addition, the system is able to delicately manipulate tissue and perform narrow motions, providing excellent control.…”

“…46,47 Indeed, Vicini et al 48 praised this aspect of the TORS approach for being able to locate and work in areas not amenable to visualization using the TLM approach. 48 In addition, the system is able to delicately manipulate tissue and perform narrow motions, providing excellent control. 49,50 Supplemental video 1 (see supplemental digital content at www.archivesofpathology.org in the November 2015 table of contents) shows the TORS resection of a T1 right tonsil tumor, whereas supplemental video 2 demonstrates resection of an inferior T1 left tongue base tumor.…”

Videolaryngoscopy during Conscious Sedation in Patients Not Suitable for Phonosurgery by Microlaryngoscopy: A Pilot Study

“…In addition, the use of this procedure in the operating room and in the presence of an anesthesiologist allows the management of any complications. Recently, transoral robotic surgery has been proposed as an alternative technique to traditional transoral laser microsurgery in cases of difficult exposure of the larynx; however, this technique cannot be applied when there are contraindications to general anesthesia [16]. …”