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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_980_Библиотеки_им_академика_М_И_Перельмана
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N. Nadjmi
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
https://t.me/medicina_free
Nadjmi hypothesized that robotic-assisted dissection of the palatal muscles
would help to preserve the innervation and vascularization of the palatal muscles
during their dissection, which in turn would optimize Eustachian tube function.
This precise dissection would be made possible by surgical robot through providing three-dimensional endoscopic vision, true depth perception for the surgeon,
and increased freedom of motion for the microendoscopic instruments. These
advantages facilitate more delicate handling of soft tissues and increased surgical
precision [16, 88].
Furthermore, robotic equipment lters tremor by incorporating the scaling of
movement, translating large movements of the hands into small movements of the
instruments.
Another important advantage is the ergonomic position on the surgeon’s console
that eliminates the unnatural and uncomfortable body postures, which is the case
during conventional palatal surgery.
According to Nadjmi the preclinical experiments in a cadaver study supported
the hypothesis that TORCS is technically feasible and could be applied to the reconstruction of the palatal muscle sling.
Based on this cadaver study, they found that the best exposure and an adequate
range of motion could be achieved using the Dingman mouth gag combined with
the three-dimensional 30° endoscope and the 5mm and 8mm instruments for working on the soft palate. The 30° angled high magnication three-dimensional camera
optics permitted tremendous visualization, which facilitated the careful identication and dissection of the palatal muscles.
In their recent observational study, Nadjmi etal. [89] investigated whether the use
of transoral robotic surgery for palatal repair resulted in a faster and more complete
recovery of the Eustachian tube functioning in comparison with manual surgery
when using his modied Furlow double-opposing Z-palatoplasty technique.
Dissection of palatal musculature was carried out using the da Vinci robot in one
group and surgical loupes in the other. Outcome parameters were the number of visits with otitis media with effusion (OME), tympanostomy tubes inserted, and hearing
loss during a 2-year follow-up. When muscle identication and dissection was performed with the use of the da Vinci robot, lower hearing thresholds and a faster resolution of OME were recorded. These results suggest that robot-enhanced surgery
facilitates a faster recovery of Eustachian tube function, compared to manual surgery.
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4.3 Rare Congenital Deformities
4.3.1 Teratoma
A teratoma is a type of rare tumor that is made up of cells from all three layers of
embryonic tissue (ectoderm, endoderm, and mesoderm). They can occur in the head
and neck area but are considered a benign lesion. However, a teratoma in newborns
can lead to signicant health issues and even death, such as fetal hydrops, premature
delivery, respiratory distress, difculty swallowing, facial disgurement, or involvement of the eye socket [90].
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N. Nadjmi
Teratomas in the aerodigestive tract mucosa most commonly occur in the nasopharynx and less commonly in the oral cavity (tonsils, tongue, palate), sinonasal
cavity, ear, and temporal bone [91]. Surgical excision is the recommended treatment, but nasopharyngeal masses may be difcult to remove completely due to their
location [92].
Nadjmi etal. performed the rst complete removal of a teratoma in a 5-day-old
infant using the da Vinci robot. The infant was admitted to the NICU with respiratory distress due to upper airway obstruction in the nasopharynx and oropharynx.
The infant had to be intubated orally and was transferred to the NICU department.
The infant required oral intubation and was transferred to the NICU.MRI showed
a soft tissue mass with fatty and multicystic components in the nasopharynx and
oropharynx, attached to the vomer and skull base (Fig.1). It was approximately
1.6cm×1.9cm×3.6cm in size (Fig.2).
a
b
c
Fig. 1 MRI showed the nasopharyngeal mass extending into the oropharyngeal cavity. (a) Fatty
and multicystic components shown on sagittal T2-weighted view. Adhesion to the vomer and skull
base was suspected. (b) The extension into the oral cavity was seen in coronal T2-weighted view.
(c) The axial T2-weighted view showed the overall extent of the mass
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
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Fig. 2 3D reconstruction
of the MRI images reveals
a mass in the nasopharynx
that has extended into
the oropharynx
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4.3.2 Surgical Management
During the surgery, a mass located in the nasopharynx was observed protruding
into the oral cavity, specically behind the soft palate and resting on the base of
the tongue. To access the oral cavity, an orotracheal tube was positioned at the
midline of the lower lip and a Dingman retractor was used to provide visibility
and access.
The soft palate was excised in the midline to expose the tumor. Unfortunately,
this was not enough to access the base of the tumor. Consequently, the intraoral incision of the soft palate was continued anteriorly, up to the half of the hard palate,
exposing the palatal shelves and posterior nasal spine (PNS). The surgical procedure continued with the removal of the posterior nasal spine (PNS) and part of the
posterior palatal bone using a round diamond bur, followed by partial removal of the
posterior part of the vomer using a rongeur. The da Vinci robot was then installed
and used to dissect the base of the tumor, which was attached to the vomer and skull
base. The remaining part of the tumor was then peeled off its attachment to the skull
base using the da Vinci system (Fig.3a–f). The removed mass was then sent for a
histopathological examination.
The soft palate was then reconstructed in layers. The surgical procedure took 2h
and 20min. The infant was transferred back to the NICU for postoperative management and could be extubated on the second postoperative day. He was discharged
from the hospital with nasogastric tube feeding for another 2 weeks.
Histological examination of the surgical margins conrmed a complete removal
of the mass. After removal of the tumor, the soft palate was reconstructed in multiple layers. The surgery lasted 2h and 20min. The infant was transferred to the
NICU for postoperative care and was extubated on the second postoperative day.
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f
e
N. Nadjmi
Fig. 3 The procedure involved accessing and removing a teratoma from the nasopharynx using da
Vinci robot. The following steps were performed: (a) making a transpalatal incision and dissecting
the levator veli palatini to access the nasopharyngeal base of the tumor; (b) dissecting the adhesion
at the os vomer; (c, d) visualizing the neck of the teratoma and removing the cystic component; (e)
performing further dissection of the attachment to the skull base, with assistance from the magnied view provided by the da Vinci robot; (f) closing the nasal mucosa, restoring the levator veli
palatini muscle and the oral mucosa based on the detailed prior dissection
The patient was discharged from the hospital with a nasogastric tube for feeding for
an additional 2 weeks.
The histological examination of the surgical margins conrmed that the mass
was completely removed during the surgery (Fig.4).
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
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Fig. 4 The resected part
of the tumor
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4.3.3 Lingual Thyroglossal Duct Cyst
Excision of a lingual thyroglossal duct cyst is also reported using a robotic surgery
system via a transoral approach or a retroauricular approach without complications
or recurrence [93–95]. A lingual thyroglossal duct cyst is a congenital brous cyst
that forms from a persistent thyroglossal duct, which was conventionally dissected
via a transcervical approach. However, the traditional surgery was always associated with an undesirable scar in the neck and a high relapse rate. In Kim etal.’s [95]
opinion, the three-dimensional, magnied visualization of the robot resulted in less
damage to the surrounding normal tissues, reduced intraoperative bleeding and
infection, and the ability to ligate the tract after carefully tracing it.
4.3.4 Laryngocele
Ciabatti etal. [96] reported short operative time and satisfactory aesthetic results
using TORS for the excision of a large mixed laryngocele. An oral diet was started
1day postoperatively and the patient was discharged 2days after TORS with no
postoperative complications.
4.3.5 Ectopic Lingual Thyroid
The aberrant migration of thyroid gland during embryological development results
in lingual thyroid. The possible symptoms are dysphagia, respiratory obstruction
dysphonia, and foreign body sensation; however it is usually asymptomatic.
Newman etal. [97] reported a robotic-assisted lingual thyroid gland excision in
three patients in May 2011, with minimal morbidity and excellent functional outcomes. Recently, an increasing number of ectopic lingual thyroids have been excised
via a robotic surgical system [23, 98, 99]. This technique resulted in the start of oral
feeding on the rst postoperative day, and no recurrence was observed within
2months of follow-up. Other authors suggested that TORS should be regarded as a
valid option for the treatment of ectopic lingual thyroid [99].
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N. Nadjmi
4.4 Maxillofacial Traumatology
To our knowledge there are still no reports on the clinical application of robotic
surgical systems in maxillofacial fractures. This is mainly due to the lack of tactile
and haptic feedback, making it difcult to provide precise navigation. Therefore it
is impossible to provide appropriate resistance during the xation period. The
author believes that the robotic-assisted virtual reality in planning of surgical treatment and its implementation will be the future.
4.5 Orthognathic Surgery
Chen et al. [100] proposed in 2010 the theoretical feasibility of robot-assisted
orthognathic surgery.
They programmed a navigation system to perform bone cutting and drilling
using the six degrees of freedom robot MOTOMAN.Although later a robotic surgical system for the design of orthognathic surgery, bone reconstruction, and intraoperative navigation was developed at Peking University, it still stays in an experimental
stage. Preliminary studies have been performed to investigate the advantage of
robot-assisted orthognathic surgery. These are not yet used in clinical practice but
are very promising after further investigation [101].
4.6 OSAS
On many occasions CPAP is considered as the primary treatment of choice for
OSAS.However, there are many OSAS sufferers unwilling or unable to comply
with this treatment option.
A patient-specic analysis of the upper airway anatomy and a properly selected
surgical treatment could be an alternative solution [102]. The surgical treatments
include tonsillectomy, uvulopalatopharyngoplasty (UPPP), the hypoglossal nerve
stimulator, reduction of the tongue base (BOT), maxillomandibular advancement,
and hyoid suspension.
The rst clinical application of TORS was reported by Vicini etal. [103] in 2010
avoiding any intraoperative and postoperative complications of conventional reduction of the BOT.They combined TORS with conventional septoplasty, UPPP, or
supraglottoplasty that resulted in an excellent functional recovery. The postoperative Apnea–Hypopnea Index (AHI) and Epworth Sleepiness Scale (ESS) were signicantly decreased from their preoperative values, and 90% of patients were
satised with the results.
Subsequently, TORS was widely applied for tonsillectomy, supraglottoplasty,
and glossectomy as a valuable surgical treatment option for OSAS sufferers [104–
114]. Most of the studies demonstrated that patients treated by TORS had a similar
therapeutic efcacy and at the same time decreased postoperative pain, hospital
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
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stay, and incidence of dysphagia compared with conventional surgery. However, the
cure rate still varies from 45 to 90%.
Hoff etal. [108] found that preoperative body mass index (BMI) may help the
clinician predict the success of TORS.They could show that patients who underwent TORS for lingual tonsillectomy and with a BMI of less than 30 had signicantly higher success rate than those with a BMI of more than 30. Friedman etal.
[106, 107] assessed the feasibility of performing robotic-assisted partial glossectomy by comparing obstructive sleep apnea-hypopnea syndrome (OSAHS) outcomes with other established techniques like submucosal minimally invasive lingual
excision and radiofrequency BOT reduction. They concluded that robotic-assisted
midline glossectomy could safely be performed without the need for preoperative
tracheotomy. Their outcome was a greater reduction in AHI but longer functional
recovery versus other conventional techniques.
The specic adverse events of using TORS reported in the literature are as follows: A transient dysgeusia rate of 12.5% was reported by Lee etal. [110] in robotic
lingual tonsillectomy. Lin etal. [111] reported a taste disturbance after robotic BOT
resection in 3 out of 12 patients included in their study. Also, transient hypogeusia
was experienced in 18.3% of patients after robot-assisted BOT resection in the
study of Crawford etal. [112], while temporary anterior tongue numbness and temporary tongue soreness were reported in all patients studied by Toh etal. [113]. At
the same time, a temporary postoperative change in taste was reported in 35% of
their patients. Further, lingual edema was reported in all six patients undergoing
robotic-assisted lingual tonsillectomy by Muderris etal. [114]. Lin and Crawford
related these complications to the pressure of the tongue blade or mouth gag
[111, 112].
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4.7 Dental Surgery
Robotic surgery in dental surgery is also constantly evolving and its applications are
continuously expanding. Recently, a rst robot-assisted surgery system that provides software for planning and navigational guidance for instrumentation during
implant surgery has been introduced and used for dental implant placement.
Interestingly, this system delivers haptic feedback and controls the position, depth,
and angulation for implant osteotomy. However, a thorough validation must be performed in terms of cost-benet and cost-effectiveness of robotic surgery in implant
dentistry.
Robotic osteotomy deviations of less than 1mm and angle deviations 2 or less
suggest the technology holds signicant promise. However, capable robotic application for determining implant insertion torque is still not available. Despite limitations and early development difculties, the future of robotic use in this eld seems
certain to ourish as systems improve and costs go down [115].
One potential disadvantage of the robotic surgical system is the lack of “natural”
tactile feedback. Although there were no signicant complications in this series,
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there is a real risk of tearing the delicate palatal tissue in the hands of an inexperienced surgeon. The high-resolution 3D imaging compatibility of the robotic system
capitalizes on the importance of visual cues and provides excellent compensation
for the lack of touch [14].
In conclusion, robotic surgery and particularly the dVSS have expanded surgical
skills, thanks to increased surgical accuracy and precision, movements beyond the
manipulation that can be achieved by the human hand, tremor reduction, 3D magnication of the operative eld, motion scaling, ergonomic advantages, and remote
operations. Phantom, cadaver, as well as clinical studies showed the increasing surgical accuracy and precision of different robotic devices. Regarding clinical feasibility, studies revealed the following main indications for robotic surgery in the eld
of OMF, craniofacial, and head and neck surgery: TORS for upper digestive and
respiratory tract lesions; TORS for skull base surgery; and TORS for transaxillary
thyroid and endocrine surgery. In pediatric surgery, adjustments to the instruments
are still needed [1].
N. Nadjmi
5 Advantages andLimitations
5.1 Advantages
5.1.1 Magnified Three-Dimensional Visualization
This enhanced surgeon’s capability to differentiate anatomical structures and therefore the ability to distinguish normal from pathological tissue to the highest extent.
This is due to 10 to 15 times magnication in the surgical space provided by 2 or
more integrated cameras that are used in the system. Thus, the dissection is performed more precisely with minimal collateral damage to the surrounding tissue.
This will lead to minimal morbidity and accelerated functional recovery.
5.1.2 Breaking theLimit ofHuman Hands
The increased degrees of freedom and extended range of motion are provided
through articulating surgical instruments mounted on the robotic arms. As a result,
the stability and accuracy of surgical procedures are improved.
5.1.3 Minimally Invasive Technique
The aim of minimally invasive surgery is to decrease surgical complications and
enhance faster functional recovery and aesthetic results. Robotic-assisted surgery
provides an excellent transoral approach in several oncological procedures and cleft
palate surgery. A retroauricular approach in robotic surgery is preferable to transcervical approach (with or without mandibulotomy or a lip-splitting incision) for the
resection of head and neck neoplasms, which is often accompanied by high morbidity and poor postoperative swallowing and speech functions.
Denition, History, andIndications ofRobotic Surgery inOral andMaxillofacial Surgery
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5.1.4 Excellent Manipulability
One of the greatest potentials of robotic surgery is the possibility of remote operation and real-time shared surgery now available through the internet and satellite
technology.
5.2 Limitations ofRobotic Surgery
5.2.1 Lack ofTactile Perception andProprioception
Due to the lack of tactile perception and proprioception, it is not possible to feel the
strength and resiliency of tissues or the radial pulse through a robotic surgical system. Therefore, it is very difcult to control accidental hemorrhage in a timely fashion. In the hands of an inexperienced surgeon, the uneventful handling of soft tissue
could be challenging.
5.2.2 Lack ofHaptic Feedback
The lack of haptic feedback might cause problems while performing ne motions
during robotic-assisted surgery. For example, a suture breakage might occur because
of uncontrolled and excessive tension. The release of soft tissue from bony structures during cleft palate surgery could be another challenge. However, with increased
experience and 3D visualization of robotic system, this lack of haptic feedback
would be compensated [15].
5.2.3 Complicated Procedures
The proper use of robot in surgical procedures requires docking of the surgical cart
in an appropriate position. This time-consuming procedure might increase operative
duration, especially in this early stage. However, as experience with the robotic
procedure increases, the duration will become comparable to that of open surgery.
5.2.4 Expensive
Cost is a major barrier to widespread use of robotic surgery. A single robotic system
costs approximately 1.5 million dollars, with yearly maintenance fees of around
100,000 dollars and additional per-patient costs of $200 for disposable instruments,
making surgeries more expensive [8]. Initially, the cost of systems, communication,
training personnel, and infrastructure may not result in cost savings [9]. However,
some studies suggest that reduced morbidity and hospitalization, as well as a
decreased need for tracheotomy, may partially offset the added cost of the robotic
surgical system [24, 28, 35].
5.2.5 Large Size
Robotic surgical systems are cumbersome and take up a lot of space. The large size
of the instruments makes it difcult to use for different application in head and neck
region. This is, for example, the case for laryngeal carcinoma patients with limited
mouth opening or jaw retraction and for transnasal and otological surgeries.
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