Robotic
surgery Applications in Otolaryngology & HNS
An
Emerging Wave.
A
role of Robotic surgery technology in otolaryngology is beginning to emerge,
particularly where precision is required or visualization is limited, and there
are a number of pioneering contributions. The first otolaryngologic application
of robotics occurred as early as 2002 with several reports from the Terris
group at the Medical College of Georgia exploring endoscopic neck procedures.7-10 The first human
application was described by McLeod and Melder11 with a case report of
excision of a vallecular cyst. Hockstein and colleagues further pursued oral
and oropharyngeal applications of robotic technology with a stepwise
experimental approach.12,13 Finally, interest in
robotic skull base surgery has emerged with the work of Hanna and colleagues.14
Experimental Origins
The first use of robotics for
otolaryngologic applications was explored in a porcine model of neck surgery
that included parotidectomy, submandibular gland resection, and selective neck
dissection.8 This work built on previous promising
findings for totally endoscopic neck surgery (also described by Terris and
collaborators15,16) and provided proof of principle, in
that the safety and efficacy of endorobotic neck surgery was demonstrated, and
quickly established that advantages in duration of surgery could be easily
achieved with the addition of robotic technology.
Robotic-assisted
surgery is poised to become a standard technique for many head and neck
surgical procedures, according to experts. Robotics has already been approved
for prostate surgery, heart surgery, gastric bypass, and hysterectomy. If
preliminary results in early studies of some head and neck surgical procedures
are borne out, transoral robotic surgery (TORS) should also be approved by the
FDA
The purpose of
these studies was to learn how to position the da Vinci arms in a patient's
mouth, Dr. weinstein described robotic-assisted procedures as follows: the
surgeon sits at a console where the surgical field is displayed in
high-quality, three-dimensional video, and small joysticks are used to control
the robotic arms. The patient is positioned remotely, approximately 10 feet
away.
Figure.Transoral robotic surgery,
offering a three-dimensional visual environment, is being studied for use in a
number of head and neck procedures.
U
TYPES OF PROCEDURES
Several types of head and neck
surgical procedures are amenable to robotic-assisted surgery. Robotics can be
used to resect benign and malignant tumors of the oral cavity, including the
pharynx and larynx, tonsil, tongue base, supraglottis, glottis, pyriform sinus,
and the parapharyngeal space.
Transoral
robotic surgery is presently ideal for cancers or benign tumors of the
oropharynx and supraglottis, and this technique is also useful for tumors in
the pyriform sinus, but access is more difficult. It should be used for tumors
not lower than the vocal cords and not higher than the lower nasopharynx.
Robotic-assisted
surgery has a potential use not only for treating benign and malignant tumors,
but also for treating inflammatory conditions such as chronic lingual
tonsillitis in the back of the tongue. When a patient complains of chronic
tongue base tonsillitis that does not respond to antibiotics, it is a real
problem for the patient and the surgeon
as it is difficult to remove the tongue base tonsils using standard
techniques. At the University of Pennsylvania, preliminary studies in a few
patients suggest that robotic-assisted surgery takes only about 15 minutes to
remove the tongue base tonsils, and no further infections have been seen with
long-term follow-up.
BENEFITS TO PATIENTS
The benefits of TORS are numerous,
according to surgeons interviewed for this article.
Some tonsil- or tongue-based cancers
require large, complex, long operative procedures involving tracheostomy,
complex skin reconstruction, and splitting the jaw, Dr. Weinstein explained.
Blood transfusions are often required for these large open procedures. Only one
patient who underwent TORS at the University of Pennsylvania required a blood
transfusion, he commented.
We can avoid tracheostomy, complex
skin reconstruction, and jaw splitting with robotics, using one three-hour
procedure and then a second procedure for another three hours to take out lymph
nodes.
Robotics causes less injury to speech
and swallowing structures, and less cosmetic damage, because it is less
invasive than open surgery. Also, robotics shortens surgical times from six to
18 hours to two hours. Robotics also allows good control of bleeding. With
robotics, we can use both hands for surgical procedures, whereas endoscopic-based
procedures are typically done with one hand, because the other hand holds the
endoscope.
For other lesions, such as lesions in
the supraglottis or larynx, the major advantages of robotics over open surgery
are better access and faster surgical times.
Robotics offers a three-dimensional
visual environment that puts the surgeon right where the surgery is happening.
This unique perspective allows the surgeon to operate at the same level as the
anatomy of interest. 'Master' control manipulators then allow the surgeon to
use precise instruments in situations and in ways that were never before
possible. For instance, the surgeon can rotate a given instrument 540 degrees
and overcome the limitations of the human wrist.
LIMITATIONS OF ROBOTIC-ASSISTED SURGERY
One limitation of robotic-assisted
surgery, with present techniques, is limited access. Some tumors are located
too deep in the laryngopharynx to allow access, Dr. Weinstein said. With
current technology, it is difficult to have greater access beyond present
boundaries (i.e., tumors not lower than the vocal cords and not higher than the
lower nasopharynx), Dr. O'Malley commented.
Also, at present there are no robotic
instruments for drilling and removing bone. ENTs use a lot of drills, and it is
expected that companies will be developing rongeurs and drills along with the
software to drive these tools using the robot.
It would also be desirable to have
haptic or tactile feedback with robotics, such as is used by the military. At
present, we have to rely on the tremendous three-dimensional visualization for
feedback. As we take the surgical robot into new frontiers, such as skull-based
surgery, it would be advantageous to have a system for tactile feedback,
According to Dr. Holsinger, at present
the CO2 laser is used with endoscopy to resect tumors and develop planes, but
this has limitations. The ideal technique would combine the precise tissue
handling properties of the CO2 laser with robotics. Research efforts are aimed
at trying to find an optimal laser to combine with robotics, he said.
TRAINING FOR ROBOTIC-ASSISTED SURGERY
The first workshop and formal educational program in robotics
for head and neck was taught by Drs. Weinstein and O'Malley at the Intuitive
Surgery Training Facility in California. That course included a core group of
12 head and neck surgeons from several institutions, including the Mayo Clinic,
M. D. Anderson Cancer Center, and Mount. Sinai Medical Center. These
individuals, including Dr. Holsinger, have now gone back to their respective
institutions to initiate IRB-approved studies of TORS. Drs. Weinstein and
O'Malley are conducting an IRB-approved study at the University of Pennsylvania
that is still open. Thus far, 120 patients have entered the trial, and only two
of them had anatomy that was inaccessible for a robotic-assisted procedure.
If TORS gains FDA approval based on
these studies, the University of Pennsylvania will offer a training course in
robotics procedures. The plan is to have a two-day course, with one day in the
laboratory and another day of observation. Other institutions will undoubtedly
offer courses in robotics as well.
The University of Pennsylvania also
plans to erect a special building for research and training in robotics, Dr.
O'Malley said. We hope that the people we trained [at the first training
session last year] will set up their own programs and spread the
seed-establishing more research and developing new procedures and applications,
he added.
THE FUTURE OF ROBOTICS
In the future, it would be ideal to
have smaller instruments to allow deeper access beyond presently defined
boundaries, Dr. Weinstein said. Smaller instruments will be developed to allow
access to the nasal cavity as an alternative to endoscopic surgery.
While the first TORS skull base
surgery cases have been reported from the University of Pennsylvania, further
miniaturization of instruments and more flexible instruments, tactile feedback,
and techniques for skull based procedures will probably be developed.
Dr. O'Malley saidtransoral approaches through
the nose to the skull base are being studied in the cadaver model using
robotic-assisted techniques. If skull base procedures can be done with
robotics, surgery could carry much less morbidity.
Another pressing need, according to
Dr. O'Malley, is two-handed, delicate, fine magnification procedures for the
vocal cords or subglottis, which may also be applicable to skull base surgery.
The technology is not there yet, but it should be in the next five or 10 years.
The team at the University of Pennsylvania is studying robotic-assisted surgery
for skull-based procedures. There is a need to refine and hone instruments for
these procedures.
We are just at the beginning of
discovering uses for robotics in head and neck surgery, similar to when DOS was
the only operating system for computers. At present, robotics allows removal of
tumor and provides a bird's eye view in areas that heretofore had difficult
transoral access. I don't have a crystal ball, but the types of approaches for
robotics will continue to increase dramatically,.It is an incredibly exciting
time.
There is unlimited potential for the
application of robotics in head and neck surgery, said Dr. O'Malley. He
predicted that 80% of the range of types of ENT surgeries will be performed
with some aspects of robotics within the next 25 years, including head and
neck, ear, sinus, certain cosmetic and skull-based procedures.
Thank you,
Dr.Desarda.K.K.
Emeritus
Prof. & Head
Otolaryngology.
KEM
Hospital
Pune
