Further Reading
2. Articular temporomandibular disease: joint dysfunction related either to (a) displacement of the meniscus disk, or (b) diseases causing degen-
1.8.7 Robotic-Assisted Head and Neck Surgery
Kuriloff DB. Basic principles and current applications of lasers in head and neck sur- gery. In: Van de Water TR, Staecker H, eds. Otolaryngology: Basic Science and Clini- cal Review. Stuttgart/New York: Thieme; 2006:178–191
Oswal V, Remacle M. The Principles and Practice of Lasers in Otorhinolaryngology and Head and Neck Surgery. The Hague: Kugler; 2002
● 3D camera : This is a high-definition camera that gives the surgeon a 3D image of the surgical field. The camera includes significant mag- nification, enabling the surgeon to zoom in on the operative field as needed.
● Console : The surgeon sits at the console, where he or she controls the four robotic hands and sees images from the 3D camera.
The four robotic hands and the 3D camera are inserted through incision(s) or a natural orifice, depending on the specific procedure. The two access points most used to date for the dVSS are transoral access for tongue base, tonsil, supraglottic, parapharyngeal, and skull base tumors as well as ob- structive sleep apnea surgery; and transaxillary access for scarless thyroi- dectomy. A third option, transcervical access for neck tumors, is currently under investigation.
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Transoral Robotic-Assisted Surgery
A surgical camera and instrumentation are passed through the patient’s open mouth and controlled by the surgeon sitting at the adjacent console.
The surgeon directs the graspers and cautery or laser to the tumor location and resects under direct visualization. Transoral robotic-assisted surgery (TORS) may preclude the need for mandibulotomy and tracheotomy and allow thorough resection of tumors under direct visualization.
McLeod reported a case using the dVSS to successfully marsupialize a vallecular cyst in a patient presenting with dysphagia. Weinstein et al docu- mented feasibility studies using the dVSS on animal and human cadaver models prior to successfully applying robotic technology to the excision of many supraglottic, base of tongue, and tonsillar malignancies. Weinstein, O’Malley, and Genden have all published reports of its successful use in transoral robotic excision of oropharyngeal and laryngeal tumors. Current investigative work is being performed using the robot for transoral resec- tion of parapharyngeal space tumors.
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Transaxillary Thyroidectomy
Transaxillary endoscopic thyroidectomy was described beginning in 2001. The goals of minimally invasive thyroid surgery are to maintain an acceptable level of safety while improving cosmesis. The patient is placed in the supine position under general anesthesia. The lesion-side arm is raised and fixed for the shortest distance from the axilla to the anterior neck. A skin incision is made in the anterior axillary fold. A subplatysmal plane is developed immediately superficial to the pectoralis major and clavicle. Once the subplatysmal plane is sufficiently large, retractors are placed and the dVSS robotic arms are docked. A second skin incision is made on the medial side of the anterior chest wall for insertion of the fourth robot arm. The operation then proceeds in similar fashion to an open thyroidectomy.
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Other Robotic Applications in Otolaryngology–Head and Neck Surgery
Robotic-assisted surgery has been applied to neurotology, though only ex- perimentally so far. The RX-130 robot (Staubli Unimation, Faverges, France) was successfully programmed to drill cochlear implant wells in human cadaveric temporal bone specimens. The use of robotic-assisted surgery in transnasal and otologic procedures is currently limited by the size of the instruments. However, with the development of smaller instruments and more flexible tools, its use can be further advanced in the fields of transna- sal and otologic surgery.
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Advantages of Robotic-Assisted Surgery
● Robotic-assisted surgery allows for minimally invasive techniques with small incisions, less blood loss, and reduced recovery time.
● It allows access to areas typically inaccessible with conventional laparo- scopic techniques.
● It increases the surgeon’s dexterity while minimizing tremor.
● It provides excellent optics and improved visualization (3D view with depth perception).
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Disadvantages of Robotic-Assisted Surgery
● It is a new technology whose uses and efficacy are still being established.
● It has a high cost.
● The size of the system is awkward: robotic systems have relatively large footprints and cumbersome robotic arms.
● There is a lack of compatible instruments and equipment.
● The surgeon has no tactile feedback (“feel of tissue”).
● No billing ICD-9 codes have been established for robotic-assisted surgery.
Further Reading
Genden EM, Desai S, Sung CK. Transoral robotic surgery for the management of head and neck cancer: a preliminary experience. Head Neck 2009;31(3):283–289 Kang SW, Lee SC, Lee SH, et al. Robotic thyroid surgery using a gasless, transaxillary
approach and the da Vinci S system: the operative outcomes of 338 consecutive patients. Surgery 2009;146(6)1048–1055
Lewis CM, Chung WY, Holsinger FC. Feasibility and surgical approach of trans- axillary robotic thyroidectomy without CO 2 insufflation. Head Neck 2010;32(1):
121–126
McLeod IK, Mair EA, Melder PC. Potential applications of the da Vinci minimally in- vasive surgical robotic system in otolaryngology. Ear Nose Throat J 2005;84(8):
483–487
O’Malley BW Jr, Weinstein GS. Robotic anterior and midline skull base surgery: preclini- cal investigations. Int J Radiat Oncol Biol Phys 2007;69(2, Suppl)S125–S128 O’Malley BW Jr, Weinstein GS, Snyder W, Hockstein NG. Transoral robotic surgery
(TORS) for base of tongue neoplasms. Laryngoscope 2006;116(8):1465–1472 Terris DJ, Haus BM, Gourin CG, Lilagan PE. Endo-robotic resection of the submandibular
gland in a cadaver model. Head Neck 2005;27(11):946–951 PubMed
Weinstein GS, O’Malley BW Jr, Snyder W, Hockstein NG. Transoral robotic sur- gery: supraglottic partial laryngectomy. Ann Otol Rhinol Laryngol 2007;116(1):
19–23
Weinstein GS, O’Malley BW Jr, Snyder W, Sherman E, Quon H. Transoral robotic sur- gery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007;133(12):
1220–1226