Transoral Robot-Assisted Surgery for Head and Neck Disease

By Mumtaz J. Khan, MD, and Joseph Scharpf, MD

In an era of minimally invasive surgery, new surgical methods must be developed to achieve desired clinical outcomes with decreased long-term functional morbidity. Transoral robot-assisted surgery (TORS) is one such advancement. Although in its infancy, it has shown great results in carefully selected patients. As refinements continue, TORS will likely have a significant impact on the future management of surgical diseases of the head and neck.

The Section of Head & Neck Surgery at Cleveland Clinic Head & Neck Institute recognizes the future significance of robotic surgery, having been involved in the initial development and application of this technique in the first robot-assisted supraglottic laryngectomy, performed in 2007. In accordance with the institute’s goals and objectives, the Transoral Robotic Surgery Program began in November 2010. The focus of practice has been on the management of benign and malignant diseases of the oropharynx, larynx and the parapharyngeal space.

An Institutional Review Board-approved prospective database has been established to gather information on patient demographics, tumor characteristics, treatments, prognosis and functional outcomes. Evaluation of this technique in the management of head and neck cancers will help define guidelines for the treatment of select cancers, particularly those of the oropharynx and larynx.

The Role of TORS in Head and Neck Cancers

Overall survival rates for head and neck cancers have not changed significantly over the past 50 years. However, disease factors, most notably human papilloma virus (HPV)-induced oropharyngeal cancer, as well as treatment protocols have changed and may have an impact on survival rates. The introduction of organ preservation protocols shows increasing concern for functional preservation. Transoral laser microsurgical procedures have shown comparable survival rates to nonsurgical organ preservation protocols, and have demonstrated better long-term functional outcomes.

There are, however, certain procedural limitations to laser microsurgery. TORS has attempted to overcome these difficulties with better optics, utilizing 3-D telescopes to visualize the area of dissection, flexibility of the arms to manipulate tissue and overcome the line-of-sight limitation of a laser coupled to a microscope, and tremor control mechanisms for precise movements.

The current system consists of a surgeon’s console that incorporates two hand controls (EndoWrist® technology) and a 3-D video projection. The robot, which has two surgical arms and a video endoscope, is stationed next to the patient. A variety of mouth gags are available and used to gain access to the surgical site. The robotic arms permit use of a full range of articulated instruments. The system tracks the surgeon’s hand movements and filters out the tremor, reproducing fine surgical maneuvers. The EndoWrist allows a large range of motion and rotation that follows the natural articulation of the human wrist; particularly advantageous in the narrow confines of the oropharynx and hypopharynx. While the primary surgeon controls the robotic instruments and camera, an assistant is responsible for changing and adjusting instruments, retracting, suctioning and aiding in hemostasis.

Limitations in mouth opening, presence of maxillary dentition, an enlarged tongue and mandible considerations may limit the movements of the robot. The other significant limitation is the lack of tactile feedback and appreciation that requires visual cues to overcome. Overall, this system allows better access, clearer visual input and increased flexibility of movements of the instruments and the tissue.

The majority of oropharyngeal cancer patients present with cancers caused by HPV. Because of the implication of HPV in the etiology of head and neck cancers, the sensitivity to radiation therapy and the improved outcomes compared to cancers related to smoking and alcohol abuse, the debate of de-escalating treatment strategies for HPV-positive tumors is of great clinical significance and demands thoughtful study. The ability to resect these primary tumors with TORS rather than by conventional, more morbid approaches may be quite appealing for select patients, and may allow for a de-intensification of postoperative radiation or chemoradiation; hence limiting the toxic effects that can impair long-term functional outcomes.

We are extremely excited about this venture, and hope to continue to provide state-of-the-art service with the highest standards of care to our patients. We believe it will be an important option in the treatment armamentarium of head and neck surgeons.

Case Study: Transoral Resection

Mrs. J. is a 46-year-old patient with a long history of tobacco use but no history of significant medical comorbidities. She presented with otalgia and a supraglottic mass to her local otolaryngologist before referral to Cleveland Clinic. Upon presentation, she was found to have a lesion centered on the laryngeal epiglottis with extension to the left aryepiglottic fold (Figure 1); it was biopsied and found to be squamous cell carcinoma. Although no cervical lymph nodes were palpable on exam, radiologic imaging with PET/CT was interpreted as being consistent with bilateral level 2 and 3 regional metastases.

She was thus clinically staged as a cT2N2CMO, stage 4 supraglottic laryngeal cancer patient. After discussion at the multidisciplinary tumor board and independent, pretreatment evaluation by the head and neck radiation oncology and medical oncology services, the patient elected to undergo a transoral robotic supraglottic laryngectomy (Figure 2) and bilateral neck dissections instead of radiation or chemoradiation options for nonsurgical management.

Her final pathologic status indicated that her margins were negative around the primary tumor, and both necks were devoid of disease. She was thus pathologically staged as a pT2NOMO, stage 2 supraglottic laryngeal cancer patient ‒ a significant downstaging from her clinical presentation stage. Her perioperative course was uncomplicated without the need for a tracheotomy, and she was taking a clear diet on postoperative day 1 with advancement to a soft diet by day 2.

The implications for the patient’s overall treatment were enormous in that she did not receive a recommendation for further intensification and avoided the long-term morbidity from nonsurgical treatment. She healed quite well (Figure 3) and will continue to have close oncologic surveillance.

Figure 1. Initial presentation

Figure 2. Intraoperative

Figure 3. 6 weeks postoperative

Dr. Khan is staff physician in the Head & Neck Institute’s Section of Head and Surgery and Oncology.

Dr. Scharpf is staff physician in the Head & Neck Institute’s Section of Head and Surgery and Oncology.