Abstract
Simple SummaryTransoral robotic surgery (TORS) with spontaneous healing is associated with improved quality of life as compared to traditional open surgery in small pharyngeal tumors. Improved surgeon experience allows very large or very complex resections, such as in a previously irradiated field where spontaneous healing is functionally insufficient or is at high risk of postoperative complications. We demonstrated very satisfactory feasibility and postoperative outcomes with a free flap microvascular reconstruction in this category of patients. TORS and free flap reconstruction has a place as a standard of care in a number of complex situations.We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.
Highlights
Since the worldwide adoption of transoral robotic surgery (TORS) using the da Vinci® Surgical System after its Food and Drug Administration (FDA) approval for the treatment of T1–2 laryngeal and pharyngeal tumors in 2009, there has been an increase in surgery for small oropharyngeal cancers compared to non-surgical treatments in situations where it could be expected to improve outcomes [1,2]
Compared to an open approach, TORS has been shown to result in fewer postoperative complications and fewer adverse effects on quality of life associated with a transoral approach and healing by secondary intention [3]
Potential postoperative complications and adverse effects on quality of life associated with the surgical defect remain issues that need to be addressed in complex surgical procedures, such as large resections, the exposure of critical structures, or salvage surgery after radiotherapy
Summary
Since the worldwide adoption of transoral robotic surgery (TORS) using the da Vinci® Surgical System after its Food and Drug Administration (FDA) approval for the treatment of T1–2 laryngeal and pharyngeal tumors in 2009, there has been an increase in surgery for small oropharyngeal cancers compared to non-surgical treatments in situations where it could be expected to improve outcomes [1,2]. Compared to an open approach, TORS has been shown to result in fewer postoperative complications and fewer adverse effects on quality of life associated with a transoral approach and healing by secondary intention [3]. This is thought to be due to the advantages of assistance by a robotic device with a 3D ‘in-field’ endoscope and EndoWrist® articulated instruments compared to ‘out-of-thefield’ conventional surgery [4,5,6,7,8,9,10,11,12,13]. Our aim in this study was to review the first 50 cases that we performed involving TORS and free flap reconstruction and describe their indications and clinical outcomes after surgery
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