TransOral Robotic Surgery for Hypopharyngeal Laryngeal cancers ChenChi

Trans-Oral Robotic Surgery for Hypopharyngeal & Laryngeal cancers Chen-Chi Wang, MD 王仲祺醫師臺中榮民總醫院耳鼻喉頭頸部陽明大學醫學系 TOS , 三總, 2018/11/4 15 mins

da-Vinci robot l 1999, USA, da-Vinci robot developed by intuitive company Tremor filtration function Endoscopic surgery with precision, dexterity and control.

• Ilha Formosa!(Portugal sailorman) – Beautiful Island. • Taiwan: Democratic China 2010 1500 beds Tertiray Referral Medical Center Taichung

TORS - UADT Transoral robotic surgery (TORS)

Step 1: Mouth opening with retractor LARS FK retractor

About 3. 5 to 4. 0 cm height

Step 2: Docking of Robot positioned 30 degrees from the bedside

Maryland dissector 3 -D telescope Spatula tip monopolar cautery

Step 3: Surgery at Console

1 Hypopharyngeal ca

Summary of practice • Check oral exposure during direct laryngoscopic biopsy & mapping to select good candidates for TORS • TORS without tracheostomy (oro-endotracheal intubation) • Send several frozen sections • Neck dissection & wait for frozen section results • Review the hypopharyngeal wound 　(resect more on doubtful margins, delayed bleeding or severe laryngeal edema) • The endotracheal tube was removed promptly or after observation • N-G tube inserted for nutrition support • Decide post-op adjuvant tx according to pathologic reports

Disease free 51 months after op Good voice and swallowing function

2016 retrospectively review first 10 cases

Oncologic Safety 6/10 patients spare post op irradiation Mean follow –up: 26 ± 12 months No local recurrence All larynx preserved One died of mediastinal LN metastasis One died of Gastric cancer

Function preservation Before operation (59 y/o Lo) Video (28 months)

update of our larger cohort : 25 cases Follow up from 5 m/o~66 m/o with mean of 29 m/o 13 patients (52%) Spare the irradiation Overall survival rate 80% Local control rate 88% Disease specific survival rate Organ preservation rate 92% 96% No tracheostomy, no tube feeding 100%

Bigger tumors? TORS IC No RT 14 months FU

2. TORS – early glottic ca, ant commissure (+)

75 y/o male , glottic ca c. T 1 a. N 0 M 0 with ant. Commissure involvement 2012 -07 -06 TORS after surgery

3. TORS – total laryngectomy

Case 1 : 64 y/o male Glottic cancer after TLM & R/T at other hospital n n Left side vocal fold ca after TLM in 2011/09 & R/T in 2011/10/03~2012/01/10 at other hospital Recurrence s/p TLM on 2012/09/26 at other hospital Bilateral vocal fold recurrence with subglottis and possible thyroid cartilage invasion TORS for total laryngectomy in 2013/11

Played in 4 x speed

2014 May FEES

Case 2 : 61 y/o male Recurrent glottic cancer after R/T 2014 Feb. TORS for total laryngectomy

Experienes of 7 cases Pt Op date Age Prior therapy Tracheostomy Pathologic stage F/U (m/o) Swallowing function Death 1 2013/11/22 64 M TLM, CRT Emergent rp. T 4 N 0 19 good 2015/ 6/27 2 2014/2/10 61 M TLM, RT Emergent yr. T 1 N 0 46 good N/A 3 2016/9/30 59 M CRT Emergent rp. T 4 a. N 0 15 good N/A 4 2016/12/2 73 M TLM Emergent rp. T 4 a. N 0 12 good N/A 5 2016/12/23 79 M TLM, RT Elective rx. T 2 N 0 12 good N/A 6 2017/5/12 67 M CRT Emergent yp. T 4 a. N 2 7 good N/A 7 2017/8/4 67 M TLM Emergent rp. T 4 N 0 5 good N/A Sex

Advantages of TORS WHY?

More panoramic view Direct laryngoscope TORS

No line of sight limitation Direct vision TORS Angled view (30 ° up vision) Angled endo-wrist instrument

Better hemostasis Endo Clip by assistant

2 men 4 hands endoscopic surgery

No need of tracheostomy Tracheostomy Open surgery TORS

Conclusion l TORS is effective in treating pharyngal & laryngeal cancers l It is a new treatment modality that is worth further investigation in the future

Thank you for your attention!