Trans Oral Robotic Surgery

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1 Trans Oral Robotic Surgery 1 by Leonardo da Vinci 2 Claudio Vicini, MD Filippo Montevecchi,MD Department of Special Surgery, Otolaryngology - Head & Neck Surgery Division, Oral Surgery Unit ( Head: Prof. Claudio Vicini ) University of Pavia in Forlì, G.B. Morgagni L. Pierantoni Hospital, Forlì, ITALY 1

2 3 TORS for OSAHS: History in pills and references First Idea: feb 2008 First case: may 2008 Ist pub.series: nd pub.series 2010 Series up now: >100 cases 4 Robotic Surgery for OSAHS: FAQs Why? When? How? 2

3 5 WHY? Da Vinci Robotic Platform: a novel seductive tecnology in H&N Surgery 6 from 2D to vision 3

4 7 Many Strong Arms and 8 Two Very Precise Hands 4

5 9 able to work inside the pharynx 10 Stealth Surgery Conventional Open Surgery TORS Surgery 5

10) significant obstruction Selection Criteria in Tongue Base (Cormak &

6 11 Smart Surgery Conventional Open Surgery TORS Surgery 12 Mild to severe OSAHS patients ( AHI>20 ) Eccessive Daytime Sleepiness (ESS > 10) significant obstruction Selection Criteria in Tongue Base (Cormak & Lehane > 2 ), and / or supraglottic area prolapse ( mouth opening > 1.5 cm) 6

7 Pre-op Vicini Alex 2012 Snoring Exclusion Criteria Mouth opening (<15 mm) ASA > 2 Psicological not stable patient 7

8 15 TORS for OSAHS Our Homemade Surgical Technique References: 16 8

17 Forlì s TORS Experience up to march 27th 2012 ( 151 cases / 46

2 / month) 107* OSAHS (BOT Reduction+Supraglottoplasty) 14 Lingual

Tonsillectomy 1 Melanoma) 4 Tongue Base Cancer (Partial Glossectomy 1

Lingual Tonsil Lymphoma (Tumorectomy) 2 Velo Pharyngeal Insufficiency

Palate Pemphygoid Adhesion (Veloplasty) * 2 in Hamad Hospital, Doha

9 17 Forlì s TORS Experience up to march 27th 2012 ( 151 cases / 46 months; 3.2 / month) 107* OSAHS (BOT Reduction+Supraglottoplasty) 14 Lingual Tonsil Hyperplasia (BOT Reduction) 11 Tonsil Cancer (Radical Tonsillectomy 1 Melanoma) 4 Tongue Base Cancer (Partial Glossectomy 1 Cilindroma) 2 Supraglottic Cancer (Supraglottic Laringectomy) 2 Lingual Tonsil Lymphoma (Tumorectomy) 2 Velo Pharyngeal Insufficiency (Veloplasty) 1 Palate Cancer 1 Vallecular Fibroma (Tumorectomy) 1 Palate Pemphygoid Adhesion (Veloplasty) * 2 in Hamad Hospital, Doha Quatar ( + 6 Robotic Thyroidectomy) OSAHS vs NOT OSAHS 18 OSAHS 1 emergency revision surgery Ø conversion to open surgery not OSAHS * first Case May 27th

10 19 TORS in SDB Surgery include two different surgical procedures usually combined in the same patient: 1. Tongue Base Reduction (TBR) 2.Supra Glotto Plasty (SGP) TOR TBR-SGP 20 The end point of TBR may be probably achieved when the obtained surgical view shifts from a Cormack & Lehane Grade IV to a Grade II, or, less commonly, to a Grade I. In all but few cases lymphoid tissue as well as tongue base muscle must be removed in order to clear the so called Retrolingual Space or Posterior Airway Space (PAS). IV to III/II 10

TB Surgical Specimen: up to 51 cc* 21 Mean tongue volume: 91.21 cc ranging from 64.1 to 138.

operation. The key of SGP is to fix the inward inspiratory collapse of floppy and/or redundant tissue in epiglottis, ary-epiglottic folds, arytenoids area. In Literature (Zalzal & Coll., Golz & Coll.

11 TB Surgical Specimen: up to 51 cc* 21 Mean tongue volume: cc ranging from 64.1 to according to the measuring method and to the selected group ( Humbert, Kondo, Yoo, Hermann) 22 SUPRA GLOTTO PLASTY: It s very often carried out after TBR in the same patient and during the same operation. The key of SGP is to fix the inward inspiratory collapse of floppy and/or redundant tissue in epiglottis, ary-epiglottic folds, arytenoids area. In Literature (Zalzal & Coll., Golz & Coll., 2001; Senders & Navarrete, 2001; Toynton & Coll.., 2001) four different surgical actions are described ad suggested, separately or in different combination: 1. resection of eccessive amount of tissue ( -ectomy or plasty ) 2. mucosal removal in order to promote scarring and retraction ( - scar-pexy ) 3. suturing in order to stabilise too mobile structures ( - suture-pexy) 4. section and release of too short ligaments. ( - release ) Robotic supraglottic larynx resection was described by Weinstein & Coll. ( 2005) in cadaver, Hockstein & Coll. (2005) introduced different robotic procedures in the same area in a similar cadaver model, and more recently Solares and Strome (2007) proposed in cadaver and dog model a Robot-Laser coupling for supraglottic laringectomy. 11

13 25 26 STEP 3: RESIDUAL OBSTRUCTION EVALUATION If Cormack & Lehane Grade > 2 is measured If overall resected tissue volume is < 7-8 cc addictional resection in true muscle area is required and planned Addictional resection is not related to the tissue to remove ( lymphoyd tissue vs muscle ) The key is to clear the inspected airway to a reasonable level of endoscopical patency 13

14 27 STEP 4: ADDICTIONAL RESECTIONS the key of this step is to remove a sufficient amount of muscle in order to open the posterior airway space as well as to avoid any possible injury to XII cranial nerve, lingual nerve and lingual artery 28 STEP 4: ADDICTIONAL RESECTIONS basically a muscle layer thinner than 10 mm may be removed without real problems inside the entire BOT limits in midline area an additional strip of 5 mm at each side of midline and 5 mm in depth may be resected without major addictional risks 14

29 STEP 4: ADDICTIONAL RESECTIONS an additional strip

equal or less lower ) and 5 mm in depth may be resected

importance of 3D Da Vinci close view with magnification

structures before to damage them, working carefully

15 29 STEP 4: ADDICTIONAL RESECTIONS an additional strip of average 5 mm at each side of midline ( more higher, equal or less lower ) and 5 mm in depth may be resected without major addictional risks the paramount importance of 3D Da Vinci close view with magnification is the key for the identification of the crucial structures before to damage them, working carefully step by step with a mix of blunt and sharp dissection with robotic arms 30 15

16 31 32 TBR by monopolar cutting 16

17 33 TBR by laser 34 Post-op day 3 17

35 Post-op month 3 36 VISUAL ANALOG SCALE from 0 to 10 8 7 6 5 4 3 2 1

18 35 Post-op month 3 36 VISUAL ANALOG SCALE from 0 to day 1 day 2 day 3 day 4 day 5 MMA TBRHE TORS EPIGL. TS Pain Score 18

4, 1999 8 Pts 38 Impact on SWALLOWING MD ANDERSON DYSPHAGIA

19 37 Impact on VOICE Voice-Related Quality & of OSA Workshop Life II V-RQOL Journal of Voice Vol.13,No.4, Pts 38 Impact on SWALLOWING MD ANDERSON DYSPHAGIA INVENTORY MDADI ARCH OLARYNGOL HEAD NECK SURG/VOL Pts 5.9 ± ±7.7 19

39 90 80 Pre-op 70 60 50 40 30 Tors 20 10 0 A R D S V A R S F

42 51 50 normality 84 78 74 65 62 77 76 67 SF36 scores pre vs

10 0 A R D S V A R S F F F G T S E M Tors 928283 74 668678 77

20 Pre-op Tors A R D S V A R S F F F G T S E M Tors Open normality SF36 scores pre vs post (TORS & OPEN) Post-op Tors A R D S V A R S F F F G T S E M Tors Open Normality

21 41 Revised Outcomes along the time 10 cases 20 cases 58 cases 10 cases

22 43 completely controlled cases May 28 th Nov 11 th pts follow-up: > 6 months Sex: 49 Male 9 Female M/F Ratio = 5 PRE OP AHI 39 POST OP AHI Success vs. Post-op AHI 80% 70% 60% 50% 40% 30% 20% 10% 0% 69% success 31% Failure s <20.1 >20.0 Post-op AHI 22

23 45 46 Selection criteria- good case triple L : low, localised, lymphatic 23

47 Selection criteria-bad case high, diffuse,

Sensitive 48 Volume of TONGUE BASE RESECTION

5 cc) up to 51 cc Outcomes are Resected Volume

24 47 Selection criteria-bad case high, diffuse, muscular, rolled Outcomes are Pathology Sensitive 48 Volume of TONGUE BASE RESECTION Average TB volume reduction is inferior to removed tissue in open TBRHE (av. 28 cc) Most cases 5-20 cc (av cc) up to 51 cc Outcomes are Resected Volume Sensitive Reduction < 7 cc probably not effective Reduction > 20 cc probably not necessary 24

25 49 Success vs. BMI distribution 80% 75% 70% 60% 50% 40% 30% 25% 56% 44% Success Failures 20% 10% 0% <30.1 >30.0 BMI Outcomes are BMI Sensitive 50 Pre vs Post AHI in different Series (1 to 4) AHI st series 2nd series 3rd series 4rd series Pre Registration timing Post 25

26 51 1st series last series

27 53 TORS vs OPEN: Techniques in our series Vicini & Coll., 2010 Vicini & Coll., TORS vs OPEN: Success Rate TORS Success Rate 80% OPEN Success Rate 83% 27

28 55 TORS vs OPEN: functional recovery TORS OPEN NGFT.. 3/40 Swallowing Recovery (days) Hospital Stay (days) 10.5 NGFT.. 12/12 Swallowing Recovery (days) Hospital Stay (days) TORS vs OPEN: complications TORS Late self limiting bleeding.. 4/40 OPEN Infection.. 2/12 Transient Hypogeusia. 9/40 Intra/post operative transient pharyngeal oedema... 1/40 Convertion to open 0/40 Death 0/40 Fistula. 2/12 Transient XII cn palsy 1/12 Bleeding 0/12 Death 0/12 28

57 TORS vs OPEN: Pain VAS 58 TORS vs OPEN: OR Times and Economical Costs TORS OPEN TB & E Surgical Time (min).. 37.8 ±13.

29 57 TORS vs OPEN: Pain VAS 58 TORS vs OPEN: OR Times and Economical Costs TORS OPEN TB & E Surgical Time (min) ±13.8 Overall OR Time (min) ±37.5 TB & E Surgical Time (min) ±45.4 Overall OR Time (min) ±54.5 Overall Cost ( ) Overall Cost ( )

59 Concluding Remarks Pro Contra TORS for OSA is no more a futuristic or experimental option Different Centres trough the world developed and tested different techiques, and many others applied the

30 59 Concluding Remarks Pro Contra TORS for OSA is no more a futuristic or experimental option Different Centres trough the world developed and tested different techiques, and many others applied the available solutions All of that proved to be feasible, safe, and well accepted by patients and surgeons Both published TORS techniques were compared with the most popular Tongue Base alternatives with good results TORS experience for OSA is up to now limited in number and follow up time The overall number of Centres in the world with a sufficient expertise is low The cost of the procedure is higher than the alternative options A new generation of robotic instruments more dedicated or applicable for TORS are strongly reccomended 60 Technology make it easier Thank you for your attention! 30

THE PATIENT STRONGLY MOTIVATED TOWARDS THE TREATMENT? & ENT

THE PATIENT STRONGLY MOTIVATED TOWARDS THE TREATMENT? & ENT SNORING & OSAHS SURGERY International Workshop Preoperative Diagnostic Protocol < 15 min Filippo Montevecchi M.D. Department of Special Surgery Head & Neck Surgery, Oral Surgery Unit (Head: C.Vicini) G.B.