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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4372_Библиотеки_им_академика_М_И_Перельмана
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34 Transoral Resection forOropharyngeal Neoplasms
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Fig. 34.1 Operating room
setting with the surgeon at the
head of the patient and the
endoscopy tower at the feet.
An articulated arm takes the
monitor close to the position
of the surgeon
Ultrosonic
scalpel
331
Endoscopy
tower
Nurse
Monitor
Surgeon
Fig. 34.2 Patient position
with the Feyh-Kastembauer
(FK) retractor and the
endoscope already in the
pharyngeal surgical eld.
Avoidance of neck extension
allows a wider internal
surgical eld
so important extension of the neck should be avoided. The
retractor is placed in the mouth, controlling the depth of the
blade position (Fig.34.2). By opening the retractor and tilting the blade, the base of the tongue is compressed towards
the submandibular space. The blade should be located basically in the midline. Exposure of the whole lesion is desirable, but if that is not possible, partial exposures and a good
planication of the resection, with or without piecemeal
resections, is an acceptable alternative. Special care must be
taken not to damage the lips or to trap the tip of the tongue
between the teeth and the retractor.
Anesthesiologist
34.2.4 Transoral Access
Wide opening of the mouth is important for a good external
exposure, but the critical aspect in endoscopic surgery is not
the mouth opening but the internal working space. In fact, as
the mouth is opened, the mandible interferes more with the
compression of the tongue base. With a wide mouth opening,
the space between the mandible and the hyoid bone is shortened (Fig. 34.3), and the mandible almost completely
restricts the compression of the tongue base and the chances
for a proper surgical eld.
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M. Fernández et al.
the base of the tongue. The minimum mouth opening is one
that allows the placement of the FK retractor, approximately
2.5cm (Fig. 34.4). Bad exposure is virtually unknown as a
contraindication for TOUSS.
A separation between the frame of the retractor and the
face of the patient is desirable for better access to the corner
of the mouth, especially when the base of the tongue is
approached (Fig.34.5). So, the frame is not the limit of the
access to the pharynx. To improve this manoeuvre, the
frame is tilted and separated from the face at the time the
base of the tongue is compressed. This space between the
frame and the face is used to introduce the instruments
more perpendicularly to the base of the tongue surface
(Fig.34.6).
34.2.5 Endoscopic Imaging
The endoscopic view can be obtained through either rigid
endoscopes or videoendoscopes. When a 5-mm endoscope is used, it should include the possibility of deecting the tip, as the endoscopic surgical eld is narrower.
The best option for the oropharynx is probably a 10-mm
endoscope, as the wide surgical endoscopic eld allows
the surgeon to work without the need to rene the endoscope position so often (see Fig. 34.8). The problem of
two-dimensional imaging with a static endoscope is the
lack of information about the depth of the resection,
besides the knowledge of the anatomy. Probably 3D endoscopes are a better option, in order to increase the safety
and reduce the time of the surgical procedure. The scope
holder arm is attached to the left side the table. The endoscope holder should avoid the area cranial from the FK
blade not to interfere with other instrumentation. It is ideally caudal to the blade (Fig.34.7).
Fig. 34.3 When the mouth is closed, there is room for compressing the
base of the tongue towards the submandibular space. When the mouth
is opened, the distance between the hyoid bone and the chin is reduced
so that the mandible itself obstructs the path of the compression of the
base of the tongue
Thus, a wide pharyngeal surgical eld is achieved with a
small mouth opening. This phenomenon is important for
approaching the lower part of the lateral pharyngeal wall and
34.2.6 The Ultrasonic Scalpel
TOUSS is a procedure mainly performed by one surgeon and
one assistant (Fig. 34.8). The resection is done with the
35-cm ultrasonic scalpel, a cutting and coagulation tool that
can safely seal vessels up to 6mm. A 20-cm scalpel can be
more comfortable for the upper oropharynx, but 35 centimetres can increase the precision of surgeon movements whilst
it is resting on the FK frame. The ultrasonic scalpel provides
enhanced capabilities to reduce bleeding complications and
preventive manoeuvres like tracheostomies after transoral
resections. Other instrumentation includes laparoscopic
instruments such as atraumatic forceps or Maryland
graspers.
34 Transoral Resection forOropharyngeal Neoplasms
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Fig. 34.4 A 2.5-cm mouth
opening is enough to place
the FK retractor. The external
exposure should be limited in
order to get a wider inner
surgical eld. As in
abdominal laparoscopic
surgery, the procedure will be
facilitated by a wide internal
surgical eld. External
exposure has less interest in
endoscopic surgery
> 2,5 cm
Mouth opening
333
Pharyngeal surgical
field
Fig. 34.5 Separation between the corner of the mouth and the frame of
the retractor. This space will allow the introduction of instruments in
the pharynx that are more perpendicular to the base of the tongue and
the lateral pharyngeal wall
34.2.7 Topographic Transoral Anatomy
oftheOropharynx
Topographic anatomy is critical for a safe procedure. The
posterior pillar follows the route of the palatopharyngeal and
stylopharyngeal muscles, behind the posterior aspect of the
hyoid bone and the superior horn of the thyroid cartilage.
This is the level of the external carotid artery, and the internal
carotid artery is found more posterior and medial to this
reference (Fig. 34.9). However, special facts should be
Fig. 34.6 The working space is wide in transoral ultrasonic surgery
(TOUSS). The instruments can be taken into the mouth through the
frame or outside it
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Fig. 34.7 The scope holder
preferably should be placed at
12 o’clock, but any position
in the green area does not
interfere with the surgical
instruments. In the gure, the
correct and incorrect areas are
represented
M. Fernández et al.
12 o’ clock
Correct
Incorrect
checked on a planning CT scan to look for anatomic
variations.
Lateral to the tonsillar fossa, the superior constrictor muscle is found. The facial and lingual arteries are found below
this area (Fig.34.10). The facial artery can be found in the
parapharyngeal fatty tissue between superior and middle
constrictor muscles, running medially to the stylohyoid muscle (Fig.34.11). The lingual artery can be found lateral to the
middle constrictor muscle, a few millimetres above the major
horn of the hyoid bone. It enters the base of the tongue after
running between the hyoglossus (laterally) and middle constrictor (medially) muscles. The following artery is the superior laryngeal artery entering the larynx anterior to the
superior cornu of the thyroid cartilage. So we can dene four
topographic “oors” in order to anticipate the position of
these vascular structures after the localization of the inferior
pole of the tonsil (inferior limit of superior constrictor muscle) hyoid bone and superior cornu of the thyroid cartilage.
Care must be taken between the superior and middle constrictor muscles, as a branch of the glossopharyngeal nerve
enters into the pharynx (Fig.34.12).
34.2.8 Resection ofOropharyngeal Neoplasms
Excision of oropharyngeal neoplasms should start with
supercial marking of the excision limits, considering the
classic limits for a clear margin. If 30–50% shrinking is
expected, at least 1cm of normal surrounding mucosa should
be included in the specimen. After excision of the mucosa,
deep resection of the lesion is done following the tactile
input from the tumoral limit as well as the aspect of normal
surrounding tissue under endoscopic magnication. A mild
traction of the tissues is convenient when the ultrasonic scalpel is used (Fig.34.13). This traction will reduce the cutting
time and avoid charring of the surgical margin, especially
where large arteries are not expected.
One of the advantages of the ultrasonic scalpel (especially
those devices that combine piezoelectric mechanical friction
and bipolar energies) is a better management of large vessels
like the lingual artery. The arteries can be exposed in the pharyngeal cavity, double sealed with the bipolar sealing device,
and cut with the ultrasonic scalpel, avoiding foreign bodies
like vascular clips in the pharyngeal cavity (Fig.34.14).
Besides the particularities of the carcinomas arising in the
posterior pharyngeal wall, this is probably the most accessible area of the oropharynx and technically the easiest,
because of direct exposure with the retractor. Resections can
leave the prevertebral fascia uncovered with good functional
results. However, care must be taken with the internal carotid
artery in posterior resections. Retropharyngeal internal
carotid arteries must be identied in the preoperative CT
scan, and adequate planication of the resection and reconstruction must be done to avoid damaging it. As a neck dis-
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Fig. 34.8 Final setup in the operating room. Positioning the mouth of the patient a little below the level of the surgeon’s elbows will allow a
comfortable and relaxed procedure as well as the close position of the screen
artery for a safer resection when the full-thickness resection
of the constrictor muscle is expected at the lateral aspect.
A close follow-up in the postoperative period is mandatory to check that correct healing is taking place and the
artery is not exposed in the pharynx. Special concern should
Carotid
artery
be taken with previously radiated patients.
The approach to the base of the tongue is more challenging due to its anterior position. The transoral exposure is
Carotid branches
based on the compression of the tissue below the tip of the
retractor’s blade (Fig.34.15). Additionally, the left hand of
the surgeon becomes crucial for extra compression of the
base of the tongue from the anterior neck, so the base of the
Fig. 34.9 Topographic transoral anatomy of the oropharynx. The
carotid arteries can be found behind the line of the posterior pillar and
the stylopharyngeal muscle. Below the line of the superior constrictor at
the level of the tonsillar fossa, the carotid branches can also be found
tongue can be approached with straight instruments with the
proper angle. If a more perpendicular angle of approach is
needed, the introduction of the instruments from outside the
frame of the retractor is convenient (as it was explained in
section is often combined with the resection of oropharyngeal
tumours, it is convenient to do that before the resection of the
primary lesion, so a gauze can be placed medial to the carotid
Fig. 34.6). In this case, the use of any lubricating product
such as vaseline is mandatory to avoid damage on the corner
of the mouth.
336
ry
Styloh
Hy
ictor muscle
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Fig. 34.10 Topographic
transoral anatomy of the
oropharynx. Four topographic
levels must be identied in
the area anterior to the
posterior pillar: area with no
carotid branches lateral to the
superior constrictor muscle,
the level of the facial artery
before reaching the
submaxillary gland. Below
this point, the laryngeal artery
can be found in front of the
superior cornu of the thyroid
cartilage
M. Fernández et al.
Floor 0
To nsil
Floor – 1
Facial artery
Floor – 2
Lingual artery
Fig. 34.11 The stylohyoid
muscle keeps medial the rst
segment of the facial artery.
The middle constrictor muscle
hides the lingual artery
medially
Floor – 3
Laryngeal arte
Mandible
Lingual artery
Facial artery
oglossus muscle
Stylohyoid muscle
yoid ligament
Stylopharyngeal muscle
Middle constr
Hyoid bone
External carotid artery
Stylohyoid ligament
Stylophar
yngeal space
a
34 Transoral Resection forOropharyngeal Neoplasms
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Fig. 34.12 The
glossopharyngeal nerve enters
into the pharynx through the
space between the superior
and middle constrictor
muscles
337
Superior constrictor
yngeal
muscle
Paraphar
fatty tissue
Glossopharyngeal
nerve
Hyoglossus muscle
Middle
constrictor
Fig. 34.13 (a and b)
Resection with the ultrasonic
scalpel is clean and bloodless,
so it permits perfect control of
the anatomy during the
resection
b
Tonsil tumor
Superior
constrictor
muscle
Suction
cannula
Active blade
Ultrasonic
scalpel
Retractor blade
Epiglottis
Base of
tongue
Mobile jaw with
heat protection
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Fig. 34.14 The arteries can be safely sealed with bipolar energy,
avoiding foreign bodies in the pharynx. Then, the vessel is cut with the
ultrasonic scalpel between both coagulated areas. Mild traction and
coagulation at the level of the constrictor muscle allows the artery to
hide behind it, avoiding the exposure of the pulsating end in the
pharynx
M. Fernández et al.
Fig. 34.15 Exposition of the base of the tongue is based on the compression and herniation of the base of the tongue with the tip of the
blade. So the superior limit can be reached easily. As the resection
moves forward, the exposure is improving
Planication of the resection is critical at the base of the
tongue. Planication should be directed to improve the surgical conditions as the resection progresses, preventing the
Fig. 34.16 Planication of the resection is critical for base of tongue
lesions. First lateral (1) and then superior (2) incisions must be done
initially. The tip of the blade should be placed far away from the surgical margin, in order to avoid any disturbance with the superior margin
already resected tissue from disturbing the resection. The
rst incisions should be done on both sides and then, on the
superior aspect of the surgical margin (Fig.34.16).
The third step is to dene the deep margin of the lesion.
Finally, the resection is nished by pulling the inferior limit
of the specimen and facing the direction of the inferior margin towards the ultrasonic scalpel (Fig.34.17).
34.2.9 Salvage Surgery
Transoral surgery is especially indicated in salvage surgery,
as the expected morbidity of an open surgical approach is
higher in this group of patients. Care must be taken when a
neck dissection is not indicated, but the need for reconstruction usually requires opening the neck to reach the neck vessels or to transfer a pedicled ap. The reconstruction can be
avoided if the constrictor muscle is left behind. The presence
of a cervicopharyngeal communication indicates that the
defect should be covered with a pedicle or a free ap. The
34 Transoral Resection forOropharyngeal Neoplasms
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Fig. 34.18 Second primary oropharyngeal lesion in a radiated patient
with a previous total laryngectomy
Fig. 34.17 After the denition of the deep margin following tactile
feedback (3), the specimen is nally attached exclusively by the inferior
mucosa, so grasping and pulling the inferior border will face it properly
towards the ultrasonic scalpel (4)
indications are the same as for open surgery. The difculties
for transoral reconstruction are related mainly to the transoral suture. Transoral suture can be done with conventional
laparoscopic instruments, but it is technically difcult when
the suture plane is close to the sagittal plane of the patient, so
it is helpful to use articulated, exible needle holders to
improve the degree of motion in the sagittal plane. Other
options include covering the defect with brin glue or sheets
with regenerative matrix (Figs.34.18, 34.19, and 34.20).
34.2.10 Results andComplications
Swallowing is usually started the day after surgery unless a
cervicopharyngeal communication was repaired. We
observed a 3.7% of permanent gastric feeding tube after
1year. Our series with a 15% of locally advanced lesions,
81.4%, have reached a satisfactory swallowing (unpublished). Major complications are unusual. Ultrasonic scalpel
and bipolar sealers can effectively control bleeding intraop-
Fig. 34.19 The same patient after a wide transoral resection. Notice
the absence of blood in the surgical eld
Fig. 34.20 Coverage of the defect with brin glue and bypass salivary
tube to avoid oesophageal stricture
eratively and in the immediate postoperative period. In our
experience, bleeding complications are mild or moderate but
commonly delayed to days 5–7 postop, so more related to an
uncovered surface left in the pharynx rather than a suboptimal coagulating energy. Other complications observed were:
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trismus in resections that affect pterygoid muscles, and mandibular luxation, more likely related to a joint hypermobility,
as a wide mouth opening is not necessary in TOUSS.Local
control is more dependent on the surgeon rather than the
transoral technique as indication and the distance between
the lesion and the scalpel are major factors in the nal result.
In our hands, we can achieve an 89% of local control on
these lesions.
34.3 Transoral Laser Microsurgery (TLM)
The most important factor as to whether a tumour is potentially resectable using transoral laser microsurgery (TLM) is
the diagnostic panendoscopy. It is important that this is done
by the surgeon who will be performing the laser resection so
that they can fully assess the extent of the tumour and
whether there is adequate access and exposure. This is particularly important as TLM is restricted by direct line of
sight.
The operating room set-up is similar to that of TOUSS
(see Fig. 34.1) with the surgeon standing at the head of the
patient. The assistant and scrub nurse stand to the right of the
surgeon and can assist with smoke suction if required. To
avoid overcrowding of equipment around the operating table
we place the stacker to the left of the patient with the screen
positioned over them, the stand of the microscope is behind
the surgeon to the left and the laser is on the right of the
patient. This provides the most ergonomic use of the space.
continuous, super-pulsed setting is typical in an attempt to
enhance tissue resection whilst minimising local thermal
damage. Ordinarily we start using it at 4–6 watts but that
may be increased up to 8–10 watts when cutting through the
tumour. The amount of focus used depends on the location of
the tumour. Tonsil tumours necessitate a focussed beam,
whereas in the tongue base, it can be helpful to use a slightly
defuse beam to aid coagulation.
34.3.2 The Technique
A variety of endoscopes and/or gags can and should be used
to maximise access. For tonsil tumours with limited inferior
extent, a simple Boyle-Davis gag can be used (Fig.34.21),
whereas for larger tumours, glossotonsillar sulcus tumours,
or tongue base tumours, a Feyh-Kastenbauer (F-K) retractor
can be used (Fig.34.22) taking care to avoid trauma to the
top lip, gum, and ventral surface of the tongue as that can
34.3.1 Laser Safety
Safe use of the laser is essential. It is important that all personnel using the laser are trained in laser safety and there
must always be a designated laser safety ofcer in theatre.
The authors use a standard silicone endotracheal (ET) tube
rather than a specic laser ET tube. The cuff of the endotracheal tube is lled with saline, or in some centres methylene
blue, rather than air in case of intra-operative puncture and a
jug of saline is kept on the instrument tray in the rare event
of an airway re. The patient’s face needs to be covered fully
with large wet swabs to protect their skin and eyes. It is
important, in longer cases, to make sure that these swabs are
kept wet as they can quickly dry out leading to an increased
risk of burns. A saline-soaked neuropathy is placed on the
posterior pharyngeal wall if performing a tonsil resection or
over the endotracheal tube if it is exposed in order to protect
them intra-operatively. Prior to each case, the laser must be
checked for alignment and this can be done by ring the laser
at a wooden tongue depressor.
Of the multiple different available lasers, the CO2 laser is
used for transoral resection of oropharyngeal tumours and a
Fig. 34.21 Boyle-Davis mouth gag
Fig. 34.22 Feyh-Kastenbauer set-up in the operating theatre
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