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Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
Robotic Surgery of the Throat
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Robotic Surgery of the Throat

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Innovative new surgical techniques at Springfield Clinic can dramatically reduce complications during throat surgery. …

Innovative new surgical techniques at Springfield Clinic can dramatically reduce complications during throat surgery.

Dr. Nate Joos, specialist in Otolaryngology/ENT, discusses robotic options for those undergoing surgery on one of the most challenging and inaccessible areas of the body: the throat. Learn how robotic surgery can provide a safer alternative for patients who require surgery.

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  • Multiple approaches have been used to address oral cancers, however these traditional solutions are all associated with major trade-offs for both the patient and the surgeon: Open Surgery : While providing direct surgical access and visualization to the target anatomy via mandibulotomy, this is a highly invasive approach. This approach is associated with high blood loss in addition to prolonged hospital stays and recovery ( Weinstein GS, O’Malley BS, Desai SC, Quon H. Transoral robotic surgery: does the ends justify the means? Curr Opin Otolaryngol Head and Neck Surg . 2009;17:126–131.) Transoral Endoscopic –or- Transoral Laser Microsurgery : provides a minimally invasive surgical technique for resection of tumors in the oropharynx or larynx. As you are familiar, this approach is limited to “line of site” access as the surgical field is viewed through a microscope. Minimally invasive surgery through a transoral approach poses challenges related to the illumination of the field, vascular control, and tissue manipulation and ablation (Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope . 2009;119: 2156 – 2164) Chemoradiation: Radiation alone, or radiation in combination with chemotherapy, offers a non-surgical alternative for many patients. However, damage to the tissue associated with this therapy can raise concern of the long-term functional outcomes in patients. Rates of swallowing complications at 2-years range between 13% and 43% in reported literature ( Quon H, O’Malley BW, Weinstein GS. Transoral robotic surgery and a paradigm shift in the management of oropharyngeal squamous cell carcinoma. J Robotic Surg . 2010. DOI 10.1007/s11701-010-0194-y). Of course, the goal of any new technique is to maintain or enhance our ability to control cancer at the primary site. An ideal technology for treatment of cancer at the primary site would be an approach with low morbidity and that maintains long-term function as cancer control is achieved.
  • What is da Vinci TORS? da Vinci TORS is potentially the most effective minimally invasive surgical treatment for diseases of the head and neck available today. Transoral Robotic Surgery (TORS) provides an alternative treatment option to open surgery, transoral laser surgery, chemoradiation and radiotherapy TORS is most commonly used for oropharyngeal and laryngeal cancer.
  • Let me explain the key components of the da Vinci Surgical System. First is 3D/High-Definition Visualization and up to 10X magnification – giving surgeons unsurpassed visualization for maximum accuracy and precision. Second is EndoWrist ® Instrumentation – providing surgeons with 7 degrees of freedom (which mimics the human wrist) for unparalleled surgical dexterity and precision. And third is Intuitive ® Motion . Surgeon’s movements are scaled and replicated precisely, while hand tremor is virtually eliminated. The end result allows a surgeon to translate their open surgical technique to a minimally invasive approach — extending the benefits of MIS to a broader patient base.
  • Over the years the installed base of da Vinci Surgical Systems has grown significantly.
  • (Refer to text on slide)
  • Let’s review the key components of the da Vinci Surgical System. First is 3D/High-Definition Visualization and 10X magnification – giving surgeons unsurpassed visualization for maximum accuracy and precision Second is EndoWrist Instrumentation – providing surgeons with 7 degrees of motion (that mimics the human wrist) for superior surgical dexterity and precision And third is Intuitive Motion . Surgeon’s movements are scaled and replicated precisely, while hand tremor is eliminated The end result allows a surgeon to translate their open surgical technique to a minimally invasive approach. da Vinci Surgery has demonstrated the ability to convert traditional open surgery to a minimally invasive approach – extending the benefits of MIS to a broader patient base. Let’s discuss how the key components of the da Vinci help to enhance your ability to operate in the oropharynx and larynx: Radical Tonsillectomy : Perform a meticulous, tissue-sparing dissection at unique angles utilizing the da Vinci EndoWrist Instrumentation Tongue Base Resection: The superior visualization and increased dexterity provided by the da Vinci System facilitates dissection in the proper tissue planes for cancer that extends deeply into the tongue base Supraglottic Partial Laryngectomy: The fully articulating EndoWrist instruments allow surgeons to mobilize the ventricular mucosa and meticulously separate the false cord from the attachments of the arytenoid cartilage.
  • So Why da Vinci TORS? Similar to other robotic options, dV TORS has the potential to offer significant advantages over traditional chemoradiation and/or open surgery. An ideal therapy would be one that combines a highly efficacious outcome with a minimally invasive approach. If graphed on the axis shown here, “ideal” therapies would appear in the upper right-left corner of the chart. Let’s examine the different treatment options that available for patients with oral cancer: Open surgery, while providing direct access to the location of the lesion, is a highly morbid and invasive approach Chemoradiation avoids this surgical intervention, however it may compromise long-term function da Vinci TORS is a novel, truly minimally invasive approach to the treatment of oropharyngeal and laryngeal cancer. Question: What have you heard about da Vinci TORS? Why are you interested in learning more? Let’s talk more about the procedural and clinical story behind da Vinci Transoral Robotic Surgery.
  • What is perhaps most important is the value that da Vinci Surgery provides to patients. In clinical studies, da Vinci TORS has shown the following potential patient benefits: Significantly less blood loss 1,2,3,4 No visible scarring or disfigurement 2 No tracheotomy 2 Minimization or elimination of need for chemoradiation therapy 2,3 Low rate of complications 1 Short hospital stay 1,4 Fast recovery, return to normal speech and swallowing 1 Excellent cancer control 1” Question: “Does this list represent outcomes and potential complications that are important to your patients?”
  • da Vinci TORS was FDA cleared in December in 2009. In the year following approval, the otolaryngology community has enthusiastically embraced this technology. As in other specialties, we are also beginning to see trends towards market consolidation. In other words, the growth in da Vinci TORS procedures appears to be outpacing the growth in the institutions, as established surgeons and programs are utilizing TORS over a larger number and broader range of patients over time.
  • In a recent edition of the Archives of Otolaryngology – Head & Neck Cancer, a paper by Dean and Rosenthal from the University of Alabama-Birmingham looked at a comparison between patients who underwent surgical resections for T1 and T2 oropharyngeal cancers. The patients were classified within three cohorts: robotic-assisted surgery for primary neoplasms, robotic-assisted salvage surgery for recurrent decrease, and open salvage surgery for recurrent decrease. Results: The median length of stay in the open salvage group was 8.2 days compared to five days for the robotic salvage group and 1.5 days for the robotic primary resection group. Regarding post-surgical diets, 43% of the patients who underwent open salvage procedures were on gastrostomy feeding tube-dependent six months following treatment compared to zero patients in the robotic surgery groups. 7% of the patients who underwent open salvage procedures also remained tracheotomy tube-dependent after six months compared with zero patients in the robotic groups. There were no complications reported in the robotic groups. However, two patients who underwent open salvage resections developed postoperative hematomas and two developed room [ph] infections. da Vinci procedures across all specialties have been associated with short length of stay and low rate of complications and it appears that transoral surgery will follow suit.
  • Transcript

    1. Robotic Surgery of the Throat A New Tool for an Old Problem Nate Joos, MD, ENT www.SpringfieldClinic.com
    2. The Scope of Ear, Nose, and Throat... <ul><li>Otolaryngology includes the care and treatment of a variety of diseases: </li></ul><ul><ul><li>Ear: Hearing loss, infections, eardrum repair </li></ul></ul><ul><ul><li>Nose: Rhinoplasty, sinus surgery, cancers of the nose and sinuses </li></ul></ul><ul><ul><li>Throat: Voice surgery, cancers of the lips, mouth, throat, voice box, thyroid and parathyroid surgery </li></ul></ul><ul><ul><li>Skin lesions of the head and neck (basal cell, squamous cell, and melanoma cancers) </li></ul></ul><ul><ul><li>Sleep medicine and surgery (Also robotic) </li></ul></ul><ul><ul><li>Allergy and immunotherapy </li></ul></ul><ul><ul><li>Facial trauma repair and facial reconstruction </li></ul></ul>
    3. Of All of Those... <ul><li>Head and neck cancer is the scariest! </li></ul><ul><ul><li>Many of these lesions are diagnosed after they have been around for some time due to their sometimes subtle and confusing symptoms </li></ul></ul><ul><ul><li>Difficult to diagnose due to their ‘hidden’ location, making discovery by your PCP a rare event </li></ul></ul>
    4. Where is it happening? <ul><li>In 2006, there were approximately 31000 cancers of the oral cavity and the throat diagnosed </li></ul><ul><ul><li>Another 9000 were diagnosed in the voice box, or larynx </li></ul></ul><ul><li>That incidence rises 10 fold across the globe, considering the different uses of oral tobacco products and carcinogens </li></ul><ul><li>Most patients are older than 45, largely between the ages of 60-80 </li></ul>
    5. Speaking of Risk Factors... <ul><li>We all know that smoking is bad for you, but often the lungs dominate the attention on that fact </li></ul><ul><ul><li>Head and neck carcinomas are dominated by the abuse of tobacco and alcoholic products </li></ul></ul><ul><ul><ul><li>2ppd smokers have been shown to have a 20 fold increased risk of occurrence when compared to nonsmokers </li></ul></ul></ul><ul><ul><ul><li>Heavy alcohol use has been associated with a 3-4 fold increase </li></ul></ul></ul><ul><ul><ul><li>But TOGETHER, they raise that risk up to 100 fold! </li></ul></ul></ul>
    6. Human Pappilloma Virus <ul><li>Certain HPV subtypes have also been implicated in the formation of tonsil/tongue/and throat </li></ul><ul><ul><li>The same types that have been shown to cause cervical cancer in women </li></ul></ul><ul><ul><li>The Gardasil vaccine prevents this association, one motivating factor in the decision to provide it to young people in the United States </li></ul></ul>
    7. Symptoms of H/N Cancer <ul><li>Chronic pain: if you have a mouth sore, or sore throat that has been present for more than 4 consecutive weeks, with or without antibiotic use, have it checked out! </li></ul><ul><li>Ear pain: The glossopharyngeal nerve is often responsible for the pain associated with these lesion. It also delivers sensation to the middle ear, and can get cross-wired! </li></ul><ul><ul><li>The ear is usually normal on examination in these cases </li></ul></ul><ul><li>Trouble swallowing or painful swallow: The base of the tongue in the throat is key in initiating a swallow </li></ul><ul><ul><li>A mass can alter the function of this muscle </li></ul></ul><ul><ul><li>Or can directly impeded the passage of food based solely on the extra mass at this narrow location </li></ul></ul>
    8. More Symptoms... <ul><li>Difficulty breathing! </li></ul><ul><ul><li>See in either smaller cancers located on the vocal cords </li></ul></ul><ul><ul><ul><li>Leading to their often earlier diagnoses </li></ul></ul></ul><ul><ul><li>Or at locations right above them (tongue, rim of the voice box) </li></ul></ul><ul><ul><li>Stridor is a term for noisy air turbulence through the voice box, or larynx, and is a serious concern! </li></ul></ul><ul><li>Difficulty opening the mouth fully, or trismus </li></ul><ul><ul><li>Can be caused by tumor invasion into the small muscles responsible for jaw motion, or directly into the jaw joint (TMJ) </li></ul></ul>
    9. More symptoms... <ul><li>Cancer has an extremely high metabolic rate, leading to: </li></ul><ul><ul><li>Unexplainable weight loss </li></ul></ul><ul><ul><li>Fever </li></ul></ul><ul><ul><li>Night sweats </li></ul></ul><ul><ul><li>Fatigue </li></ul></ul><ul><li>Any unexplainable blood in the mouth or throat should be investigated! </li></ul>
    10. If you have any of these... <ul><li>Schedule a visit with your PCP! There can be a number of different diagnoses overlapping in these symptoms, so don’t build anxiety over it, just go get it checked out! </li></ul><ul><li>If your PCP is concerned, they’ll likely refer you to an ENT specialist for a workup. </li></ul>
    11. How are these lesions diagnosed? <ul><li>Your ENT provider will perform a complete physical examination and history </li></ul><ul><li>Often times, you may receive a flexible laryngoscopic exam in the office as well </li></ul><ul><li>A CT scan with contrast provides detailed anatomic information regarding the size and extent of the issue </li></ul>
    12. How are these lesions diagnosed? <ul><li>A sample of the lesion must be obtained to conform the tissue diagnosis </li></ul><ul><ul><li>This is usually done through a short outpatient procedure known as a direct laryngoscopy </li></ul></ul><ul><ul><li>If the presenting problem was a firm neck mass (which is the case 20% of the time), a specimen may be obtained initially through a fine needle aspiration </li></ul></ul><ul><li>Squamous cell carcinoma accounts for the vast majority of these problematic lesions </li></ul>
    13. How is it Treated? <ul><li>There are many treatment modalities available in cases of head and neck cancer. </li></ul><ul><li>Generally, a team of physicians made up of surgeons, medical oncologist, and radiation oncologist accompanied by dietitians and speech therapists will tailor a therapy specific to each patient. </li></ul><ul><li>These decisions are made based upon the tumor size, location, extent of involvement, and patient function with regards to speech and swallow </li></ul><ul><li>And of course.... STOP SMOKING! </li></ul>
    14. Primary Cancer Site Treatment Surgical Non-surgical Transoral Endoscopic
    15. What are the Pros and Cons of Each?
    16. Open Surgery <ul><li>Pro: </li></ul><ul><ul><li>Able to address any sized lesion </li></ul></ul><ul><ul><li>Able to clearly see the margins of resection </li></ul></ul><ul><ul><li>Able to simultaneously address any neck disease in appropriate patients </li></ul></ul><ul><li>Cons: </li></ul><ul><ul><li>Very invasive </li></ul></ul><ul><ul><li>High complication rates </li></ul></ul><ul><ul><li>Longest hospital stay </li></ul></ul><ul><ul><li>Pain control more difficult </li></ul></ul>
    17. Chemotherapy and Radiation <ul><li>Pros: </li></ul><ul><ul><li>No incisions involved </li></ul></ul><ul><ul><li>Able to cure with similar rates to surgery in appropriate patients </li></ul></ul><ul><ul><li>Able to keep all of the voice box in laryngeal tumors </li></ul></ul><ul><li>Cons: </li></ul><ul><ul><li>Decreased saliva flow </li></ul></ul><ul><ul><li>Pain of the mucous membranes </li></ul></ul><ul><ul><li>Skin changes </li></ul></ul><ul><ul><li>Can have compromised swallow function and laryngeal function in some cases </li></ul></ul>
    18. Minimally Invasive Surgery <ul><li>Pros: </li></ul><ul><ul><li>Able to remove lesions without external incisions </li></ul></ul><ul><ul><li>Similar cure rates to open surgery in appropriate patients </li></ul></ul><ul><ul><li>Short hospital stay </li></ul></ul><ul><ul><li>Lower complication rates </li></ul></ul><ul><li>Cons: </li></ul><ul><ul><li>Not able to handle tumors larger than about 3-4cm </li></ul></ul><ul><ul><li>May still need radiation therapy in some cases, so patient selection is important! </li></ul></ul><ul><ul><li>Can still have compromised laryngeal function in some cases </li></ul></ul>
    19. What is da Vinci TORS? <ul><li>Transoral Robotic Surgery (TORS) provides an alternative treatment option to open surgery, transoral laser surgery, chemoradiation and radiotherapy. </li></ul><ul><li>While TORS is cleared for resections of T1 and T2 lesions as well as benign tissue in otolaryngological procedures, TORS is most commonly used to treat oropharyngeal and laryngeal cancer. </li></ul>
    20. Robotic System Overview
    21. da Vinci ® Surgical System U.S. Installed Base 1999 – 2011 1999 2000 2001 2002 2003 2004 Alaska 2005 Hawaii 2006 2007 2008 2009 Puerto Rico 2010 2011
    22. Common TORS Procedures TORS is ideally suited for the treatment of oropharyngeal and laryngeal cancers and specifically treats: Tonsillar cancer Tumor Location: tonsil, superoposterior tongue, soft palate, lateral and posterior walls of oropharynx Base of tongue cancer Tumor Location: inferoposterior tongue (base), lateral and posterior walls of oropharynx, superior to epiglottis Supraglottic cancer Tumor Location: anatomy superior to glottis (vocal cords), including epiglottis, lateral and posterior walls of superior larynx Oropharynx Larynx
    23. Common da Vinci TORS Procedures Radical Tonsillectomy Perform a meticulous, tissue-sparing dissection at unique angles utilizing the da Vinci EndoWrist Instrumentation Tongue Base Resection The superior visualization and increased dexterity provided by the da Vinci System facilitates dissection in the proper tissue planes for cancer that extends deeply into the tongue base Supraglottic Partial Laryngectomy The fully articulating EndoWrist instruments allow surgeons to mobilize the ventricular mucosa and meticulously separate the false cord from the attachments of the arytenoid cartilage
    24. Why da Vinci TORS? • Chemoradiation • da Vinci • Surgery
    25. Value for the Patient: <ul><ul><li>Low blood loss 1,2,3,4 </li></ul></ul><ul><ul><li>No visible scarring or disfigurement 2 </li></ul></ul><ul><ul><li>No tracheotomy 2 </li></ul></ul><ul><ul><li>Minimization or elimination of need for chemoradiation therapy 2,3 </li></ul></ul><ul><ul><li>Low rate of complications 1 </li></ul></ul><ul><ul><li>Short length of stay 1,4 </li></ul></ul><ul><ul><li>Fast recovery, return to normal speech and swallowing 1 </li></ul></ul><ul><ul><li>Excellent cancer control 1 </li></ul></ul>1 Weinstein GS,O’Malley Jr BS, Desai SC, Quon H; Transoral robotic surgery: does the ends justify the means? Current Opinion in Otolaryngology & Head and Neck Surgery,17:126–131, 2009 2 O’Malley Jr. B, Weinstein GS, Snyder W, Hockstein, NG; Transoral Robotic Surgery (TORS) for Base Tongue Neoplasms, Laryngoscope 116: August 2006. 3 Weinstein GS, O’Malley Jr. BW, Synder W, Sherman E, Quon H; Transoral Robotic Surgery, Radical Tonsillectomy; Arch Otolaryngol. Head Neck Surg/Vol. 133 (No. 12), Dec 2007. 4 Boudreaux BA, Rosenthal EL, Magnuson SJ, Newman RJ,, Desmond RA, Clemons L, Carroll WR; Robot-Assisted Surgery for Upper Aerodigestive Tract Neoplasms; Arch Otolaryngol Head Neck Surg/Vol 135 (No. 4), Apr 2009
    26. da Vinci TORS Adoption <ul><li>FDA cleared in December 2009: Resection of Benign and Cancerous (T1 & T2) Lesions </li></ul>
    27. da Vinci Transoral Surgery Outcomes Data from: Dean NR, Rosenthal EL, Carroll WR, Kostrzewa JP, Jones VL, Desmond RA, Clemons L, Magnuson JS. Robotic-assisted surgery for primary or recurrent oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg.  2010;136(4):380-384. * Stated P values compare the Robotic-assisted salvage group to the Open salvage group . Measure Robotic-Assisted for primary neoplasm (N=15) Robotic-assisted salvage (N=7) Open salvage (N=14) P value* Median Length of Stay (days) 1.5 5.0 8.2 .14 Gastrostomy tube dependent @ 6 mos 0% 0% 43% .06 Tracheotomy tube dependent @ 6 mos 0% 0% 7% .48 Negative margins 100%* 100% 86% NS Complications 0% 0% 4/14 NS
    28. <ul><li>“ Transoral Robotic Surgery (TORS) not only offers our patients comparable or better oncologic outcomes for oropharyngeal and supraglottic cancer, it does so without  decreasing quality of life in terms of speech and swallowing.  This technology has changed the game entirely. Finally we have  an FDA cleared technique that can be performed by well trained clinicians and offer them excellent outcomes for their patients.” </li></ul>Gregory Weinstein, MD
    29. Other Robotic Uses in ENT <ul><li>Thyroid Surgery: </li></ul><ul><ul><li>Portions of the thyroid gland may be removed through the axilla, eliminating any scar on the neck </li></ul></ul><ul><ul><li>Possible due to the visibility provided by the robotic system </li></ul></ul><ul><li>Sleep surgery </li></ul><ul><ul><li>Chronic snoring and sleep apnea may be addressed in appropriate patients with the robot </li></ul></ul><ul><ul><li>Allows visibility to the base of the tongue to allow a reduction in tissue size at this narrow location </li></ul></ul><ul><ul><li>Come hear more about this topic next month at MMC! </li></ul></ul>
    30. Thank You! Questions?
    31. Title of Slide is Here <ul><li>First bullet is here </li></ul><ul><li>Second bullet is here </li></ul><ul><ul><li>More info. is here </li></ul></ul><ul><ul><ul><li>More info. is here </li></ul></ul></ul>
    32. Title of Slide is Here <ul><li>First bullet is here </li></ul><ul><li>Second bullet </li></ul><ul><li>More info goes here, here, here </li></ul>
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