Transoral Robotic Surgery Procedures Research Articles

Predictors for Success and Failure in Transoral Robotic Surgery-A Retrospective Study in the North of the Netherlands.

Transoral Robotic Surgery (TORS) is utilized for treating various malignancies, such as early-stage oropharyngeal cancer and lymph node metastasis of an unknown primary tumor (CUP), and also benign conditions, like obstructive sleep apnea (OSA) and chronic lingual tonsillitis. However, the success and failure of TORS have not been analyzed to date. In this retrospective observational multicenter cohort study, we evaluated patients treated with TORS using the da Vinci surgical system. Success criteria were defined as identification of the primary tumor for CUP, >2 mm resection margin for malignant conditions, and improvement on respiratory polygraphy and tonsillitis complaints for benign conditions. A total of 220 interventions in 211 patients were included. We identified predictors of success, such as low comorbidity status ACE-27, positive P16 status, and lower age for CUP, and female gender and OSA severity for benign conditions. For other malignancies, no predictors for success were found. Predictors of failure based on postoperative complications included high comorbidity scores (ASA) and anticoagulant use, and for postoperative pain, younger age and female gender were identified. This study provides valuable insights into the outcomes and predictors of success and failure in TORS procedures across various conditions and may also help in patient selection and counseling.

Prospective development study of the Versius Surgical System for use in transoral robotic surgery: an IDEAL stage 1/2a first in human and initial case series experience

PurposeTransoral robotic surgery is well established in the treatment paradigm of oropharyngeal pathology. The Versius Surgical System (CMR Surgical) is a robotic platform in clinical use in multiple specialities but is currently untested in the head and neck. This study utilises the IDEAL framework of surgical innovation to prospectively evaluate and report a first in human clinical experience and single centre case series of transoral robotic surgery (TORS) with Versius.MethodsFollowing IDEAL framework stages 1 and 2a, the study evaluated Versius to perform first in human TORS before transitioning from benign to malignant cases. Iterative adjustments were made to system setup, instrumentation, and technique, recorded in accordance with IDEAL recommendations. Evaluation criteria included successful procedure completion, setup time, operative time, complications, and subjective impressions. Further evaluation of the system to perform four-arm surgery was conducted.Results30 TORS procedures were successfully completed (15 benign, 15 malignant) without intraoperative complication or conversion to open surgery. Setup time significantly decreased over the study period. Instrumentation challenges were identified, urging the need for TORS-specific instruments. The study introduced four-arm surgery, showcasing Versius’ unique capabilities, although limitations in distal access were observed.ConclusionsTORS is feasible with the Versius Surgical System. The development of TORS-specific instruments would benefit performance and wider adoption of the system. 4-arm surgery is possible however further evaluation is required. Multicentre evaluation (IDEAL stage 2b) is recommended.

Topical Hemostatic Agents and Risk of Postoperative Hemorrhage After Transoral Robotic Surgery.

Objective: Postoperative hemorrhage is the most common complication of transoral robotic surgery (TORS). The available research literature on topical hemostatic agents is deficient, despite their wide use. This study aims to evaluate the frequency and severity of hemorrhagic events after TORS procedures, performed with various topical hemostatic agents. Methods: This study was planned as a retrospective review to identify postoperative hemorrhage events in a database of all consecutive adult patients who required TORS from January 1, 2015, to April 1, 2020. All procedures were performed in one single institution by the same surgeon. In 2017, bovine gelatin matrix with thrombin (BgMT) was replaced by the porcine gelatin matrix with thrombin (PgMT) for all procedures. Postoperative hemorrhage was identified, along with hemostatic agents employed and other variables. Results: A cohort of 80 TORS procedures was obtained from a population of 78 individuals (60 males:18 females). BgMT was used in 28 procedures (35%), and five cases of postoperative hemorrhage were identified (17.8%), two of them were severe. PgMT was used in 52 procedures (65%) just observing one minor hemorrhagic event (1.92%). Although a significant difference was observed for total events between groups (P = .0183), there was no difference between major or severe hemorrhagic events (P = .1196). The overall rate of major and severe postoperative hemorrhage in the study population was 2.5% (n = 80). Conclusions: This is the first study to evaluate topical hemostatic agents during TORS procedures. The PgMT group had a reduced incidence of total postoperative hemorrhages, although there was no difference in the number of severe hemorrhagic events. The overall simplicity and cost-effectiveness of these agents would support their use, particularly considering the potential risk associated with airway hemorrhage.

Comparison of margins and survival between transoral robotic surgery (TORS) and non-robotic endoscopic surgery for oropharyngeal cancer

ObjectiveTo evaluate the impact of transoral robotic surgery (TORS) and non-robotic transoral endoscopic surgery on margin positivity, rates of adjuvant therapy and survival in early stage oropharyngeal squamous cell carcinoma. Study designRetrospective cohort review. Subjects and methodsThe National Cancer Database was queried to form a cohort of patients with T1-T2 N0-N1 MO oropharyngeal squamous cell carcinoma who underwent TORS or Non-robotic endoscopic surgery from 2010 to 2015. Demographics, disease characteristics and rate of positive margin and adjuvant therapy were summarized. A binary logistic regression and a cox-proportional hazard model were performed to evaluate patient demographic, disease, and treatment factors that could predict margin positivity and survival respectively. Results1026 patients received TORS treatment while 734 patients received non-robotic endoscopic primary surgery. Non-robotic surgery was more likely to have residual tumor (31.6 % of all cases) compared to TORS procedures (13.6 % of TORS cases); p < .0001. Non-robotic surgery more frequently had non-evaluable margins at 8.1 % compared to only 1.4 % of TORS cases (p < .0001). Non-robotic cases had a significantly higher proportion of patients receiving adjuvant radiotherapy and systemic therapy compared to TORS (66.4 % vs 51.3 % for radiotherapy; p < .0001 and 33.4 % vs 22.2 % for chemotherapy; p < .0001). There was no difference in mortality between the two modalities (non-robotic vs TORS, HR 1.357, 95 % CI 0.937–1.967). ConclusionTORS and non-robotic surgery may have a similar impact on survival in early-stage OPSCC, but non-robotic surgery was found to have a higher likelihood of positive margins and a higher rate of adjuvant chemoradiation therapy.

Characteristics and outcomes of transoral robotic surgery with free-flap reconstruction for oropharyngeal cancer: a systematic review.

Transoral robotic surgery (TORS) approach for the treatment of oropharyngeal cancer allows for reduced patient morbidity, amongst other advantages over the traditional lip-splitting mandibulotomy method. Free-flap reconstruction is commonly utilized in head and neck cancer surgeries; however, safety and outcomes of this technique in TORS procedures have not been well studied. The objective of this study was to perform a systematic review to evaluate the efficacy and safety of TORS with free-flap reconstruction (TORS-FFR) for oropharyngeal cancer. A systematic search of Scopus, EMBASE, CINAHL and PubMed databases was completed. Following PRISMA guidelines, case series/reports, retrospective and prospective cohort studies were included. Primary outcomes measured were deaths and complication rates associated with TORS-FFR for oropharyngeal cancers. Secondary outcomes included functional swallowing and airway outcomes, operative time and length of hospital stay. Twenty-one studies met the inclusion criteria comprising a total of 132 patients. The mean patient age was 58.4years. The most frequent complication was infection (8.9%) followed by flap wound dehiscence (4.2%). The average total operative time was 710min (n = 48), while average length of hospital stay was 13.5days (n = 48). Reconstructions were most commonly fashioned from radial forearm free flaps (RFFF), with anterolateral thigh flaps (ALT) representing the second most common free-flap subtype. TORS-FFR procedures for oropharyngeal cancer are safe, with low serious complication rates. This surgical approach may be associated with decreased length of hospital stay; however, further studies are required to better characterize post-operative outcomes.Level of evidence 1a.

Utilizing Trans-Oral Robotic Surgery (TORS) in head and neck malignancy – is it practical in oropharyngeal squamous cell carcinoma (OPSCC)? A case report

Introduction: Oropharyngeal squamous cell carcinoma (OPSCC) is often managed by multimodal methods, including open surgical resection and reconstruction in advanced cases. Trans-oral Robotic Surgery (TORS) was introduced to minimize and avoid complications caused by the open surgery method and chemo-radiation therapy in treating oropharyngeal squamous cell carcinoma (OPSCC). In Malaysia, TORS is still a new, rare, and limited surgical technique practiced in our healthcare system. Case Presentation: We present a case of the base of tongue lesion which presented with chronic globus sensation for four months associated with chronic dysphagia and cough. Endoscopy examination revealed a lobulated mass situated at the left side base of the tongue. Contrast Enhanced Computed Tomography (CECT) of the neck revealed an enhancing lesion at the same site. There were multiple subcentimeter cervical lymph nodes bilaterally from level II to level V. The patient underwent a TORS procedure using the da Vinci Surgery System for incisional biopsy. By using TORS, we were able to obtain a good tumor sample including the margins for the biopsy. Histopathology examination (HPE) of the sample reported moderate to poorly differentiated squamous cell carcinoma. Based on the HPE and CECT results, the patient was diagnosed with oropharyngeal squamous cell carcinoma (OPSCC) with a clinical stage of T3N2cMx. Conclusion: Management strategies for patients with OPSCC continue to evolve to minimize the morbidities and complications of treatments. Minimally invasive surgical techniques such as TORS offer impressive functional and oncologic outcomes particularly for patients (therapeutic function) compared to the traditional method of treatments.

A Survey of Transoral Robotic Mechanisms: Distal Dexterity, Variable Stiffness, and Triangulation.

Robot-assisted technologies are being investigated to overcome the limitations of the current solutions for transoral surgeries, which suffer from constrained insertion ports, lengthy and indirect passageways, and narrow anatomical structures. This paper reviews distal dexterity mechanisms, variable stiffness mechanisms, and triangulation mechanisms, which are closely related to the specific technical challenges of transoral robotic surgery (TORS). According to the structure features in moving and orienting end effectors, the distal dexterity designs can be classified into 4 categories: serial mechanism, continuum mechanism, parallel mechanism, and hybrid mechanism. To ensure adequate adaptability, conformability, and safety, surgical robots must have high flexibility, which can be achieved by varying the stiffness. Variable stiffness (VS) mechanisms based on their working principles in TORS include phase-transition-based VS mechanism, jamming-based VS mechanism, and structure-based VS mechanism. Triangulations aim to obtain enough workspace and create adequate traction and counter traction for various operations, including visualization, retraction, dissection, and suturing, with independently controllable manipulators. The merits and demerits of these designs are discussed to provide a reference for developing new surgical robotic systems (SRSs) capable of overcoming the limitations of existing systems and addressing challenges imposed by TORS procedures.

TORS as Part of Multilevel Surgery in OSA: The Importance of Careful Patient Selection and Outcomes.

Transoral robotic surgery (TORS) for Obstructive Sleep Apnea (OSA) is a relatively young technique principally devised for managing apneas in the tongue base area. This study summarizes and presents our personal experience with TORS for OSA treatment, with the aim to provide information regarding its safety, efficacy, and postoperative complications. A retrospective study was conducted on patients undergoing TORS with lingual tonsillectomy through the Da Vinci robot. The effectiveness of the surgical procedure was assessed employing the Epworth Sleepiness Scale (ESS) and overnight polysomnography with the Apnea-Hypopnea Index (AHI). A total of 57 patients were included. Eighteen patients (31.6%) had undergone previous surgery. The mean time of TORS procedure was 30 min. Base of tongue (BOT) management was associated with other procedures in all patients: pharyngoplasty (94%), tonsillectomy (66%), and septoplasty (58%). At 6 months follow-up visit, there was a significant improvement in AHI values (from 38.62 ± 20.36 to 24.33 ± 19.68) and ESS values (from 14.25 ± 3.97 to 8.25 ± 3.3). The surgical success rate was achieved in 35.5% of patients. The most frequent major complication was bleeding, with the need for operative intervention in three cases (5.3%). The most common minor complications were mild dehydration and pain. TORS for OSA treatment appears to be an effective and safe procedure for adequately selected patients looking for an alternative therapy to CPAP.

Airway management during transoral robotic surgery for head and neck cancers: a French GETTEC group survey.

The aim of the survey was to define the indications for preventive tracheostomy in transoral robotic surgery (TORS) for head and neck cancers. From October 2019 to January 2020, an online questionnaire was e-mailed to French surgical ENT teams with considerable experience of the TORS procedure (Gettec group). A descriptive analysis of the answers was performed. Eighteen French surgical teams answered the questionnaire. For 77.8% of the surgical teams, a past history of radiotherapy with residual edema was an indication for prophylactic tracheostomy, and for 88.9%, > 75mg of antiplatelet medication or anticoagulation treatment was an indication. Early preventive tracheostomy during TORS can protect airway from uncommon but potentially life-threatening complications, such as transoral hemorrhage or airway edema. We recommend it in high-risk situations, such as a past history of radiotherapy or antiplatelet therapy associated with large resections. Further studies are needed to establish evidence-based recommendations.

Detection of Plasma Circulating Tumor-Tissue Modified HPV DNA Following Trans-Oral Robotic Surgery (TORS) and Neck Dissection for p16+ Oropharyngeal Squamous Cell Carcinoma

This study sought to measure circulating plasma tumor-tissue modified human papilloma virus DNA (TTMV-HPV DNA) and kinetics following trans-oral robotic surgery (TORS), neck dissection, and adjuvant (chemo)radiation for p16+ oropharyngeal squamous cell carcinoma (OPSCC).Patients with p16+ OPSCC currently enrolled on an ongoing phase II clinical trial investigating radiation dose de-intensification following TORS and neck dissection (TORS version 2.0, NCT03729518) with available post-operative plasma samples were included. Plasma was collected following TORS procedure (∼6 weeks post-operatively), during adjuvant (chemo)radiation, and at treatment completion. Plasma samples were analyzed for TTMV-HPV DNA using a liquid biopsy assay. Multivariate robust linear regression analysis was used to identify clinicopathologic features associated with detectable post-operative TTMV-HPV DNA levels.Thirty-four patients were included (median age 59 years, IQR 55-62 years; 94% male). The majority of patients had pT1-2 (n = 32, 94%; 1 pT0,1 pT3) and pN1 (n = 32, 94%; 2 pN0) disease. Other pathologic features included LVI (n = 5, 15%), PNI (n = 2, 6%), close or positive margin (n = 9, 26%), number of positive nodes (median 1.5, IQR 1-2), largest node size (median 3.7 cm, IQR 3.0-4.4 cm), and ENE (n = 8, 24%; 4 macroscopic). The majority of patients had undetectable TTMV-HPV DNA following TORS (n = 31, 91%). Three patients (9%) had detectable TTMV-HPV DNA post-operatively with 2 having very low detectable levels (≤ 10 copies/mL) and 1 having a high detectable level (4421 copies/mL). Largest node size (P = 0.0083) and ENE (P = 0.041) were significantly associated with detectable post-operative TTMV-HPV DNA levels. Of those with initially undetectable TTMV-HPV DNA, levels remained undetectable during and after adjuvant (chemo)radiation with 1 patient developing a very low detectable level (7 copies/mL) following treatment. The 2 patients with low detectable TTMV-HPV DNA levels post-operatively (≤ 10 copies/mL) had complete clearance following adjuvant therapy. There were no locoregional recurrences (median follow-up 15 months, IQR 12-21 months) including the patient who developed a low detectable level (7 copies/mL) following treatment (currently 24 months post-TORS). The patient with the high detectable level post-operatively (4421 copies/mL) developed osseous metastatic disease 5 months post-TORS.Tumor-tissue modified HPV DNA can be detected with high sensitivity following definitive surgery for p16+ OPSCC. Further prospective studies are warranted to determine if the observed range of post-operative values allows for stratification of patients into those with distant metastatic disease, persistent locoregional disease that warrants adjuvant therapy, versus active surveillance.

Transoral robotic surgery in Ireland: the beginning.

Transoral robotic surgery (TORS) has shown promising results in the treatment of myriad head and neck pathologies but is now most commonly used in the investigation and management of oropharyngeal squamous cell carcinoma. The aim of this study was to report our cases of the newly introduced TORS, particularly its role in identifying primary of unknown origin and the potential implications for patients. A literature review and our early experience should begin to debunk some of the criticisms of TORS including setup times and cost. Prospective data was collected from all patients undergoing transoral robotic surgery including demographics, indication, histology results in primary of unknown origin and complications. We have performed 36 TORS procedures in total ranging from intermediate to major complex. Our complication rate is low, and this has improved with the passage of time. Haemorrhage rates remain at 5.6% (n = 2), and the average length of stay is 1day. Successful identification of a primary tumour in cancer of unknown primary was 80% (n = 8). We anticipate the integration of TORS into routine practice in the investigation and management of a number of ENT pathologies following robust clinical trials.

Adverse event reporting in head and neck transoral robotic surgery: a MAUDE database study.

Transoral robotic surgery (TORS) using the da Vinci Surgical system was approved by the US Food and Drug Administration in 2009. Currently, most available safety information on TORS procedures describes adverse events occurring in the context of clinical trials or series at high-volume academic centers. The goal of this study was to catalog reported adverse events associated with the da Vinci device in head and neck procedures by querying an FDA database. A search was performed on the MAUDE database inspecting for TORS safety incident reports generated from January 2009 through May 2020 using key words "da Vinci" and "Intuitive Surgical". A total of 3312 medical device records were produced. Of these 36 head and neck adverse events, reports were identified through manual screening of the data by the authors. Death was found to be the most common adverse event reported overall, manifesting in 44% of all reported incidents. The most frequent source of mortality was found to be hemorrhaging in the perioperative period rather than incidents of device malfunction or structural damage from surgery. This was found to be similar to the results of other published series for transoral ablative surgery. This study suggests that the small number of reported adverse events related to TORS with the da Vinci system seems to mirror what would be expected from the same procedures using other methods for transoral surgery.

Soft tissue necrosis in patients treated with transoral robotic surgery and postoperative radiotherapy: preliminary results

Postoperative radiotherapy (PORT) is indicated in almost two-thirds of patients treated with transoral robotic surgery (TORS) for head and neck tumors. The aim of this study was to quantify the toxicity profile of patients treated with PORT after TORS in oropharyngeal and supraglottic laryngeal cancer focusing on soft tissue necrosis (STN). We retrospectively reviewed 28 patients. Acute and late toxicity were examined. Incidence and severity of STN were recorded. No patient experienced acute grade 3 skin or mucosal toxicity; 1 patient had grade 3 dysphagia. At 12 months, no evaluated patient required enteral nutrition and 2 patients had tracheostomy. STN occurred in 4 (14%) patients: 3 out of 4 (75%) patients with STN had diabetes, whereas 6 out of 13 (25%) patients without STN had diabetes (p = 0.05). We found an acceptable toxicity profile of PORT performed after a TORS procedure. Diabetes mellitus might be a risk factor for STN.

Transoral robotic surgery: Differences between online information and academic literature.

Evaluate the authorship, content, quality, and readability of information on Transoral Robotic Surgery (TORS) available to patients online. The technical search term "TORS Surgery" and layperson's term "robotic surgery of the mouth" were utilized to conduct a search of the top 50 websites on Google, Bing, and Yahoo. Websites were evaluated according to the HONcode evaluation of content and quality, and readability was assessed using the Flesch Reading Ease Formula, Flesch-Kincaid Grade Level Formula, SMOG readability formula, Coleman Liau Index formula, and Gunning Fog Index. Statistical analysis was conducted using the Fisher Freeman- Halton test to compare differences in authorship, quality, and content between the three search engines and the Fisher exact test was used to determine if there was a difference in these variables between the two search terms. Overall, websites were predominantly from academic institutions with 97% mentioning benefits of TORS with 24% mentioning risks. 45% of TORS websites had no description of the TORS procedure, while 62% allowed individuals to make appointments. There was a significant difference in authorship with the layperson's terms yielding more news sources, but there were no significant differences in quality and content of information elicited through the technical and layperson search terms. The mean readability scores were Flesch Kincaid Grade Level 13.81(±3.32), Gunning-Fog Index 16.51(±3.39), SMOG 12.53(±2.40), and Automated Readability Index 14.05 (±4.17). Current online information on TORS surgery may not provide balanced information for patients to make informed healthcare decisions. The current readability of online information regarding TORS far exceeds the average literacy level of average American adults.

Transoral Robot-Assisted Surgery in Supraglottic and Oropharyngeal Squamous Cell Carcinoma: Laser Versus Monopolar Electrocautery.

Background: Monopolar electrocautery (EC) is the surgical cutting and haemostatic tool most commonly used for transoral robotic surgery (TORS). The aim of this study was to retrospectively compare EC efficacy in the treatment of patients affected by T1 or T2 oropharyngeal and supraglottic squamous cell carcinomas with the more recently introduced laser fibres. Methods: We considered all TORS patients admitted to our department from January 2010 to June 2019. The outcomes of patients treated with Thulium: yttrium aluminium garnet (YAG) laser (TY-TORS), CO2 laser (CO2-TORS) and EC (EC-TORS) were analysed in order to assess surgical performances, functional outcomes and postoperative complications. Results: Twenty patients satisfied the enrolling criteria, of which nine underwent laser-TORS, and the remaining 11 underwent EC-TORS. In all candidates, TORS procedures were completed without the need for microscopic/open conversion. Close or positive margins were significantly more frequent in EC-TORS (p = 0.028). A considerable difference was found in overall functional parameters: times of nasogastric tube and tracheostomy removal and time of hospital discharge were significantly shorter in laser-TORS (p = 0.04, p = 0.05, p = 0.04, respectively). Conclusions: Laser-TORS showed better results in comparison with EC-TORS in term of tumour resection margins and patient functional outcomes. Our findings can be justified with the greater tissue thermal damage caused by EC-TORS, despite prospective randomized trials and increased patient numbers being needed to confirm these preliminary conclusions.

Treatment trends in oropharyngeal carcinoma: Surgical technology meets the epidemic

ObjectiveTo characterize temporal trends in treatment patterns for oropharyngeal carcinoma, and to evaluate the emerging role of surgical therapy in the era of transoral robotic surgery (TORS). MethodsPatients with oropharynx cancer between 2004 and 2016 identified using the National Cancer Database. Demographics and primary treatment modalities were obtained. Treatment was classified as surgery alone, surgery with radiation/chemotherapy, or primary radiation/chemotherapy. Annual distribution of cases treated by the various modalities was tabulated by site and early (I/II) versus late (III/IV) stage disease (AJCC 7th edition). The “TORS era” was defined as beginning in 2010. Results149,534 patients were identified. The majority (56.8%) were treated with radiation ± chemotherapy. 53,069 patients had surgery as part of treatment, 72.6% (N = 38,533) of which received adjuvant therapy. 5293 TORS procedures were performed between 2010 and 2016 with trends away from open and other endoscopic procedures. Despite a 31.0% increase in the number of cases treated surgically from before TORS (2009) to 2016, the percentage of cases treated surgically decreased from 35.0% to 32.7%, with a 44.2% increase in non-surgical therapy. Increases in the percentage of patients treated surgically were observed for base of tongue tumors (24.3–25.2%) and early stage disease (59.9–62.2%). ConclusionDespite the increase in the overall number of patients with oropharynx cancer, the percentages of patients treated surgically remains relatively stable. Notable increases were observed for base of tongue tumors and early stage disease.

Perioperative safety, feasibility, and oncologic utility of transoral robotic surgery with da Vinci Xi platform.

Transoral robotic surgery (TORS) is a common modality for treatment of oropharyngeal and laryngeal cancer. Current FDA approval extends to the da Vinci S and Si platforms. Many hospitals are adopting the da Vinci Xi platform. Reports of head and neck surgical outcomes with this platform are scant. This study reports outcomes of TORS procedures performed with the da Vinci Xi platform including perioperative adverse events, functional outcomes, and short-term local control. A retrospective review of TORS performed with the da Vinci Xi platform is undertaken. Twenty-two consecutive TORS cases with the Xi platform are reviewed. Procedures performed include radical tonsillectomy, base of tongue resection, and lingual tonsillectomy. Two bleeding events occurred (9% of cases), both of intermediate severity as per Mayo criteria. Three procedures resulted in positive margin status, early in the case series, and two were cleared with revision resection. One-year local control rate, where available, is 100%. There were no perioperative deaths, long-term gastrostomy dependence, or performance of tracheostomy. Advantages of this platform include ease of robot deployment and setup. Disadvantages include increased width of instrumentation compared with previous platforms with crowding of access. The availability of a specific robotic platform may be dictated by hospital-wide policy across service lines. This report suggests that the da Vinci Xi permits performance of TORS with safety and oncologic outcomes similar to previous platforms; however, long-term follow-up is needed.

Transoral robotic surgery for the parapharyngeal space: expanding the transoral corridor.

To analyze the feasibility, surgical outcomes and possible risks and complications encountered during transoral robotic surgery (TORS) for approaching parapharyngeal space (PPS) tumours, a retrospective cohort study was conducted. Out of 108 TORS procedures performed, 5 PPS tumours were identified from May 2011- November 2017. This study included 2 retrostyloid (benign nerve sheath tumour) and 3 prestyloid tumours (pleomorphic adenoma), of which one patient had previously undergone a transcervical approach for deep lobe of parotid pleomorphic adenoma. Average tumour dimensions were 4.56 × 4.5 × 3.64cm, with largest antero-posterior, medial-lateral and craniocaudal dimensions being, 5.1cm, 7.1cm and 6.5cm, respectively. Adverse peri-operative events encountered were tumour fragmentation (n = 1), Secondary hemorrhage (n = 1) and Horner's syndrome (n = 1). Oral feeds could be initiated after 7.6 days. No recurrences were noted during a mean follow up of 21.6 months. Therefore, in properly selected cases, excellent results in terms of extracapsular resection and low morbidity can be obtained with TORS without resorting to mandibulotomy or transcervical incision.

Oncological and functional outcomes of trans-oral robotic surgery for pyriform sinus carcinoma: A French GETTEC group study

BackgroundPyriform sinus carcinomas (SCC) present specific functional and oncological issues. The recent advent of trans-oral robotic surgery (TORS), as a conservative procedure, has opened up new perspectives. ObjectivesTo present the oncological and functional outcomes of TORS for pyriform sinus SCC. Materials and methodsWe included, retrospectively, all TORS procedures for pyriform sinus SCC performed between 2009 and 2017 in eight French tertiary referral centers. We excluded lesions involving the pyriform sinus that had developed from the oropharynx, larynx, or other anatomic sub-sites of the hypopharynx. ResultsWe included 57 TORS procedures. Median hospital stay was 10 days. A preventive tracheotomy was performed in seven cases (12%), and all were successfully decannulated. Oral re-feeding was possible for 93%, after a median of 5 days. The main surgical complications were hemorrhages (three cases), all successfully handled, although 2 patients with heavy comorbidities died from blood loss in the days after. Adjuvant therapy was proposed in 31 cases (54%), including two cases of salvage surgery (total pharyngolaryngectomy). After a median follow-up of 23 months, overall and disease-free survival were, respectively, 84% and 74% at 24 months, and 66% and 50% at 48 months. At the end of follow-up, organ preservation rate was 96%. None of the surviving patients needed a tracheotomy and oral diet was possible for 96%. ConclusionThe functional and oncological outcomes of TORS for pyriform sinus cancer are encouraging, and this procedure can be considered safe for selected early or moderately advanced cases as a conservative treatment.

Use of the self-retaining Alexis ring retractor in transoral robotic surgery.

Ring retractors, such as the Alexis® wound retractor, are simple devices used in a wide range of surgical settings to provide atraumatic exposure while protecting wound edges. Here, we describe the application of the Alexis® to provide access during transoral robotic surgery (TORS). Its ease of application and many benefits, including maximization of intraoral space and protection of perioral soft tissues, make this device an excellent adjunct for TORS procedures.