Robotic‐assisted lingual tonsillectomy

Abstract

This report presents a new technique of transoral robotic-assisted lingual tonsillectomy (RALT). The lingual tonsil area is difficult to visualize and access in the oropharynx. When a lingual tonsillectomy is performed to obtain diagnostic tissue, visualization of this area is important. Transoral robotic surgery (TORS) has been reported to be feasible and safe in other areas of the oral cavity and is reported frequently in resection of tonsillar squamous cell carcinomas.1, 2 We report a single institution's experience with RALT, including the feasibility, safety, utility of the procedure, as well as functional and quality-of-life (QOL) data. Institutional review board approval was obtained from The Ohio State University Office of Responsible Research Practices. Patients undergoing RALT were identified from The Ohio State University Medical Center TORS database. RALT was performed under general anesthesia with a laser-safe endotracheal tube. The da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) was positioned on the right side of the patient, and the bedside surgical assistant was seated at the patient's head. A Crow-Davis retractor was used in a majority of the cases to expose the base of tongue (BOT) and the lingual tonsil area. A Feyh-Kastenbauer retractor (Gyrus ACMI, Southborough, MA) was used if greater visualization of the base of tongue was necessary. The end of the retractor was placed anteriorly just enough to visualize the anterior extent of the lingual tonsil and to expose the posterior aspect of the BOT. The retractor was suspended with a Storz endoscope holder (Karl Storz, Tuttlingen, Germany). The position of the robotic arms included a central 0° video endoscope, and the robotic surgical arms with bipolar cautery and grasper trocars coming in on either side of the endoscope. The procedure was commenced by making an incision on the lateral aspect of the lingual tonsil area with a 5-mm spatula cautery (Fig. 1A). The specimen was retracted medially with a 5-mm Maryland forceps to provide visualization and tension for dissection. The dissection proceeded in a lateral to medial direction (Fig. 1B). Once the specimen was resected, it was removed from the oral cavity en block, oriented with a suture, and submitted to pathology for histopathological analysis (Fig. 2). The defect was allowed to heal by secondary intention (Fig. 1C). (A) Exposure of the lingual tonsil area for robotic-assisted lingual tonsillectomy. (B) Medial to lateral dissection of left lingual tonsil. (C) Lingual tonsil area following dissection. Surgical specimen from bilateral lingual tonsillectomy. Suture marks the superior pole. Demographic, clinicopathological, and operative data was collected for each patient. QOL data was assessed with the Head and Neck Cancer Inventory3 at 3 weeks, 3 months, and 6 months postoperatively. A total of six patients with a median age of 54 years (range, 37–61 years) underwent RALT; four (67%) were females. Median follow-up time was 7 months (range, 2–12 months). Four (67%) of the patients had a previous history of cancer, including neck, lung, esophageal, and ovarian cancer. All patients experienced BOT asymmetry, and three (50%) patients had increased uptake in the BOT on positron emission tomography/computed tomography (Table I). All patients underwent RALT for diagnostic purposes. There were three cases of bilateral and three cases of unilateral lingual tonsillectomy. Median operating room RALT setup time was 31 minutes (range, 20–46 minutes), and RALT operative time was 10 minutes (range, 2–20 minutes), with a median estimated blood loss of 3.8 mL (range, 2–5 mL). Final pathological review showed benign pathology in four (67%) patients, whereas prominent lymphoid tissue and lymphoid infiltrate with focal atypia was seen in the remaining two patients. Two patients stayed in the hospital for 1 night, whereas the rest were discharged home the same day as their surgery. No patients experienced imm