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Transoral robotic excision of laryngeal papillomas with Flex® Robotic System — A novel surgical approach
Am J Otolaryngol xxx (xxxx) xxx–xxx
Contents lists available at ScienceDirect
Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto
Transoral robotic excision of laryngeal papillomas with Flex® Robotic System — A novel surgical approach☆ ⁎
Bernar Tan Wen Shenga, , Patrick Wongb, Constance Teo Ee Hoona a b
Department of Otolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore Department of Anaesthesiology, Singapore General Hospital, Singapore
A R T I C L E I N F O
A B S T R A C T
Keywords: Laryngeal papillomatosis Recurrent respiratory papillomatosis Transoral robotic surgery Flex robotic system
Introduction: Recurrent respiratory papillomatosis results in hoarseness, stridor and airway obstruction. Management is surgical, with most surgeons using microdebrider or laser. Transoral robotic surgery (TORS) has been successfully utilised for the excision of oropharyngeal malignancies and paediatric airway surgery. This is the first case report of TORS being used for the excision of laryngeal papillomas. Case report: A 36 year old Chinese female was diagnosed with juvenile onset recurrent respiratory papillomatosis. She had 4 previous laryngeal surgeries. She was pregnant in her 2nd trimester and experienced rapid progression of her disease, leading to impending airway compromise. At her latest surgery (2 years ago), poor laryngeal exposure was encountered during laryngoscopy which made the surgery technically challenging. Thus, a flexible robotic system (Flex® Robotic System, Medrobotics Corporation, Raynham, Massachusetts, USA) was utilised with the aim of providing better surgical exposure. During surgery, laryngeal intubation was not possible and her airway was secured with needle cricothyroidotomy followed by tracheotomy. Transoral robotic excision of laryngeal papillomas was performed successfully. Complete excision of obstructing papillomas was achieved with postoperative restoration of airway and voice. Discussion: Utilisation of TORS improved visualisation, dexterity and access. Drawbacks include cost, set up time, requirement for special equipment and advanced training. TORS approach can be considered as an alternative to the usual laryngoscopic technique, especially in cases where difficult anatomy and poor laryngeal exposure is anticipated.
1. Introduction Recurrent respiratory papillomatosis (RRP) is a benign disease. Patients develop multiple papillomas in the larynx, and may also have papillomas in the upper aerodigestive tract as well as the lower tracheobronchial tree. Majority of cases are juvenile onset and a minority are adult onset. Diagnosis typically occurs at ages 2–3. RRP is thought to be caused by Human Papilloma Virus (HPV), acquired from the mother's birth canal. Patients present with hoarseness, stridor and airway obstruction. Physical examination reveals multiple verrucous, polypoid growths overlying the vocal folds and supraglottis. Management is surgical with the aim of debulking the papillomas to restore voice and airway. In severe cases, multiple surgeries as well as tracheostomy may be required Established surgical modalities include—microdebrider and CO2/KTP laser [1,2]. Numerous adjuvant therapies have been described, including interferon, acyclovir, cidofovir, bevacizumab and HPV vaccination [4]. Transoral robotic surgery
has been successfully utilised for the excision of oropharyngeal and laryngeal tumours [5–8], as well as for paediatric airway surgery [9]. This is the first case report of this modality being used for the excision of laryngeal papillomas. 2. Case report A 36-year old Chinese female was diagnosed with juvenile onset recurrent respiratory papillomatosis. She had 4 previous laryngeal surgeries (transoral laser microsurgery using laryngoscope and microscope) during her childhood, following which her disease was quiescent after puberty. She was pregnant in her 2nd trimester and experienced a relapse her disease, leading to airway obstruction (Picture 1). Urgent surgery was arranged. At her latest surgery (2 years ago), poor laryngeal exposure was encountered during laryngoscopy which made the surgery technically challenging. Thus, a flexible robotic system (Flex® Robotic System, Medrobotics Corporation, Raynham, Massachusetts,
☆ ⁎
Declaration: The authors have no conflicts of interest or financial disclosures. Corresponding author. E-mail address: [email protected] (B. Tan Wen Sheng).
https://doi.org/10.1016/j.amjoto.2018.03.011 Received 23 January 2018 0196-0709/ © 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Sheng, B.T.W., Am J Otolaryngol (2018), https://doi.org/10.1016/j.amjoto.2018.03.011
Am J Otolaryngol xxx (xxxx) xxx–xxx
B. Tan Wen Sheng et al.
Picture 1. Preoperative image of the patient's larynx showing extensive laryngeal papillomatosis involving supraglottis and glottis. Intubation was not possible and patient required a needle cricothyroidotomy followed by tracheostomy.
Picture 2. Flex® Retractor: a suspension and mouth gag compatible with Flex® Robotic System.
was achieved with application of adrenaline soaked patties. Complete excision of obstructing papillomas was achieved with postoperative restoration of airway and voice. Patient was decannulated and discharged on 3rd postoperative day. 1 week postoperatively, the surgical site was healing well, airway was patent and voice was functional (Picture 5). 4 months postoperatively, she remained well with no recurrence of papillomas.
USA) was utilised with the aim of providing better surgical exposure. During induction of general anaesthesia, laryngeal intubation was not possible and her airway was secured with needle cricothyroidotomy followed by tracheotomy (Picture 1). Transoral robotic excision of laryngeal papillomas was performed. A tongue retaining stitch (silk 2/ 0) was applied, followed by the Flex® Retractor – a suspension and mouth gag compatible with Flex® Robotic System (Picture 2). The robotic system was advanced into the hypopharynx and the larynx visualised (Picture 3). The papillomas were excised using Maryland grasping forceps and monopolar diathermy (Picture 4). Haemostasis 2
Am J Otolaryngol xxx (xxxx) xxx–xxx
B. Tan Wen Sheng et al.
Picture 3. The robotic system was advanced and the larynx visualised.
Picture 4. The papillomas were excised using Maryland grasping forceps and monopolar diathermy.
3. Discussion
Achieving good exposure during laryngeal surgery can often be hindered by anatomical issues. In turn, inadequate laryngeal exposure may lead to surgical failure. Vicini et al. [8] report a series of 3 cases where difficult laryngeal exposure was encountered during laser laryngeal microsurgery where TORS was successfully applied. Drawbacks include cost, requirement for special equipment and advanced training. Usage of the Flex® Robotic System involves additional costs to patient which range from S$3000–5000 (USD $2300–3800); the vendor waived charges for this case. Surgeons are required to undergo advanced training to be accredited in the usage of the Flex® Robotic System. Lastly, the surgical robot needs to be
Utilisation of TORS improved visualisation, dexterity and access. Images of the surgical field were magnified and in high definition. A variety of instruments were available - including grasping forceps, monopolar diathermy, laser and scissors. Flexible instruments allowed for ease of surgical manoeuvring. The Flex® Robotic System was able to navigate a non-linear path along the oropharynx to visualise the larynx and hypopharynx (Picture 6), hyper-extension of the patient's neck was not necessary. This gives TORS a distinct advantage over traditional laryngoscopic microsurgery - direct line of sight is not required. 3
Am J Otolaryngol xxx (xxxx) xxx–xxx
B. Tan Wen Sheng et al.
Picture 5. Good healing and functional outcomes, 1 week after surgery.
with a flexible robotic system can be considered as an alternative to the usual laryngoscopic technique. References [1] Fortes HR, von Ranke FM, Escuissato DL, Araujo Neto CA, Zanetti G, Hochhegger B, et al. Recurrent respiratory papillomatosis: a state-of-the-art review. Respir Med 2017 May;126:116–21. [2] Wiatrak BJ, Wiatrak DW, Broker TR, Lewis L. Recurrent respiratory papillomatosis: a longitudinal study comparing severity associated with human papilloma viral types 6 and 11 and other risk factors in a large pediatric population. Laryngoscope 2004 Nov;114(11 Pt 2 Suppl 104):1–23. (Review). [4] Young DL, Moore MM, Halstead LA. The use of the quadrivalent human papillomavirus vaccine (gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma. J Voice 2015 Mar;29(2):223–9. [5] Johnson PJ, Rivera Serrano CM, Castro M, Kuenzler R, Choset H, Tully S, et al. Demonstration of transoral surgery in cadaveric specimens with the medrobotics flex system. Laryngoscope 2013 May;123(5):1168–72. [6] Lang S, Mattheis S, Hasskamp P, Lawson G, Güldner C, Mandapathil M, et al. A European multicenter study evaluating the flex robotic system in transoral robotic surgery. Laryngoscope 2017 Feb;127(2):391–5. [7] Mattheis S, Hasskamp P, Holtmann L, Schäfer C, Geisthoff U, Dominas N, et al. Flex Robotic System in transoral robotic surgery: the first 40 patients. Head Neck 2017 Mar;39(3):471–5. [8] Vicini C, Leone CA, Montevecchi F, Dinelli E, Seccia V, Dallan I. Successful application of transoral robotic surgery in failures of traditional transoral laser microsurgery: critical considerations. ORL J Otorhinolaryngol Relat Spec 2014;76(2):98–104. [9] Ferrell JK, Roy S, Karni RJ, Yuksel S. Applications for transoral robotic surgery in the pediatric airway. Laryngoscope 2014 Nov;124(11):2630–5.
Picture 6. The Flex® Robotic System navigating a non-linear path along the oropharynx to visualise the larynx and hypopharynx, direct line of sight not required (Source: Medrobotics).
available for usage in the institution. This case highlights that for laryngeal surgery where difficult anatomy and poor laryngeal exposure is anticipated, a TORS approach
4
Contents lists available at ScienceDirect
Am J Otolaryngol journal homepage: www.elsevier.com/locate/amjoto
Transoral robotic excision of laryngeal papillomas with Flex® Robotic System — A novel surgical approach☆ ⁎
Bernar Tan Wen Shenga, , Patrick Wongb, Constance Teo Ee Hoona a b
Department of Otolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore Department of Anaesthesiology, Singapore General Hospital, Singapore
A R T I C L E I N F O
A B S T R A C T
Keywords: Laryngeal papillomatosis Recurrent respiratory papillomatosis Transoral robotic surgery Flex robotic system
Introduction: Recurrent respiratory papillomatosis results in hoarseness, stridor and airway obstruction. Management is surgical, with most surgeons using microdebrider or laser. Transoral robotic surgery (TORS) has been successfully utilised for the excision of oropharyngeal malignancies and paediatric airway surgery. This is the first case report of TORS being used for the excision of laryngeal papillomas. Case report: A 36 year old Chinese female was diagnosed with juvenile onset recurrent respiratory papillomatosis. She had 4 previous laryngeal surgeries. She was pregnant in her 2nd trimester and experienced rapid progression of her disease, leading to impending airway compromise. At her latest surgery (2 years ago), poor laryngeal exposure was encountered during laryngoscopy which made the surgery technically challenging. Thus, a flexible robotic system (Flex® Robotic System, Medrobotics Corporation, Raynham, Massachusetts, USA) was utilised with the aim of providing better surgical exposure. During surgery, laryngeal intubation was not possible and her airway was secured with needle cricothyroidotomy followed by tracheotomy. Transoral robotic excision of laryngeal papillomas was performed successfully. Complete excision of obstructing papillomas was achieved with postoperative restoration of airway and voice. Discussion: Utilisation of TORS improved visualisation, dexterity and access. Drawbacks include cost, set up time, requirement for special equipment and advanced training. TORS approach can be considered as an alternative to the usual laryngoscopic technique, especially in cases where difficult anatomy and poor laryngeal exposure is anticipated.
1. Introduction Recurrent respiratory papillomatosis (RRP) is a benign disease. Patients develop multiple papillomas in the larynx, and may also have papillomas in the upper aerodigestive tract as well as the lower tracheobronchial tree. Majority of cases are juvenile onset and a minority are adult onset. Diagnosis typically occurs at ages 2–3. RRP is thought to be caused by Human Papilloma Virus (HPV), acquired from the mother's birth canal. Patients present with hoarseness, stridor and airway obstruction. Physical examination reveals multiple verrucous, polypoid growths overlying the vocal folds and supraglottis. Management is surgical with the aim of debulking the papillomas to restore voice and airway. In severe cases, multiple surgeries as well as tracheostomy may be required Established surgical modalities include—microdebrider and CO2/KTP laser [1,2]. Numerous adjuvant therapies have been described, including interferon, acyclovir, cidofovir, bevacizumab and HPV vaccination [4]. Transoral robotic surgery
has been successfully utilised for the excision of oropharyngeal and laryngeal tumours [5–8], as well as for paediatric airway surgery [9]. This is the first case report of this modality being used for the excision of laryngeal papillomas. 2. Case report A 36-year old Chinese female was diagnosed with juvenile onset recurrent respiratory papillomatosis. She had 4 previous laryngeal surgeries (transoral laser microsurgery using laryngoscope and microscope) during her childhood, following which her disease was quiescent after puberty. She was pregnant in her 2nd trimester and experienced a relapse her disease, leading to airway obstruction (Picture 1). Urgent surgery was arranged. At her latest surgery (2 years ago), poor laryngeal exposure was encountered during laryngoscopy which made the surgery technically challenging. Thus, a flexible robotic system (Flex® Robotic System, Medrobotics Corporation, Raynham, Massachusetts,
☆ ⁎
Declaration: The authors have no conflicts of interest or financial disclosures. Corresponding author. E-mail address: [email protected] (B. Tan Wen Sheng).
https://doi.org/10.1016/j.amjoto.2018.03.011 Received 23 January 2018 0196-0709/ © 2018 Elsevier Inc. All rights reserved.
Please cite this article as: Sheng, B.T.W., Am J Otolaryngol (2018), https://doi.org/10.1016/j.amjoto.2018.03.011
Am J Otolaryngol xxx (xxxx) xxx–xxx
B. Tan Wen Sheng et al.
Picture 1. Preoperative image of the patient's larynx showing extensive laryngeal papillomatosis involving supraglottis and glottis. Intubation was not possible and patient required a needle cricothyroidotomy followed by tracheostomy.
Picture 2. Flex® Retractor: a suspension and mouth gag compatible with Flex® Robotic System.
was achieved with application of adrenaline soaked patties. Complete excision of obstructing papillomas was achieved with postoperative restoration of airway and voice. Patient was decannulated and discharged on 3rd postoperative day. 1 week postoperatively, the surgical site was healing well, airway was patent and voice was functional (Picture 5). 4 months postoperatively, she remained well with no recurrence of papillomas.
USA) was utilised with the aim of providing better surgical exposure. During induction of general anaesthesia, laryngeal intubation was not possible and her airway was secured with needle cricothyroidotomy followed by tracheotomy (Picture 1). Transoral robotic excision of laryngeal papillomas was performed. A tongue retaining stitch (silk 2/ 0) was applied, followed by the Flex® Retractor – a suspension and mouth gag compatible with Flex® Robotic System (Picture 2). The robotic system was advanced into the hypopharynx and the larynx visualised (Picture 3). The papillomas were excised using Maryland grasping forceps and monopolar diathermy (Picture 4). Haemostasis 2
Am J Otolaryngol xxx (xxxx) xxx–xxx
B. Tan Wen Sheng et al.
Picture 3. The robotic system was advanced and the larynx visualised.
Picture 4. The papillomas were excised using Maryland grasping forceps and monopolar diathermy.
3. Discussion
Achieving good exposure during laryngeal surgery can often be hindered by anatomical issues. In turn, inadequate laryngeal exposure may lead to surgical failure. Vicini et al. [8] report a series of 3 cases where difficult laryngeal exposure was encountered during laser laryngeal microsurgery where TORS was successfully applied. Drawbacks include cost, requirement for special equipment and advanced training. Usage of the Flex® Robotic System involves additional costs to patient which range from S$3000–5000 (USD $2300–3800); the vendor waived charges for this case. Surgeons are required to undergo advanced training to be accredited in the usage of the Flex® Robotic System. Lastly, the surgical robot needs to be
Utilisation of TORS improved visualisation, dexterity and access. Images of the surgical field were magnified and in high definition. A variety of instruments were available - including grasping forceps, monopolar diathermy, laser and scissors. Flexible instruments allowed for ease of surgical manoeuvring. The Flex® Robotic System was able to navigate a non-linear path along the oropharynx to visualise the larynx and hypopharynx (Picture 6), hyper-extension of the patient's neck was not necessary. This gives TORS a distinct advantage over traditional laryngoscopic microsurgery - direct line of sight is not required. 3
Am J Otolaryngol xxx (xxxx) xxx–xxx
B. Tan Wen Sheng et al.
Picture 5. Good healing and functional outcomes, 1 week after surgery.
with a flexible robotic system can be considered as an alternative to the usual laryngoscopic technique. References [1] Fortes HR, von Ranke FM, Escuissato DL, Araujo Neto CA, Zanetti G, Hochhegger B, et al. Recurrent respiratory papillomatosis: a state-of-the-art review. Respir Med 2017 May;126:116–21. [2] Wiatrak BJ, Wiatrak DW, Broker TR, Lewis L. Recurrent respiratory papillomatosis: a longitudinal study comparing severity associated with human papilloma viral types 6 and 11 and other risk factors in a large pediatric population. Laryngoscope 2004 Nov;114(11 Pt 2 Suppl 104):1–23. (Review). [4] Young DL, Moore MM, Halstead LA. The use of the quadrivalent human papillomavirus vaccine (gardasil) as adjuvant therapy in the treatment of recurrent respiratory papilloma. J Voice 2015 Mar;29(2):223–9. [5] Johnson PJ, Rivera Serrano CM, Castro M, Kuenzler R, Choset H, Tully S, et al. Demonstration of transoral surgery in cadaveric specimens with the medrobotics flex system. Laryngoscope 2013 May;123(5):1168–72. [6] Lang S, Mattheis S, Hasskamp P, Lawson G, Güldner C, Mandapathil M, et al. A European multicenter study evaluating the flex robotic system in transoral robotic surgery. Laryngoscope 2017 Feb;127(2):391–5. [7] Mattheis S, Hasskamp P, Holtmann L, Schäfer C, Geisthoff U, Dominas N, et al. Flex Robotic System in transoral robotic surgery: the first 40 patients. Head Neck 2017 Mar;39(3):471–5. [8] Vicini C, Leone CA, Montevecchi F, Dinelli E, Seccia V, Dallan I. Successful application of transoral robotic surgery in failures of traditional transoral laser microsurgery: critical considerations. ORL J Otorhinolaryngol Relat Spec 2014;76(2):98–104. [9] Ferrell JK, Roy S, Karni RJ, Yuksel S. Applications for transoral robotic surgery in the pediatric airway. Laryngoscope 2014 Nov;124(11):2630–5.
Picture 6. The Flex® Robotic System navigating a non-linear path along the oropharynx to visualise the larynx and hypopharynx, direct line of sight not required (Source: Medrobotics).
available for usage in the institution. This case highlights that for laryngeal surgery where difficult anatomy and poor laryngeal exposure is anticipated, a TORS approach
4