Transoral robotic surgery total laryngectomy

Abstract

Transoral robotic surgery (TORS) has expedited patient rehabilitation while maintaining excellent outcomes following oropharyngectomy.1 The further application of TORS to supraglottic laryngectomy2 and hypopharyngectomy3 has been reported with feasibility trials and promising initial data. The combination of the two procedures, supraglottic and hypopharyngeal TORS resection, can be adapted to perform a TORS total laryngectomy (TORS-TL). In the past, TORS-TL has been met with skeptical criticism as to its ultimate clinical benefit. Conversely, the authors suggest that the minimally invasive TORS approach offers significant benefits toward improving patient recuperation and the avoidance of substantial postoperative morbidity. However, such benefits can only be demonstrated following repeated clinical experience. It is the purpose of this report to describe the surgical protocol utilized by the authors to encourage further application and study of this promising surgical advancement. TORS-TL is an off-label use of the da Vinci Surgical Robotic system (Intuitive Surgical, Sunnyvale, CA). TORS-TL should only be performed in centers experienced in TORS supraglottic laryngectomy and hypopharyngectomy. Prospective patients must be counseled appropriately as to the potential risks and benefits as compared to the conventional open approach to total laryngectomy. Because of the caudal extent of the surgical dissection, a minimal system requirement of the da Vinci S Surgical Robotic System is suggested due to the improved arm spacing. In addition, a pharyngoscope retractor system, such as the LARS4 (Fentex Medical, Neuhausen, Germany) or the WO-FK (Gyrus ACMI, Tuttlingen, Germany), with wide extension of the lateral supports is recommended. The procedure begins with a standard tracheostomy skin incision, approximately 4 cm in length, midway between the cricoid cartilage and the sternal notch. After the superior subplatysmal skin flap is raised, the strap muscles are divided along the midline raphe to expose the trachea and cricoid cartilages (Fig. 1A). A thyroid isthmusectomy is performed, and the lateral lobes are dissected off of the lateral tracheal walls. A complete transection of the trachea is placed at the third tracheal space with rising posterior tracheal mucosal cuts. Inferior stomal stitches are placed to secure the caudal trachea. The 4-cm skin incision allows ample visualization to dissect around the remaining rostral trachea and cricoid cartilage, which includes sectioning bilateral recurrent laryngeal nerves. At this point, heavy braided sutures are placed around the lateral walls of the rostral trachea and are threaded through glottis for intraoral retraction (Fig. 1B). The stoma site is covered with sterile drapes. Transoral robotic surgery total laryngectomy: cervical exposure. (A) A 4-cm incision is shown overlying second tracheal ring, dividing the strap muscles in midline, and exposing the trachea. (B) The thyroid gland is divided, trachea is transected, inferior stomaplasty is performed, superior tracheal and cricoid is dissected free, and lateral retraction sutures are placed through lateral tracheal walls. Initial placement uses the intraoral retractor blade overlying the epiglottis. The 0-degree da Vinci endoscope, along with 5-mm Maryland dissector and 5-mm Bovie spatula (Intuitive Surgical, Inc., Sunnyvale, CA), is used. After optimal retraction and visualization are obtained, the initial intraoral incision is placed along the superior aspect of the arytenoid mucosa (Fig. 2A). With the dissector retracting the postcricoid mucosa, the Bovie separates this mucosal layer from the cricoid cartilage. Subsequently, the epiglottis is then released from retraction, and the vallecula incision is made along lingual surface of the epiglottis in the direction toward the superior border of thyroid cartilage (Fig. 2B). Extending the vallecular incision laterally and posteriorly, the superior laryngeal vessels are encountered