Transoral robotic total laryngectomy: Report of 3 cases

CASE REPORT Amy Chen, MD, Section Editor Transoral robotic total laryngectomy: Report of 3 cases Samuel Dowthwaite, MBBS, 1 Anthony C Nichols, MD, 1 John Yoo, MD, 1 Richard V. Smith, MD, 2 Sandeep Dhaliwal, BSc, 1 John Basmaji, BSc, 1 Jason H. Franklin, MD, 1 Kevin Fung, MD 1 1 Department of Otolaryngology Head and Neck Surgery, Western University, London, Ontario, Canada, 2 Department of Otorhinolaryngology Head and Neck Surgery, Montefiore Medical Center, Bronx, New York. Accepted 26 November 2012 Published online 8 March 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI 10.1002/hed.23226 ABSTRACT: Background. Because of the significant toxicity of chemoradiation regimens, there has been a resurgence of interest in the primary surgical management of head and neck cancer and, in particular, the use of minimally invasive surgery. One such technique is transoral robotic surgery (TORS). We aim to discuss the potential role of TORS in patients requiring total laryngectomy (TL). Methods and Results. Three patients underwent TORS-assisted narrowfield TL. Relative data on preoperative, intraoperative, and postoperative management were collated including postoperative complications. Conclusions. We present 3 cases of transoral robotic surgery (TORS) assisted TL in patients requiring narrow field laryngectomy without requirement for neck dissection. In reviewing these cases we provide a discussion of pertinent preoperative and intraoperative considerations that can assist in facilitating successful completion of the procedure. In particular, appropriate assessment at the pinsertlinepola_del_blank_pgpola_shift_frameport_rem_fpg_underremovelinetabminilanning endoscopy in addition to a methodical surgical approach are vital to the successful use of the robot in TORSassisted TL. VC 2013 Wiley Periodicals, Inc. Head Neck 35: E338 E342, 2013 KEY WORDS: transoral robotic surgery, total laryngectomy, minimally invasive surgery INTRODUCTION Due to the significant toxicity of chemoradiation regimens, there has been a resurgence of interest in the primary surgical management of head and neck cancer using minimally invasive techniques. In the past, only a small number of centers routinely used transoral laser excision of cancers of the laryngopharynx. However, since U.S. Food and Drug Administration (FDA) approval of the da Vinci surgical robot (Intuitive Surgery, Sunnyvale, CA) for extirpation of T1 T2 tumors of the oropharynx and larynx in December 2009, there has been an incredible number centers in the United States and worldwide that have implemented transoral robotic surgery (TORS). This is in part due to the excellent cure rates and functional outcomes that have been reported in early case series. 1 3 Just as important to the adoptance of TORS, however, is the ability of the robot to make challenging transoral laser surgery easier by scaling down movements, providing tremor filtration, overcoming line of sight limitations, and improved ability to access tumors. 4,5 There is little question that TORS resections for oropharyngeal and partial laryngeal surgery are less morbid *Corresponding author: K. Fung, MD, Victoria Hospital, London Health Science Centre, Department of Otolaryngology-Head and Neck Surgery, London, Ontario, Canada. E-mail: Kevin.Fung@lhsc.on.ca than open surgery. 4,6 8 However, the benefits of TORS may extend to more extensive resections such as total laryngectomy (TL). In this report we outline the management of 3 patients with indications for narrow-field laryngectomy that underwent attempted TORS-assisted minimally invasive TL. In doing so we wish to demonstrate that this technique is feasible given appropriate patient selection, intraoperative resources, and preoperative assessment. Potential concomitant benefits to the patient consist of less extensive soft tissue dissection with associated improved postoperative recovery and shorter inpatient hospitalization. This can potentially extrapolate into cost benefit for the health care system in addition to less morbidity for the patient. Study approval was obtained from the Western University Research Ethics Board. All patients provided written consent for TORS-assisted TL. Case 1 A 41-year-old man presented to London Health Sciences Center with a subglottic mass that significantly effaced his airway and was associated with an immobile left vocal fold. He underwent an awake tracheotomy and panendoscopy. Intraoperative findings included a lesion involving the left vocal cord and posterior cricoid cartilage effacing 80% of the airway. Biopsy revealed low-grade chondrosarcoma and a TORS-assisted TL was planned. E338 HEAD & NECK DOI 10.1002/HED NOVEMBER 2013

TRANSORAL ROBOTIC TOTAL LARYNGECTOMY The total operative time was 4 hours and 31 minutes. He was discharged on a soft diet on postoperative day 8. He obtained excellent tracheoesophageal prosthesis (TEP) voice postoperatively. FIGURE 1. Laryngeal exposure using the Feyh-Kastenbauer retractor. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] At the time of definitive surgery, the fashioning of the stoma and dissection of the strap muscles down to the underlying laryngeal skeleton were initially performed via a 5-cm minilaryngectomy incision. Once the end stoma had been secured and the midline structures mobilized, the da Vinci robot (Intuitive Surgery, Sunnyvale, CA) was positioned for completion of the mucosal incisions. Access was secured with a Feyh-Kastenbauer (FK) retractor (GyrusACMI (www.gyrus-ent.com)/explorent GmbH, Tuttlingen Germany), although optimal visualization of the larynx and hypopharynx was poor due to the patient s poor mouth opening, retrognathic jaw, and significant soft tissue edema resulting from the transcervical dissection. Attempts to proceed with a TORS approach were abandoned after incisions through the vallecula and aryepiglottic folds purely due to poor visualization and pressure of the retractor on the patient s oral tongue. The operation was completed via an open approach without incident. Case 2 A 73-year-old man underwent external beam radiotherapy in 1997 through the London Health Sciences Center for treatment of his metastatic cervical squamous cell carcinoma of unknown primary origin. Over the subsequent 14 years, he had no signs of recurrent disease but unfortunately developed chondronecrosis of his larynx, rendering him tracheotomy- and gastrostomy-tube dependent. Appropriate radiologic and clinical work-up revealed no signs of malignancy. The patient s inability to attain adequate vocalization with the tracheotomy in situ meant he was unable to continue effectively in his position of self-employment. This combined with his G-tube dependence had a significant deleterious impact on his quality of life. Total laryngectomy was discussed as a means to provide vocal rehabilitation via Blom-Singer TEP and potentially improved swallowing. TORS-assisted TL was discussed with the patient. An initial planning panendoscopy under general anesthetic was performed to exclude malignancy and assess access. The patient was edentulous, had a Mallampati score of 3, and although he had neck changes consistent with his previous radical radiotherapy he still had excellent neck extension. An FK retractor was appropriately positioned and allowed suitable access to the larynx and hypopharynx (Figure 1A). He subsequently underwent a TORS-assisted TL. The procedural steps are illustrated in Figures 2A 2C. Initial surgical dissection was performed with the robot, with the mucosal incisions being performed and the pyriform fossae mobilized from the lateral thyroid cartilage (Figures 2A, 2B). Once the lateral soft tissue dissection had been FIGURE 2. Schematic demonstration of the steps of the procedure. (A) Initial endolaryngeal incisions performed robotically. (B) Robotic dissection of perilaryngeal soft tissue attachments. (C) Once soft tissue attachments have been released, the specimen can be removed transorally. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] HEAD & NECK DOI 10.1002/HED NOVEMBER 2013 E339

DOWTHWAITE ET AL. FIGURE 5. Robotic endoscopic closure of the pharyngotomy. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] FIGURE 3. The minicervical incision 5-cm width. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] No significant complications were encountered throughout the procedure and blood loss was minimal. The total operative time was 4 hours and 27 minutes. The patient was discharged home on postoperative day seven on a clear fluid diet. He was seen in follow-up in clinic with an excellent cosmetic result (see Figure 7) and obtained excellent TEP voice. performed robotically, a transcervical approach was used to complete the remainder of the dissection through a 5- cm minilaryngectomy incision (see Figure 3). Once completed, the larynx was able to be delivered transorally (Figures 2C and 4). The pharyngotomy was then closed transorally in a T-shape with interrupted 3-0 vicryl sutures using the robot (see Figure 5). Via the neck incision, 2 further layers of closure were performed with reapproximation of the preserved infrahyoid musculature, and the end-stoma was completed with a polydioxanone suture (PDS) and monocryl interrupted sutures (see Figure 6). Case 3 A 59-year-old woman with aphonia rendered G-tubeand tracheostomy-dependent secondary to idiopathic bilateral vocal cord paralysis (with cords paralyzed in the lateral position) was assessed at the London Health Sciences Center. Various surgical and medical interventions had been tried and failed and the patient consented to a functional TORS-assisted TL. An initial planning panendoscopy demonstrated favorable anatomy and excellent exposure of the endolarynx with the FK retractor. The subsequent TORS-assisted TL proceeded with our proposed technique of maximum upfront dissection initially with the robot. The larynx was able to be removed transorally and the closure proceeded in a standard fashion, with closure of the mucosa robotically and reapposition of the infrahyoid strap muscles as FIGURE 4. Transoral removal of the total laryngectomy (TL) specimen. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] FIGURE 6. Final fashioning of the stoma incorporating the entire minicervical incision. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] E340 HEAD & NECK DOI 10.1002/HED NOVEMBER 2013

TRANSORAL ROBOTIC TOTAL LARYNGECTOMY FIGURE 7. Photo demonstrating healed stoma 6 months following surgery. Note the absence of incisions and scarring. [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.com.] a second layer of closure. A primary tracheoesophageal puncture was performed. Total operative time was 4 hours and 9 minutes. The patient was restarted on an oral diet after day 7 after an uneventful initial recovery phase. On day 9 she developed brisk bleeding, requiring a return to the operating theater for an examination under general anesthesia, and was found to have a bleed from the pharyngeal suture line. This was managed with cautery and pharyngeal packing for 24 hours while sedated in the intensive care unit. She was discharged home on postoperative day 14. A delay in oral intake until week 3 was required, with eventual restoration of normal diet and full use of her voice prosthesis. DISCUSSION The evolution of robotic surgery provides an exciting opportunity for the development of minimally invasive techniques in head and neck surgery. Traditional surgical techniques in patients requiring a TL require extensive dissection through complex anatomical regions potentially associated with morbidity that can be either temporary or permanent. Where possible, adopting a more conservative TORS-assisted approach in these patients may serve to expedite postoperative recovery and improve quality of life consistent with published results in other TORS series. 4,7 10 The surgical morbidity associated with a TL can be significant, particularly in those patients undergoing salvage surgery. 11 Transcervical incisions can be associated with significant neck dysthesia, scarring, and fibrosis with concomitant reduction in quality of life. In addition, the extensive soft tissue dissection combined with a large pharyngotomy can potentially lead to pharyngocutaneous fistula and the inherent sequelae coupled to this morbid complication. As well as surgical technique, other factors linked to poor healing in head and neck surgical patients include anemia, cigarette smoking, excessive alcohol intake, previous radiotherapy 6 chemotherapy, and comorbid illness. 12 In a patient demographic that inherently has reduced reparative capacity secondary to some or all of the aforementioned factors, improving healing conditions by any means possible is desirable. In our study we present 3 patients who underwent attempted TORS-assisted TL. The first case presented difficulties associated with robotic access not appreciated at the patient s diagnostic endoscopy. Appropriate evaluation with the retractor system used at our facility (FK retractor) was not undertaken at this initial endoscopy. Our second and third patients had complete evaluations with the FK retractor as part of their planning diagnostic endoscopy that both demonstrated excellent access to the larynx and hypopharynx. Given that the robot is a finite resource shared between multiple surgical specialties at our facility, this simple step during careful planning can help avoid expensive and inappropriate bookings. Another obstruction to successful completion of our first case was the amount of transcervical soft tissue dissection performed before using the robot. Overenthusiastic dissection of the laryngeal skeleton before completing the robotically assisted transoral mucosal dissection ultimately obscured access to the endolarynx and contributed to conversion to an open laryngectomy. The surgical approach during the second TORS-assisted laryngectomy was modified so that the robotic surgery was performed early before proceeding to the open dissection of the infrahyoid strap muscles. This, combined with enhanced endoscopic access, significantly improved the anatomic differentiation and facilitated extensive, safe robotic dissection of the pyriform fossae and soft tissues related to the lateral borders of the thyroid cartilage. Use of the robot in our latter 2 TORS-assisted TL cases also provided excellent access for transoral primary closure of the pharyngeal mucosal defect that has not previously been possible. This closure was performed robotically with interrupted absorbable sutures and reinforced with a further 2 layers of closure via a transcervical approach including reapproximation of the retained infrahyoid strap muscles in the midline. Our first 2 patients had uncomplicated recovery phases without evidence of pharyngocutaneous fistula and restoration of oral diet at day 7 postoperatively. Our third case developed a pharyngeal bleed that required surgical management and a delay in eventual full recovery. In light of this complication, the need to convert to an open procedure in the first case, the prolonged operative time (average 4 hours 32 minutes) and a comparable length of hospital stay compared with that of an open technique, further prospective studies of this novel surgical approach is required to obtain objective data on potential health benefits to the patient and cost savings to our health system. CONCLUSION We presented 3 cases of TORS-assisted TL to demonstrate that it is feasible in carefully selected patients. Our experience highlights the importance of a preoperative evaluation under anesthesia and the technical advantage of performing the robotic portion of the procedure first. The procedure is not without risk because of evidence by the bleeding that 1 of our patients endured complications. Future prospective studies are warranted to determine the true benefits of this technique compared with a standard open laryngectomy in terms of complications, health care HEAD & NECK DOI 10.1002/HED NOVEMBER 2013 E341

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