H&N Robotic Surgery Update. September 1, 2022

What´s new in PubMed this week

Charters E, Pelham C, Novakovic D, Madill C, Clark J. Velopharyngeal incompetence following transoral robotic surgery for oropharyngeal carcinoma: A scoping review. Int J Speech Lang Pathol. 2022 Aug 17:1-9. doi: 10.1080/17549507.2022.2104927. Epub ahead of print. PMID: 35975948

Velophayngeal incompetence after TORS lateral oropharyngectomy is an understandable concern, particularly for those who are not familiar with the surgical procedure. Concerns might even worsen when they learn that no reconstructive procedures are added in most of the cases.

The standard radical tonsillectomy (lateral oropharyngectomy) as described by Weinstein and O´Malley will nor produce incompetence at all in any primary case. Certainly, the sugical bed will appear awful the first days, buy the scar will retract, closing most of the gap in the resected phayngeal constrictor muscle and at the same time pulling from the uvula and conforming a new competent velum.

Every surgeon knows when the risk of incompetence exist. It might happen mainly when more than half of the soft palate is resected (resection carried further from the uvula) or in patients with previous radiation therapy. In the first situation we migth consider alternative treatment with radiochemotherapy, and in the second using a flap. However, yes, expected functional sequelae (on swallow and speech) are probably the main factor when choosing the primary treatment (that is why we usually prefer surgery).

Olson B, Cahill E, Imanguli M. Feasibility and safety of the da Vinci Xi surgical robot for transoral robotic surgery. J Robot Surg. 2022 Aug 16. doi: 10.1007/s11701-022-01449-y. Epub ahead of print. PMID: 35972598.

Everybody everywhere is using the da Vinci Xi “multi-arm” for TORS. We have no choice, although we miss the 5mm endowrist (particularly for supraglottic surgery). We performed our first TORS dV Xi surgery on april 4, 2016. That was when we changed the old da Vinci S HD. Since then, that is the only platform availble for us.

We will see what happens with the da Vinci Xi Single Port (SP). Going to 6mm endowrist is an improvement, certainly.

Silverman DA, Birkeland AC, Bewley AF. Oropharyngeal reconstruction after transoral robotic surgery. Curr Opin Otolaryngol Head Neck Surg. 2022 Oct 1;30(5):384-391. doi: 10.1097/MOO.0000000000000842. Epub 2022 Aug 3. PMID: 36004787

A recurrent topic. The historical reality is that we all mostly stoped using free flaps after oropharyngeal resections when the minimally invasive approach became the standard thanks to TORS.

However, yes again, as with growing experience we became more ambitious some of our resections started to be wider, and more difficult cases included (ie. salvage surgery). Many of this patients will actually need a flap. So surgical options need to be revisited.

Kim KH, Ji YB, Song CM, Kim E, Kim KN, Tae K. Learning curve of transoral robotic thyroidectomy. Surg Endosc. 2022 Aug 24. doi: 10.1007/s00464-022-09549-4. Epub ahead of print. PMID: 36002679

We have to thank again Prof. Kyung Tae for another insight into a relevant topic.

Yes, remote access thyroidectomy is a challenging surgical procedure, with a long learning curve. Previous experience in robotic surgery and open thyroidectomy are not just helpful, but a must.

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