Surgical Robots Transform Head and Neck Procedures
Edward Damrose MD, demonstrates; the Feyh-Kastenbauer Retractor used in more advanced transoral robotic surgeries at Stanford Hospital & Clinics.
Twenty-five years ago, a patient with mouth or throat cancer faced disfiguring, open surgery that required breaking the jaw and splitting the lip and mandible to reach tumors lodged deep in the throat or at the back of the tongue. With the advent of microscopes and carbon dioxide lasers in the 1980s, transoral surgery was born, giving surgeons the ability to remove these tumors through the mouth. But they were limited by rudimentary optics and constrained by the inability to use multiple tools at once.
Enter the DaVinci robot five years ago. With greatly improved optics, precision instrumentation and the ability to fit multiple instruments in the mouth at once, surgeons can now perform advanced surgeries via the mouth for tumors deep in the throat, esophagus or at the back of the tongue. The robot has also aided reconstructive work in this hard to reach area. Known as transoral robotic surgery, or TORS, Stanford is one of the few places in the country using the DaVinci surgical robot for head and neck surgeries.
"The robot opened up our field of view, allowed us to have many instruments in the mouth at once and improved the optics," says Stanford head and neck surgeon Edward Damrose, MD. "That has really energized the field of transoral surgery. It's helping us accomplish procedures endoscopically that a few years ago would likely have not been possible."
As Damrose describes, he can deploy the robot through the mouth, which gives him binocular vision, depth perception, dexterity and reach far beyond what was available 50 years ago. These advances allow surgeons to do things through the mouth with no incisions, which means a significant reduction in morbidity to the patient. "We can avoid tracheotomy, which used to be mandatory, lessen blood loss and offer patients a faster return to swallowing function," he explains.
The robot also extinguishes the natural tremor in a surgeon's hand, and it is multi-dexterous. It comes with an arsenal of instruments that can be introduced into a patient's mouth – such as a fiber optic laser and harmonic scalpel – devices that allow surgeons to minimize the cauterization and thermal injury effects of traditional instrumentation.
"The robot gives us the ability to preserve the function of healthy tissue while removing the diseased tissue," says Damrose, chief, division of laryngology, and associate professor, department of otolaryngology/head & neck surgery. "The more healthy tissue we can preserve, the better patients will swallow, the better they'll speak and the better the outcome."
Robots improve treatment options
The vast majority – 90 percent – of malignant tumors that appear in the mouth, the base of the tongue and the throat are squamous cell carcinomas. And the incidence of these cancers is increasing at a fairly alarming rate, according to Damrose, affecting a younger group of patients in their 40s, 50s and 60s. Many experts are associating this trend with the spread of human papillomavirus (HPV).
Transoral robotic surgery will allow these younger patients a less invasive and less morbid approach to curing their cancer, says Damrose, which might be life-saving in the future. "Many of these younger patients are going to live long enough to go on and develop second tumors and we're going to wish we had preserved more treatment options for them later on in life," he says.
The advent of the robotic transoral approach is also causing physicians to rethink the standard protocol for treating head and neck cancers. Although the current chemotherapy and radiation regime is highly effective at killing the cancer, it is also highly toxic to healthy tissue. In the most extreme cases, patients' throats are so badly damaged by treatment that they lose the ability to swallow, and breathing becomes compromised.
Taking a leading edge approach, Damrose is beginning to do minimally invasive transoral robotic surgery first to remove tumors in some patients, which then allows oncologists to de-escalate the amount of systemic treatment given to the patient after surgery. The goal is to affect a cure without impairing a patient's ability to breathe and swallow. Transoral robotic surgery is also being used to repair scarring and injury in patients with complicated swallowing or breathing problems
As the technology continues to improve, Damrose foresees expanding the types of tumors that can be removed from the head and neck, such as those deep within the nasopharynx or those that invade the skull base and brain. "I suspect we are just breaching the utility of this device in treating head and neck diseases," he says.
By Grace Hammerstrom
