日期：113年2月16日 主題：達文西機械手臂手術於耳鼻喉之應用 講師：高雄長庚耳鼻喉科 蘇彥燁 主治醫師

1. 達文西機械手臂手術於耳鼻喉之應用
Robotic-assisted Transoral Surgery in Otolaryngology
Yan-Ye Su MD
2024/02/16
Department of Otorhinolaryngology-Head and Neck
Kaohsiung Chang Gung Memorial Hospital

2. Outline
⚫The introduction of da Vinci system
⚫The indications for TORS
⚫Surgical technique (lateral oropharyngectomy)
⚫The personal limited experience sharing
⚫The contraindications for TORS
⚫The complications of TORS

3. Approved by FDA in 2000
Minimally Invasive Surgery
Introduction of Da Vinci System

4. da Vinci surgery system
4
• 1999 : First generation of da Vinci surgical system
(Intuitive Surgical, USA)
• 2000 : Approved by the Food and Drug Administration(FDA)
• 2006: da Vinci S System
• 2009: da Vinci Si System
Transoral robotic surgery (TORS) for T1 or T2 oropharyngeal tumors
• 2014: da Vinci Xi System
Benign base of tongue resection procedure
• 2016: da Vinci Sp System (Single port flexible system)
• 2017: da Vinci X System

5. 8,703 Worldwide as of 2024

11. The Benefits of Robotic Surgery
⚫For patient ---
⚫Cosmetic effect (minimal scaring) 外觀較佳
⚫Reduced blood loss and wound infection due to smaller incision
出血量較少，破壞性較小
⚫Shorter hospitalization 住院天數少
⚫For surgeon ---
⚫Improve surgical approach 較容易腫瘤處理
⚫Greater visualization (magnified vision system that gives surgeons a
3D HD view inside the patient’s body) HD螢幕手術視野佳
⚫Less hand tremor 減少手震手抖

12. The Application of Robotic Surgery in H&N
⚫ Pharynx/Larynx/Nasopharynx/Sinuses and anterior skull base/Otology and lateral skull base/Neck dissection/Thyroid
Recent advances in robot-assisted head and neck surgery.
Friedrich DT1, Scheithauer MO1, Greve J1, Hoffmann TK1, Schuler PJ1.
Int J Med Robotics Comput Assist Surg (2016)

13. Robotic Surgery in H&N
⚫TORS
⚫ Lateral oropharyngectomy
⚫ Tongue base tumor resection
⚫ Glottic cancer, supraglottic cancer, hypopharyngeal cancer
⚫ Partial or total laryngectomy
⚫ Parapharyngeal and retropharygeal space tumor
⚫ Locally advanced oropharyngeal cancer
⚫ Obstructive sleep apnea surgery
⚫ Transoral thyroidectomy
⚫ Trans-palatal nasopharyngeal tumor resection
⚫ Resection of submandibular gland and submandibular duct stone removal
⚫Robot-assisted surgery
⚫ Neck mass excision (BCC, submandibular gland, neurologic tumor …)
⚫ Thyroidectomy
⚫ Neck dissection
達文西機械手臂是幫助手術順利執行的一項工具

14. The Consideration of Cancer Treatment
⚫Survival
⚫Functional preservation (swallowing and speech)
⚫Cosmetic consideration
⚫Cost
14

15. The Indications for TORS
⚫Oropharyngeal cancer (T1 & T2) (FDA approved in 2009)
⚫Small lesion with limited size resection (surgical wound
secondary healing )
⚫…………..

16. Oropharyngeal tumor
(口咽部腫塊)

17. Operation
⚫Transoral tumor resection (小且可目視之腫瘤)
⚫
⚫Transcervical approach
⚫Mandibular swing approach (大且嚴重侵犯之腫瘤)

18. Mandibular Swing Approach

19. TORS for Selective Opx and Hpx Tumor
⚫The concept of Inside-Out
⚫Get adequate margin (survival)
⚫Avoid pharyngeal wall mucosal damage (functional preservation)

20. Operation
⚫Transoral tumor resection
⚫TORS（trans-oral robotic surgery）
經口達文西機械手臂手術
⚫Transcervical approach
⚫Mandibular swing approach

21. Surgical technique

22. Mandibular swing approach vs TORS

23. ⚫Steps:
⚫1. Pterygomandibular raphe (cut superior constrictor m.
(transverse m.) and expose medial pterygoid m.(longitudinal m.))
⚫2. Upper margin (soft palate)
⚫3. Inferior margin (tongue base)
⚫4. Medial margin (posterior pharyngeal wall)
⚫5. Tumor resection along with superior constrictor m.
⚫6. Well hemostasis
Lateral Oropharyngectomy
(Tonsil cancer)

24. • The parapharyngeal fat is an important landmark for
the internal carotid artery
• The styloid muscular diaphragm is a guide to the
vasculature because the major vessels lie lateral to this
Hemostatic Options for Transoral Robotic Surgery of the Pharynx
and Base of Tongue
Julia A. Crawford, MBBS, Ahmed Yassin Bahgat, MD,Hilliary N. White, MD, J. Scott Magnuson, MD
Otolaryngol Clin N Am 49 (2016) 715–725

26. Post TORS Wound Secondary Healing

27. The Indications for TORS
⚫Oropharyngeal cancer (T1 & T2) (FDA approved in 2009)
⚫Small lesion with limited size resection (surgical wound
secondary healing )
⚫Obstructive sleep apnea surgery (OSAS)
⚫…………..

28. OSA Surgery
Not a substitute for CPAP
Salvage procedure for those who failed
CPAP and other conservative therapies
Surgical success of UPPP as an isolated
procedure in non-selected patients:
40.7%
~ Sher AE. Sleep 1996.

29. ⚫Classify the obstruction levels as:
- Type 1, oropharynx only
- Type 2, multilevel obstruction: a combination of oro- and hypo-pharyngeal obstruction.
- Type 3, hypopharynx only.
⚫Of the 239 patients, 93.3% (223 patients) were identified as having multilevel obstruction, type 2.
⚫Only 16 patients (6.7%) had single level obstruction. (10 P’t had type 1 obstruction and 6 P’ts had type 3 obstruction.
~ Riley RW, Powell NB, Guilleminault C. Obstructive sleep apnea
syndrome: a review of 306 consecutively treated surgical patients.
Otolaryngol Head Neck Surg 1993;108:117.
87% of the 893 patient population had multilevel obstruction.
~ Abdullah VJ, van Hasselt CA. “Video Sleep Nasoendoscopy.” “Surgical
Management of Sleep Apnea and Snoring.” Taylor & Francis Group; 2005:143-154.
Multilevel Obstruction

30. 30

31. Concept of Multilevel Disease
Most OSA patients have multilevel disease
Appropriate surgical treatment should be multilevel approach
Since 1996 , most studies have involved multilevel surgery

32. Sleep Surgery
1970’s – Tracheotomy (Kuhlo, 1969)
1980’s – UPPP (1979, Fujita)
CPAP (1979, Sullivan)
1990’s – LAUP (1990, Kamami)
2000’s – Modified oropharyngeal techniques,
RF, Pillar implant, Coblator, Repose
system … etc.
2010’s – TORS, HGN …etc.
BOT Surgery for OSA !

33. Hypopharyngeal Surgery for OSA
⚫Clinical challenge issue
⚫Traditional techniques: usually invasive

34. Evolution of Tongue Base Surgery
2000
1996
1992
1989
1983
1981
1962-
1970
1984 1990
1991
1994 2001 2007
2006
Friedman
SMILE
Riley & Powell
MMA
Riley & Powell
GGA
Riley & Powell
Multilevel Surgery Fujita & Woodson
Midline Glossectomy
Lingual Tonsillectomies
Riley & Powell
HMS
Handler
Mortised O
2010
Vicini
TORS
Powell
RF surgery
DeRowe
Repose
Woodson
Lingualplasty
Datillo
Elliptical Window
2012
Lin HC
Eco-TBR

35. OSA BOT Resection
“Limited
View”
SMILE Eco-TBR

36. TORS-assisted BOT Surgery
Subjective Objective
ESS PSG
Snoring (VAS) (> 3 M)
Peri~ and post-op.
complications
~ Retrospective review study ~
~ Oct., 2015 - July, 2018 ~

37. Palatal Procedure
• Lin H-C. Acta Oto-Laryngologica 2010;130: 1070.
• Lin H-C. OtoHNS 2014;150:178.

38. Results & Morbidities
Subjective (Snoring VAS)
improvement: 87.0% (148 / 170 p’ts)
Post-op. airway compromise: None.
Intra-op. massive BOT bleeding: None.
Delay BOT bleeding: 1.76% (3 / 170 p’ts)
# up to 2018-07
# Mean of Resect BOT: 6.5 gm (3.6-13.2 gm), 6.3 ml (4-13.5 ml)
n = 170, 17F / 153M, 46.3 Yr., BMI 26.8

39. TORS Outcomes with PSG
* By paired t-test.
Pre-op. Pot-op. P * value
ESS 8.98 ± 4.75.2 2.5 ± 3.9 0.0084
Snoring index 401.1 ± 315.5 271.3 ± 209.2 <0.0001
AHI (/hr.) 45.5 ± 22.9 25.4 ± 21.8 <0.0001
Mean O2(%) 94.5 ± 2.7 95.2 ± 7.2 0.3576
LSAT (%) 75.1 ± 11.6 82.7 ± 9.9 <0.0001
Response: 66.2% (78/ 117 p’ts)
Success: 61.5% (72 / 117 p’ts)
(n = 117, 11F / 106M, 42.9 Y/O, BMI 26.8)
# up to 2018-07

40. Author Year Country N Palate Surgery Epi~
Complication
(bleeding)
Complication
(airway)
Surgical
success
Surgical
cure
Vicini 2010 Italy 10 Multiple step - - - 20 20
Friedman 2012 USA 27 ZPPP - - - 66.7
Lee 2012 USA 20 UPPP - 4.2% bleeding - 45
Vicini 2012 Italy 20 Multiple step - - - 60
Lin 2013 USA 12 - - - - 50
Glazer 2014 USA 166 Tonsillectomy + 7.2% bleeding 1 aspiration
Hoff 2014 USA 285
UPPP, LP,
tonsillectomy, ZPPP
- -
Richmon 2014 USA 91 - - - -
Toh 2014 Singapore 20 UPPP - - - 55 35
Vicini 2014 Italy 24 UPPP, ESP - - -
Vicini 2014 Italy 243
UPPP, EPS, ZPPP,
tonsillectomy
+ 1.7% bleeding - 30.9 22.9
Easa 2015 Italy 78 - + - 82% tracheotomy
Hoff 2015 USA 121 nose, palate. pharynx + 4.1% bleeding 2 reintubation 51.2 14
Lin 2015 USA 39 UPPP + - - 53.8
Muderris 2015 Turkey 6 - + - -
Thaler 2016 USA 75 UPPP - 5.5% bleeding
2.7%
reintubation
45
Mark A. 2016 USA 243 Multiple step + 4.1% bleeding - 66.9
Fatma 2016 Turkey 25 Multiple step + - - 80 72
Summary of TORS OSA Surgery

41. da Vinci surgery system in KCGMH
41
•2015: da Vinci Si System (One)
2015/06/15 First Patient with Hypopharyngeal Cancer
•2020: da Vinci Xi System (Two)
2021/09 Total 478 cases
Yonsei- Shinchon Severance Training Center
2017 Professor SH Kim
2015 Professor YW Koh KCGMH Taiwan

42. Transoral Robotic Surgery(Tumor)
KCGMH Taiwan

43. Cancer Stage
Patient No.
Sex
Male
Female
38 (91.7%)
3 (8.3%)
Histology
Squamous cell carcinoma
Mucoepideromid carcinoma
40 (97.2%)
1 (2.8%)
T status
pT1
pT2
23 (50%)
18 (50%)
KCGMH Taiwan

44. Personal Limited Experience(TORS)
⚫From 2017.05 to 2021.11
Patient No.
Sex
Male
Female
31 (91%)
3 (9%)
Histology
Malignancy
Benign
32 (94%)
2 (6%)
Site
Soft palate
Tonsil
Base of tongue
Post pharyngeal wall
Epiglottis(benign)
7 (20%)
20 (59%)
4 (12%)
1 (3%)
2 (6%)

45. Locally Advanced Oropharyngeal Cancer
⚫A New Clinical Trial of Neoadjuvant Chemotherapy Combined
With Transoral Robotic Surgery and Customized Adjuvant
Therapy for Patients With T3 or T4 Oropharyngeal Cancer.
(N=31)
⚫ Park YM, Jung CM, Cha D, Kim DH, Kim HR, Keum KC, Cho NH, Kim SH.
⚫ Ann Surg Oncol. 2017 Oct;24(11):3424-3429.
⚫Transoral robotic surgery-based therapy in patients with stage
III-IV oropharyngeal squamous cell carcinoma. (N=80)
⚫ Park YM, Kim HR, Cho BC, Keum KC, Cho NH, Kim SH.
⚫ Oral Oncol. 2017 Dec;75:16-21.
45

46. Ann Surg Oncol. 2017 Oct;24(11):3424-3429.
(N=31)
N =4
CCRT: N=16
RT: N=11

47. Oral Oncol. 2017 Dec;75:16-21.
(N=80)

48. Oral Oncol. 2017 Dec;75:16-21.
Survival rate

49. Surgical Options for Locally Advanced Oropharyngeal Cancer
Curr Treat Options Oncol. 2019 Apr 1;20(5):36.
⚫ TORS and TLM have made surgical resection a viable treatment
option for patients with stage III–IV OPSCC.
⚫ TORS and TLM cannot only achieve favorable oncologic outcomes in
these cases but also result in superior long-term swallowing
outcomes compared to CCRT.
⚫ Open surgical approaches, such as lip-split mandibulotomy and
lateral pharyngotomy, continue to be practical surgical approaches in
the setting of salvage surgery
⚫ Currently, there are several ongoing clinical trials investigating the
use of TORS to de-escalate postoperative adjuvant therapy.

50. The Indications for TORS
⚫Oropharyngeal cancer (T1 & T2) (FDA approved in 2009)
⚫Small lesion with limited size resection (surgical wound
secondary healing )
⚫Obstructive sleep apnea surgery (OSAS)
⚫…………..
⚫Now, selected cases and discuss with patients
⚫Not contraindication …(candidate)

51. Contraindications for TORS for Opx cancer
⚫Vascular contraindication
⚫Functional contraindication
⚫Oncologic contraindication
⚫Non-oncologic contraindication

52. Vascular contraindications
⚫Tonsillar cancer with a retropharyngeal
carotid artery
⚫Epicenter of the tumor(midline of tongue
base or vallecula) ➔ risks of bilateral
lingual arteries ligation
⚫Tumor adjacent to carotid bulb or internal
carotid artery ➔ exposure of ICA
⚫Encasement of the carotid artery by the
primary tumor (T4b) or by a metastatic
neck node.
Revisiting Vascular Contraindications for Transoral
Robotic Surgery for Oropharyngeal Cancer
Laryngoscope Investigative Otolaryngology 3: April 2018
Need flap reconstruction

53. Functional contraindications
⚫Tumor resection requiring more than
⚫50 % of the deep tongue base musculature
⚫50 % of the posterior pharyngeal wall
⚫50 % of the tongue base as well as the entire epiglottis
➔ swallowing dysfunction and choking
⚫# Contralateral soft palatal resection ➔ VPI

54. Oncologic contraindications
⚫Unresectable tumor or neck disease
⚫ All T4b cancers
⚫ Prevertebral fascia invasion
⚫ Unresectable neck disease
⚫Neoplastic related trismus
⚫Multiple distant metastases

55. Non-oncologic contraindications
⚫Medical disease with antiplatelet medications or comorbidity
⚫ A medical condition that precludes stopping antiplatelet medications or anticoagulants
⚫ Any systemic or degenerative disease which is associated with unacceptable
morbidity or mortality during general anesthesia or during the postoperative period
⚫Non-cancer related trismus which prevents robotic access via
the oral cavity
⚫Cervical spine disease that interferes with necessary patient
positioning during TORS

56. Complications
⚫Hemorrhage
⚫ 18% (22/122) of patients experienced a Clavien-Dindo grade 3, 4 or 5 complication after
TORS
⚫ Dysphagia
⚫ Aspiration pneumonia
⚫ Local oropharyngeal complication(infection, necrosis, injury…)
⚫ Non-TORS related complication …
⚫ Leaning curve reflected major complication rate decreasing (33% in 2010 to10% in 2015)
⚫ Age over 60 years and a larger extent of surgical resection were the two significant factors
predictive of complications following TORS
Complications following transoral robotic surgery (TORS): A detailed institutional
review of complications
Ashley Hay, Jocelyn Migliacci, Daniella Karassawa Zanoni , Jay O Boyle, Bhuvanesh Singh
, Richard J Wong , Snehal G Patel , Ian Ganly
Oral Oncol. 2017 Apr;67:160-166

57. 57

58. Surgeon Experience vs TORS Complications
⚫ The complication rate decreased significantly with higher surgeon case
volume (0.7% VS 4.2%)
⚫ Postoperative hemorrhage(3.1%, 62/2015) was the most common cause of
hospital readmission and post-operative mortality
>50 cases Complications
Surgeon experience and complications with Transoral
Robotic Surgery (TORS)
Stanley H Chia, Neil D Gross, Jeremy D Richmon
Otolaryngol Head Necck Surg. 2013 Dec;149(6):885-92.

59. ⚫The overall complication rate 10.1%
⚫Hemorrhage rate 3.1%
⚫The mortality rate 0.3% Surgeon experience and complications with Transoral Robotic Surgery (TORS)
Otolaryngol Head Necck Surg. 2013 Dec;149(6):885-92.
N=2015

60. Take Home Message
⚫The application of robotic surgery in selected cases
⚫Robotic surgery is an instrument to help surgeon
complete surgery
⚫No only in early stage cancer; TORS could use in
some selected advanced stage cases and provide
good results
⚫For sleep multilevel surgery