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LA
SG
MP
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Fig. 35.4 Index mucosal cuts are made
early (prior to extensive mobilisation of
tumour) along the posterior pharyngeal
wall to avoid excessive resection of
posterior pharyngeal mucosa
[palatopharyngeal (PP), superior
constrictor (SC) muscle]
351
FB
SC
PPF
Fig. 35.5 With continued inferior dissection, the styloglossus/stylopharyngeus is seen. Excision of a cuff of styloglossus muscle is undertaken to ensure an adequate oncological margin is achieved [styloglossus
(SG) muscle, stylopharyngeus (SP) muscle, lingual artery (LA), medial
pterygoid (MP) muscle
SP
more vertically oriented, fan-like stylopharyngeus muscle,
found medial and posterior to the styloglossus. Gradual dissection, using the spatula parallel to the constrictor, is used
to develop a plane between the prevertebral fascia and stylopharyngeus muscle. Once this is done, the Maryland is used
to lift and retract the stylopharyngeus and constrictors muscle as one entity, which is divided with the monopolar cautery (Fig.35.6). This step is repeated until the muscles are
completely divided and the specimen released from its lateral attachment, taking care to avoid potential damage to the
underlying glossopharyngeal nerve. Bleeding from the pharyngeal venous plexus may also be encountered at this stage
and managed with bipolar cautery. Care is taken when dissecting at the level of styloglossus to avoid damage to the
higher-calibre branches of the external carotid, including
the lingual artery, which lies 5–8mm deep to the muscle and
may require ligation with surgical clips along the whole
length of the exposed vessel.
Fig. 35.6 Further release of specimen is achieved with progressive
dissection of the stylopharyngeus muscle and a cuff of tongue base (A)
to ensure an adequate inferior margin
Tip
Prior to dividing muscle, always delineate and elevate
from surrounding structures to avoid potential damage
to underlying blood vessels. The stylopharyngeus and
styloglossus are key landmarks in protecting the underlying neurovascular structures, including the ICA,
which lies lateral to these muscles at the level of the
oropharynx. Variation may exist, and radiological correlation is crucial to ensure presence of the parapharyngeal fat pad and to exclude a retropharyngeal ICA,
which is a contraindication for TORS.
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Tip
Whenever fascia is encountered, use blunt dissection
to expose underlying vessels while avoiding directly
cutting into fascia. Although small vessels may be
managed with cautery alone, larger named vessels
(branches of the facial, lingual and ascending pharyngeal) should be controlled with surgical clips.
Inferiorly, the dissection includes approximately 1 cm
cuff of the tongue base muscle, between the anterior and posterior pillars, to ensure an appropriate oncological margin,
but this may need to be extended in cases where the tonsil
tumour extends into the tongue base (Fig. 35.6). Counter
traction is obtained with the Maryland forceps pushing the
tongue base posteriorly, opposed by the assistant retracting
the anterior portion of the tongue base and incising from
medial to lateral, will ensure an appropriate cuff of tongue
base. By remaining supercial to the styloglossus in the
early part of the dissection until wide exposure is obtained,
signicant bleeding in a narrow surgical eld can be avoided.
S. Siddiq et al.
tion if access is limited. A vertical midline incision is made rst
with the monopolar cautery, from the level of the circumvallate
papillae towards the vallecula, just up to the muscle layer of the
tongue base (Fig.35.7). Unlike the palatine tonsils, the lingual
tonsils are not encapsulated, but a plane of dissection is described
[43] deep to the lingual tonsil and supercial to the underlying
minor salivary gland and muscle of the tongue base. This is a
relatively avascular plane, and therefore with appropriate retraction, dissection in the correct plane is relatively bloodless.
Tip
Ensure an adequate depth and length to the initial incision is made, to ensure the avascular plane can be
identied. Resist the urge to grasp the specimen with
the Maryland forceps, which can cause tearing and
crush artefact to the specimen margins; instead, use
the Maryland forceps like a claw retractor, parked
close to the site of dissection. Counter traction by the
assistant will allow the specimen to fall into the operative eld.
35.4.2 Tongue Base Mucosectomy
A similar set up to tongue base tumours (see 35.4.3) is advised
for choice of endoscope and retraction. The orotracheal tube
may be manipulated to each side respectively by the assistant
during TBM, however some surgeons may prefer nasal intuba-
A horizontal superior incision is made from the superior
limb of the midline incision, extending laterally to the glossotonsillar sulci, again just to the depth of the tongue base
musculature (Fig.35.8).
Using the Maryland grasper to retract the specimen, a plane
between the submucosa and the muscle is developed from a
medial to a lateral direction with the monopolar cautery, and
the entire mucosal layer of the tongue base is dissected down
to the vallecula (Fig.35.9). The specimen is thinner laterally,
and it may be easier to dene the avascular plane here if dif-
Maryland Monapolar
Fig. 35.7 An initial vertical midline tongue base incision is made
immediately distal to the circumvallate papillae just into extrinsic
tongue musculature extending to the vallecula
Fig. 35.8 The superior incision continues from the initial midline and
extends laterally to encompass the lingual tonsil bearing tissue in the
glossotonsillar sulcus
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353
Fig. 35.9 Sharp dissection continues with the monopolar spatula inferiorly from a medial to lateral direction along a broad front to develop
the avascular plane between the tongue musculature and lingual tonsillar mucosal bearing tissue to the level of the vallecula
culty is encountered closer to the midline. Once one side of the
TBM is completed, it is oriented immediately before commencing the contralateral TBM. Haemostasis is achieved with
bipolar cautery as the operation progresses.
Tip
The epiglottis should be kept in view throughout the
procedure to determine the inferior extent of the resection. While it is feasible to remove the entire tongue
base tonsillar tissue as a single specimen, the authors
recommend a midline incision to remove the two sides
separately to minimise trauma to the specimen,
improve access and facilitate orientation. In patients
with difcult access, it is reasonable to perform TBM
as a mosaic resection, as removing anteriorly placed
lingual tonsils offer better access to the more remote
part of the anatomy. In these instances, the specimen
must be meticulously oriented.
35.4.3 Tongue Base Tumours
A reinforced endotracheal tube is placed and positioned to
the contralateral side of the tongue and secured in place with
a 2-0 silk suture placed between the lateral border of the
tongue and retromolar trigone. The suture is left long and
attached to a haemostat, then placed to the side of the external mouth to ensure it is removed postoperatively.
Combined with the 30° endoscope, the Feyh-Kastenbauer
(FK) retractor provides an excellent view of the tongue base
for all the operative steps.
Fig. 35.10 The initial lateral incision continues to depth of the styloglossus extending anteriorly towards the midline, taking an adequate
margin just distal to the tongue retractor blade. This allows the creation
of a shelf of tissue and if required adjustment of the retractor blade to
aid dissection
With the da Vinci arms docked as above, the dissection
commences laterally; based on the location of the tumour,
the lower third of the tonsil is mobilised if needed for margins (Fig.35.10). Dissection is limited to the level of the styloglossus. The lateral cut is continued medially as the anterior
horizontal cut through mucosa of the tongue base, just behind
the tongue blade of the FK retractor to a depth of a centimetre, with the trajectory of the cut towards the hyoid bone.
An incision is made in the midline from the medial aspect
of the horizontal cut down to the depth of the vallecula, which
will help dene the nal depth of the horizontal cut
(Fig.35.11). There is no signicant vasculature at the level of
the midline tongue. Dissection is continued from medial to
lateral, at the depth dened by the midline cut, which usually
denes the loop of the dorsal lingual branch of the lingual
artery (Fig.35.12); Liga clips are applied over the exposed
part of the artery, and the specimen is removed. Some of the
extrinsic muscles, usually the cranial portion of the hyoglossus, may need to be resected based on the depth of the tumour,
which exposes the lingual artery. Normal musculature will be
seen with the high visual optics to separate more easily and
contract during the dissection avoiding inadvertent entry into
tissue involved with or close to the tumour.
Tip
If excessive bleeding results from the lingual artery, external pressure can be applied by the assistant in the area of
the greater cornu of the hyoid bone to tamponade and
slow down bleeding until vascular clips are applied.
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Dorsal lingual
Lingual artery
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Fig. 35.11 The midline tongue base incision is extended to the inferior
limit of the vallecula and with continued dissection the tumour progressively drops into the oropharynx
artery
Fig. 35.12 Final inferior incision at the level of the vallecula, incising
the mucosa to release the specimen. The relationship of the lingual
artery and dorsal lingual branches are shown
The inferior cut should be made at the level of the vallecula to avoid excessive removal and trauma to the pharyngeal mucosa of the epiglottis. This can be made earlier during
the dissection to ensure early recognition of the inferior limit
of dissection.
With any TORS resection, just before the tumour is completely excised, it should be reoriented and, once freed,
removed by the assistant in the correctly oriented position.
The specimen is mounted, with appropriate clinical photography and labelling of specimens to ensure optimal communication with the pathology team [44]. This is particularly
important if immediate transfer of the specimen and liaison
with the pathologist is not logistically feasible. Intraoperative
S. Siddiq et al.
frozen section is recommended to address any margins of
uncertainty intraoperatively at the same sitting. To avoid attening and distorting the deep convex margin (and thereby
underestimation of the margin), the TORS specimen should
be mounted with the deeper convex aspect facing upward to
ensure the natural convexity is maintained during formalin
xation.
35.5 Postoperative Care
Throat pain, odynophagia and dysphagia will often result
following any TORS procedure. Early and optimal management of these sequelae are important to avoid the more serious complications of aspiration pneumonia and
dehydration.
35.5.1 Postoperative Pain andAirway
Compromise
Crucially, the return to normal swallow will depend upon the
optimal control of postoperative pain. Often, this will comprise multi-modal opioid-based analgesia in combination
with acetaminophen, nonsteroidal anti-inammatory drugs
(NSAID) and neurotransmitter modulators such as gabapentin, although the latter has not been associated with improved
pain control [45]. In the setting of tonsillectomy [46], the
administration of steroids has been shown to improve pain,
expedite return to oral intake and reduce postoperative nausea and vomiting. Following TORS procedures, corticosteroids are often administered both intraoperatively and for the
rst 24–72h to minimise airway oedema, and randomised
control data [47] suggests extended use up to 4days postsurgery is safe and leads to earlier improvement in diet consistency and decreased length of hospital stay (median
1day). Some surgeons, however, prefer to minimise the routine use of steroids after cancer resection unless required for
airway management.
The decision regarding immediate extubation versus
extended intubation following surgery up to 24h is dependent on concerns of potential airway obstruction, often secondary to signicant tongue oedema related to compression
from the retractor blade and reperfusion. Generally, a routine
tracheostomy is not required in appropriately selected
patients following TORS in the primary setting. In the setting of TORS for early-stage oropharyngeal malignancy, the
need for tracheotomy following TORS is low, with rates of
0–31% reported [15], with the higher rates reecting
advanced stage cases.
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35.5.2 Swallow Function
Generally, nasogastric feeding tubes are placed intraoperatively in all patients undergoing TORS for malignancy. These
are removed following assessment by the speech and language therapist (SALT) once the patient is deemed safe to
swallow and achieve adequate oral intake. The degree of dysphagia will depend upon the extent of resection (TBM versus
resection tongue base into muscle), number of sub-sites and
patient age [48]. All patients planned for TORS should
undergo a preoperative swallow assessment to predict and
risk-stratify their potential post-treatment swallow function
and degree of expected dysphagia [48]. Postoperative swallow assessment is key to ensure timely discharge and to
assess for any potential neurological decit as a result of
injury to glossopharyngeal, hypoglossal or lingual nerves.
Direct injury is less likely if anatomical landmarks are
respected; however, compression injury to the lingual nerve
may occur depending on the duration and extent of tongue
retraction, which may result in hypogeusia.
The majority of patients will initiate oral intake by postoperative day 1in early T1/T2 oropharynx cancer. Delays in
resuming diet are associated with higher T stage or laryngeal
subsite of surgery [15], with the average length of hospital
stay in heterogenous TORS datasets of 4.2days [49], but
reduced to <2 days [48, 50] in early-stage oropharynx
tumours. Similar rates are seen post-TBM [51].
Aspiration pneumonia rates in TORS procedures for
malignancy range from 0 to 7% [15] with higher rates noted
in higher T stage or laryngeal subsite of primary tumour.
35.5.3 Complications
Rates of serious complications following TORS have been
reported in 16–18% [48] of cases, with postoperative bleeding being the most common. Although infrequent, postoperative bleeding following TORS can be potentially
life-threatening. TORS is associated with a 3–8% [15, 52,
53] risk of postoperative bleed rate, most occurring around
the tenth postoperative day [42, 53], with the majority requir-
ing return to theatre for denitive management. Hence, clear
postoperative written instructions should be provided to
patients on discharge regarding the most likely times for
bleeding and management in the event of a bleed. This
should include placing their head in a dependent position
while awaiting attendance of emergency services to avoid
risks of aspiration/asphyxiation.
Studies [54] have shown statistically signicant postoperative bleeding rates in patients taking anticoagulant and
anti-platelet medication due to other co-morbidities, despite
being terminated/bridged prior to TORS.Some authors [55]
have noted postoperative bleeding episodes following the re-
initiation of anticoagulation therapy and recommend withholding anticoagulation up to 4 weeks postoperatively in
TORS for obstructive sleep apnoea.
There is paucity of evidence, with studies suggesting no
statistical signicance of bleeding rate [41, 42] in the context
of transcervical vessel ligation. However, when comparing
patients who have undergone transcervical ligation of vessels, the frequency of ‘severe’ bleeding (dened as bleeding
resulting in hypoxia/airway compromise requiring tracheostomy, cardiopulmonary arrest or hemodynamic instability
requiring a blood transfusion) is lower in patients who have
undergone vessel ligation [41, 42]. Therefore, transcervical
vessel ligation is strongly recommended to prevent a serious
or life-threatening postoperative bleed.
References
1. O’Malley BW Jr, Weinstein GS. FDA clears transoral robotic
surgery—developed at Penn—for tumors of mouth, throat,
and voice box. 2009. http://www.uphs.upenn.edu/news/News_
Releases/2009/12/tors- robotic- head- neck- surgery/. Accessed 20
Nov 2019.
2. Weinstein GS, O’Malley BW Jr, Cohen MA, Quon H. Transoral
robotic surgery for advanced oropharyngeal carcinoma. Arch
Otolaryngol Head Neck Surg. 2010;136(11):1079–85.
3. Hardman JC, Holsinger FC, Brady GC, et al. Transoral Robotic
Surgery for Recurrent Tumors of the Upper Aerodigestive Tract
(RECUT): an international cohort study. J Natl Cancer Inst.
2022;114:1400–9. https://doi.org/10.1093/jnci/djac130.
4. Holsinger FC, Ferris RL.Transoral endoscopic head and neck surgery and its role within the multidisciplinary treatment paradigm of
oropharynx cancer: robotics, lasers, and clinical trials. J Clin Oncol.
2015;33(29):3285–92.
5. Isaksson J, Salander P, Lilliehorn S, Laurell G.Living an everyday
life with head and neck cancer 2–2.5 years post-diagnosis: a qualitative prospective study of 56 patients. Soc Sci Med. 2016;154:54–61.
6. Threader J, McCormack L. Cancer-related trauma, stigma and
growth: the ‘lived’ experience of head and neck cancer. Eur J
Cancer Care (Engl). 2016;25(1):157–69.
7. Wu Y-S, Lin P-Y, Chien C-Y, Fang F-M, Chiu N-M, Hung C-F,
et al. Anxiety and depression in patients with head and neck
cancer: 6-month follow-up study. Neuropsychiatr Dis Treat.
2016;12:1029–36.
8. Machtay M, Moughan J, Trotti A, Garden AS, Weber RS, Cooper
JS, etal. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an
RTOG analysis. J Clin Oncol. 2008;26:3582–9.
9. McLeod IK, Melder PC.Da Vinci robot-assisted excision of a vallecular cyst: a case report. Ear Nose Throat J. 2005;84(3):170–2.
10. de Almeida JR, Li R, Magnuson JS, Smith RV, Moore E, Lawson
G, et al. Oncologic outcomes after transoral robotic surgery: a
multi-institutional study. JAMA Otolaryngol Head Neck Surg.
2015;141:1043–51.
11. de Almeida JR, Byrd JK, Wu R, Stucken CL, Duvvuri U, Goldstein
DP, et al. A systematic review of transoral robotic surgery and
radiotherapy for early oropharynx cancer: a systematic review.
Laryngoscope. 2014;124:2096–102.
12. Ferris RL, Flamand Y, Weinstein GS, etal. Transoral robotic surgical resection followed by randomization to low- or standard-dose
IMRT in resectable p16+ locally advanced oropharynx cancer: a
356
https://t.me/med1917
S. Siddiq et al.
trial of the ECOG-ACRIN Cancer Research Group (E3311). J Clin
Oncol. 2020;38(15_suppl):6500.
13. Owen S, Puvanendran M, Meikle D, Bowe I, O’Hara J, Patterson
J, etal. Baseline swallowing measures predict recovery at 6 weeks
after transoral robotic surgery for head and neck cancer. Clin
Otolaryngol. 2017;42:366–72.
14. More YI, Tsue TT, Girod DA, Harbison J, Sykes KJ, Williams C,
etal. Functional swallowing outcomes following transoral robotic
surgery vs primary chemoradiotherapy in patients with advancedstage oropharynx and supraglottis cancers. JAMA Otolaryngol
Head Neck Surg. 2013;139(1):43–8.
15. Hutcheson KA, Holsinger FC, Kupferman ME, Lewin JS.Functional
outcomes after TORS for oropharyngeal cancer: a systematic
review. Eur Arch Otorhinolaryngol. 2015;272(2):463–71.
16. Nichols AC, Theurer J, Prisman E, Read N, Berthelet E, Tran E,
etal. Radiotherapy versus transoral robotic surgery and neck dissection for oropharyngeal squamous cell carcinoma (ORATOR):
an open-label, phase 2, randomised trial. Lancet Oncol.
2019;20(10):P1349–59.
17. Mehta V, Johnson P, Tassler A, Kim S, Ferris RL, Nance M, etal.
A new paradigm for the diagnosis and management of unknown
primary tumors of the head and neck: a role for transoral robotic
surgery. Laryngoscope. 2013;123(1):146–51.
18. Geltzeiler M, Doerer S, Turner M, Albergotti WG, Kubik M,
Kim S, etal. Transoral robotic surgery for management of cervical
unknown primary squamous cell carcinoma: updates on efcacy,
surgical technique and margin status. Oral Oncol. 2017;66:9–13.
19. Kwee TC, Kwee RM.Combined FDG-PET/CT for the detection
of unknown primary tumors: systematic review and meta-analysis.
Eur Radiol. 2009;19:731–44.
20. Zhu L, Wang N. 18F-uorodeoxyglucose positron emission
tomography- computed tomography as a diagnostic tool in patients
with cervical nodal metastases of unknown primary site: a metaanalysis. Surg Oncol. 2013;22:190–4.
21. Hermans R.Imaging in cervical nodal metastases of unknown primary. Cancer Imaging. 2011;11(1A):S9–14.
22. Rumboldt Z, Gordon L, Gordon L, Bonsall R, Ackermann
S.Imaging in head and neck cancer. Curr Treat Options in Oncol.
2006;7:23–34.
23. Fu TS, Foreman A, Goldstein DP, de Almeida JR. The role of
transoral robotic surgery, transoral laser microsurgery, and lingual
tonsillectomy in the identication of head and neck squamous
cell carcinoma of unknown primary origin: a systematic review. J
Otolaryngol Head Neck Surg. 2016;45(1):28.
24. Winter SC, Ofo E, Meikle D, Silva P, Fraser L, O’Hara J, et al.
Trans-oral robotic assisted tongue base mucosectomy for investigation of cancer of unknown primary in the head and neck region. The
UK experience. Clin Otolaryngol. 2017;42(6):1247–51.
25. Farooq S, Khandavilli S, Dretzke J, Moore D, Nankivell PC, Sharma
N, etal. Transoral tongue base mucosectomy for the identication
of the primary site in the work-up of cancers of unknown origin:
systematic review and meta-analysis. Oral Oncol. 2019;91:97–106.
26. Investigation and management of the unknown primary with metastatic neck disease: United Kingdom National Multidisciplinary
guidelines. (Revised guidelines submitted for publication).
27. Maghami E, Ismaila N, Alvarez A, Chernock R, Duvvuri U, Geiger
J, etal. Diagnosis and management of squamous cell carcinoma of
unknown primary in the head and neck: ASCO guideline. J Clin
Oncol. 2020;38(22):2570–96.
28. Evaluation of the role of tongue base MucOsectomy and Step sErial
Sectioning in the management of the unknown primary squamous
cell cancer in the head and neck (MOSES). https://clinicaltrials.
gov/ProvidedDocs/34/NCT04151134/Prot_000.pdf.
29. Haas I, Hoffmann TK, Engers R, Ganzer U.Diagnostic strategies
in cervical carcinoma of an unknown primary (CUP). Eur Arch
Otorhinolaryngol. 2002;259:325–33.
30. de Almeida JR, Goldstein DP, Martino R, Su J, Hosni A, Bratman
SV, et al. Transoral robotic surgery (TORS)-guided radiotherapy
(RT) volume de-intensication in p16-positive unknown primary
squamous cell carcinoma (SCC) of the neck: a phase 2 trial (FIND).
J Clin Oncol. 2022;40(suppl 16):abstr 6067.
31. Richards TM, Bhide SA, Miah AB, Del Rosario L, Bodla S, Thway
K, etal. Total mucosal irradiation with intensity-modulated radiotherapy in patients with head and neck carcinoma of unknown primary: a pooled analysis of two prospective studies. Clin Oncol (R
Coll Radiol). 2016;28(9):e77–84.
32. Chen AM, Li BQ, Farwell DG, Marsano J, Vijayakumar S, Purdy
JA.Improved dosimetric and clinical outcomes with IMRT for head
and neck cancer of unknown primary origin. Int J Radiat Oncol
Biol Phys. 2011;79(3):756–62.
33. Owadally W, Hurt C, Timmins H, Parsons E, Townsend S, Patterson
J, etal. PATHOS: a phase II/III trial of risk-stratied, reduced intensity adjuvant treatment in patients undergoing transoral surgery for
human papillomavirus (HPV) positive oropharyngeal cancer. BMC
Cancer. 2015;15:602.
34. Ofo E, Spiers H, Kim D, Duvvuri U. Transoral robotic surgery and the unknown primary. J Otorhinolaryngol Relat Spec.
2018;80(3–4):148–55.
35. Siddiq S, Cartlidge D, Stephen S, Sathasivam HP, Fox H, O’Hara
J, et al. Robotic lateral oropharyngectomy following diagnostic tonsillectomy is oncologically safe in patients with high risk
human papillomavirus related squamous cell cancer. Eur Arch
Otorhinolaryngol. 2018;275(7):1853–60.
36. Weinstein GS, O’Malley BW, Rinaldo A, Silver CE, Werner JA,
Ferlito A.Understanding contraindication for transoral robotic surgery (TORS) for oropharyngeal cancer. Eur Arch Otorhinolaryngol.
2015;272:1551–2.
37. Lörincz BB, Jewett N, Knecht R.Decision management in transoral robotic surgery: indications, individual patient selection,
and role in the multidisciplinary treatment for head and neck
cancer from a European perspective. Head Neck. 2016;38(Suppl
1):E2190–6.
38. Moore EJ, Olsen KD, Martin EJ.Concurrent neck dissection and
transoral robotic surgery. Laryngoscope. 2011;121(3):541–4.
39. Kucur C, Durmus K, Gun R, Old MO, Agrawal A, Teknos TN, etal.
Safety and efcacy of concurrent neck dissection and transoral
robotic surgery. Head Neck. 2016;38(Suppl 1):E519–23.
40. Howard BE, Hinni ML, Nagel TH, Chang YH, Cheng MR, Hayden
RE.Submandibular gland preservation during concurrent neck dissection and transoral surgery for oropharyngeal squamous cell carcinoma. Otolaryngol Head Neck Surg. 2014;150(4):587–93.
41. Mandal R, Duvvuri U, Ferris RL, Kaffenberger TM, Choby
GW, Kim S. Analysis of post-transoral robotic-assisted surgery
hemorrhage: frequency, outcomes and prevention. Head Neck.
2016;38(1):E776–82.
42. Pollei TR, Hinni ML, Moore EJ, Hayden RE, Olsen KD, Casler JD,
etal. Analysis of postoperative bleeding and risk factors in transoral
surgery of the oropharynx. JAMA Otolaryngol Head Neck Surg.
2013;139(11):1212–8.
43. Son EL, Underbrink MP, Qiu S, Resto VA.The surgical plane for
lingual tonsillectomy: an anatomic study. J Otolaryngol Head Neck
Surg. 2016;45:22.
44. Robinson M, O’Hara J, Siddiq S, Jones TM, Paleri P, Sandison
A, et al. Trans-oral robotic surgery for oropharyngeal
cancer- implications for the pathologists. Diagn Histopathol.
2020;26(4):181–7.
35 Robotic Surgery
https://t.me/med1917
357
45. Van Abel KM, Sauer AB, Kruthiventi SC, Weingarten TN, Noel
DB, Price DL, etal. Non-opioid analgesics and post-operative pain
following transoral robotic surgery for oropharyngeal cancer. J
Laryngol Otol. 2022;136(6):527–34.
46. Baugh RF, Archer SM, Mitchell RB, Rosenfeld RM, Amin R,
Burns JJ, etal. Clinical practice guideline: tonsillectomy in children. Otolaryngol Head Neck Surg. 2011;144(1 Suppl):S1–30.
47. Clayburgh D, Stott W, Bolognone R, Palmer A, Achim V, Troob S,
etal. A randomised controlled trial of corticosteroids for pain after
transoral robotic surgery. Laryngoscope. 2017;127:2558–64.
48. Hay A, Migliacci J, Zanoni D, Boyle JO, Singh B, Wong RJ,
etal. Complication following Transoral Robotic Surgery (TORS):
a detailed institutional review of complications. Oral Oncol.
2017;67:160–6.
49. Richmon JD, Feng AL, Yang W, Starmer H, Quon H, Gourin
CG.Feasibility of rapid discharge after transoral robotic surgery of
the oropharynx. Laryngoscope. 2014;124:2518–25.
50. Weinstein GS, O’Malley BW Jr, Magnuson JS, Carroll WR, Olsen
KD, Daio L, etal. Transoral robotic surgery: a multicenter study
to assess feasibility, safety, and surgical margins. Laryngoscope.
2012;122:1701–7.
51. Krishnan S, Connell J, Ofo E. Transoral robotic surgery base of
tongue mucosectomy for head and neck cancer of unknown primary. ANZ J Surg. 2017;87:E281–4.
52. Chia SH, Gross ND, Richmon JD.Surgeon experience and complications with Transoral robotic surgery (TORS). Otolaryngol Head
Neck Surg. 2013;149(6):885–92.
53. Asher SA, White HN, Kejner AE, Rosenthal EL, Carroll WR,
Magnuson JS. Haemorrhage after transoral robotic-assisted surgery. Otolaryngol Head Neck Surg. 2013;149(1):112–7.
54. Glazer TA, Hoff PT, Spector ME. Transoral robotic surgery for
obstructive sleep apnea: preoperative management and postoperative complications. JAMA Otolaryngol Head Neck Surg.
2014;140(12):1207–12.
55. Hoff PT, D’Agnostino MA, Thaler ER.Transoral robotic surgery in
benign diseases including obstructive sleep apnea: safety and feasibility. Laryngoscope. 2015;125(5):1249.
Part XIV
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Laryngeal Surgery: Transoral Approaches
Transoral Laser Resection forGlottic
https://t.me/med1917
andSupraglottic Tumours
LauraWarner, IsabelVilaseca, andJamesO’Hara
36
36.1 Introduction
Otolaryngologists were amongst the rst medical professionals to realise the potential of laser surgery [1].
Briedemeier’s development of endoscopic equipment and
the micromanipulator enabled the delivery of carbon dioxide
(CO2) laser energy to the larynx with the microscope [2].
Laser surgery for laryngeal malignancy was pioneered by
Vaughan in 1978 [3], and since then, transoral laser surgery
for early glottic and supraglottic carcinomas has increased in
popularity, offering organ preservation surgery as an alternative to radiotherapy. Wolfgang Steiner and colleagues made
signicant advances in transoral laser surgery, extending the
application of this technique to locally advanced and recurrent laryngeal cancers [4–6].
Lasers work by passing light through a laser medium
where the light energy stimulates electrons in the molecules
of the medium substance (e.g. CO2), to move to a higher
level. When these electrons return to their usual state energy
is emitted in the form of photons. In this way, the wavelength
and cutting properties of the laser differ, according to the
medium substance used. The photons are amplied in a
mirror- lined ‘laser cavity’ and are emitted as a focused beam,
which cuts by vapourising tissues and by producing photocoagulation. The CO2 laser is most commonly used for tran-
L. Warner (*)
Department of Ear, Nose and Throat, Head and Neck Cancer,
Freeman Hospital, Newcastle upon Tyne Hospitals NHS
Foundation Trust, Newcastle upon Tyne, UK
e-mail: laura.warner2@nuth.nhs.uk
I. Vilaseca
Department of Otorhinolaryngology, University of Barcelona,
Hospital Clinic, Barcelona, Spain
e-mail: ivila@clinic.cat
J. O’Hara
Department of Otolaryngology, The Freeman Hospital,
Newcastle-upon-Tyne, UK
e-mail: James.Ohara@nuth.nhs.uk
soral laryngeal surgery. With a wavelength of 10,600nm, in
the mild-infrared area of the light spectrum, the CO2 laser is
readily absorbed by water in the mucosal tissues of the upper
aero-digestive tract. The CO2 laser’s depth of penetration is
20μm, which prevents injury from inadvertent deep penetration of the tissues. Furthermore, the ability to focus the CO2
laser beam to a 100-μm spot creates a highly precise cutting
tool, or ‘laser blade’ [7].
The CO2 laser can be used in a continuous or pulsed
mode. When the pulsed mode is selected, no energy is emitted between pulses, thereby allowing tissues to recover from
the thermal energy. This reduces thermal damage to the tissues and minimises tissue charring, resulting in cleaner
cutting.
36.2 Preoperative Checklist,
Considerations andAnaesthesia
36.2.1 Safety Precautions
The safety of the patient and operating team is paramount
during laser surgery, and the following precautions must be
followed:
• Eye protection is mandatory and should be specic to
wavelength of the laser in use.
• Laser face masks to protect from inhalation of the laser
plume.
• A 50 mL syringe of 0.9% saline should be prepared in
case of airway re.
• Dampened swabs placed over the patients face to protect
from inadvertent skin burns.
• All staff must be familiar with local laser safety policies.
As the CO2 laser is not in the visible light spectrum a laser
beam of visible light (usually a helium–neon laser) is projected to enable visualisation of the laser blade. Prior to use,
© Springer Nature Switzerland AG 2024
R. Simo et al. (eds.), Atlas of Head and Neck Surgery, Springer Surgery Atlas Series,
https://doi.org/10.1007/978-3-031-36593-5_36
361
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L. Warner et al.
it is important to check the alignment of the laser with the
visual indicator by testing the laser on a wet wooden tongue
depressor.
36.2.2 Equipment
Many different sizes and shapes of laryngoscope are available to gain exposure of the larynx, with suspension equipment that enables hand-free access. Micro-laryngeal
instruments are used to grasp and manipulate the tumour.
Two separate suction devices are required; one for the laser
plume is attached to the laryngoscope, and a second one is
used for blood and secretions. Laser laryngeal surgery is
most commonly performed with the operating microscope
and micromanipulator, which directs the laser; however, the
CO2 laser may also be delivered via a bre with a laryngeal
hand-piece.
36.2.3 Laser Settings
The CO2 laser is preferred for laryngeal surgery, for the reasons mentioned above. The power is typically set between 2
and 8 watts and may be used in a continuous or pulsed mode.
The cutting beam of the laser may be set as a dot, <1mm in
diameter, or as a curved or straight line. A defocused, continuous, high-power setting is useful for ablating tumours
causing airway obstruction.
36.2.4 Anaesthesia
During laser laryngeal surgery, the airway is shared between
surgeon and anaesthetist, meaning clear communication and
effective team working is essential. The requirement for an
un-obstructed view of the operative eld and an immobile
larynx whilst delivering oxygen and eliminating carbon
dioxide makes anaesthesia particularly challenging.
Surgeon and anaesthetist should decide upon the method
of anaesthesia preoperatively, taking into account the size
and location of the tumour and any potential difculties in
securing the airway or maintaining ventilation. The following modes of ventilation are used for laser laryngeal
surgery:
• Intermittent positive pressure ventilation (IPPV) :
Endotracheal intubation with a laser-safe micro-laryngeal
tube (MLT) provides the most reliable ventilation and
elimination of CO2, with protection of the distal airway
from aspiration of blood. However, endotracheal intuba-
tion with a MLT obscures the posterior glottis and can
prevent a wide view of the operative eld. Laser-safe,
reinforced tubes are recommended, to prevent airway re.
These have a double cuff, which should be lled with
saline. Standard endotracheal tubes carry a risk of inciting
airway re; however, this may be mitigated by covering
the tube with a foil tape or a wet neurosurgical patty. The
angle at which the laser hits the tube also determines the
likelihood of penetration; at 90°, it takes less than a second to penetrate, whereas it takes 42s to puncture the tube
if the laser hit at 45° [8]. In the rare event of an airway
re, the endotracheal tube will be the material ignited. As
such, the rst manoeuvre should be to remove the endotracheal tube and then re-secure the airway.
• Jet catheter ventilation: High-frequency jet ventilation is
delivered by a narrow catheter placed in the sub-glottis,
attached to the laryngoscope for supraglottic ventilation
or via a cricothyroidotomy. Ventilation is driven manually
or by an electronically controlled high-frequency ow
interrupter, which delivers intermittent pulses of ventilation. Total intravenous anaesthesia (TIVA) is frequently
used with this ventilatory method, although anaesthetic
gasses can be delivered via the jet catheter to maintain
depth of anaesthesia [9]. The main advantage of these
techniques is that a relatively un-obstructed surgical eld
is provided; however, CO2 elimination and ventilatory
monitoring are compromised, and the airway is not protected from inhalation of tumour or blood. Furthermore,
the pressure of the high-frequency jet can result in barotrauma and pneumothorax.
• Tubeless anaesthesia: Tubeless anaesthesia relies upon
TIVA to induce and maintain anaesthesia, whilst the larynx is immobilised with topical local anaesthetic [10].
This mode of anaesthesia enables an unobstructed view;
however, maintaining depth of anaesthesia and an immobile eld can be challenging.
36.3 Indications
Transoral laser surgery is particularly suited to early laryngeal cancers but may also be undertaken for more advanced
tumours.
For early laryngeal SCC, transoral laser surgery offers
organ and function preservation surgery with survival outcomes similar to radiotherapy, as demonstrated by systematic review data [11, 12]. Whilst there is no randomised trial
data on this topic, there is an abundance of retrospective data
reporting oncological outcomes after transoral laser surgery
for early laryngeal cancers. Canis et al. [13] report 5-year
disease-specic survival and laryngeal preservation rates of
98% and 97.3%, respectively, in a series of 404 patients with
T1a glottic SCC treated with transoral laser microsurgery.
Other series of T1a cancers demonstrate similar results; the
Dalhousie University group reports 5-year local control and
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