Alexander Langerman, MD, FACS, discusses his topic in Transoral Robotic Surgery.
[MUSIC PLAYING] Hello, everyone. My name is Alex Langerman, and today I'm going to be talking about transoral robotic surgery, which essentially means application of robotic technology to the head and neck. First I'm going to talk a little bit about what robotic surgery is, and then some of the techniques. And then I'm going to go into how we can apply robotic technology to cancer care and also to sleep apnea treatment. The important thing to know is that the robot is just a tool, and every patient is unique and treatments must be customized to the individual patient. So this is the DaVinci surgical system. Presently robotic surgery is synonymous with using the DaVinci surgical system, but there are other emerging robotic technologies that may also be available in the near future. The robot is really just a tool. Now many of my patients ask me, they say, well, how much of the surgery is the robot going to be doing and how much of the surgery are you going to be doing? And the reality is the robot doesn't do anything without me. It's essentially just a way for me to move my hands into the throat. By moving special instruments, I'm able to control the finer, delicate robotic instruments inside the mouth. This is a video I took when I was training in fellowship years ago, and it was when robotic technology was just emerging. And what you can see is my fellowship mentor here, and what I want you to do is watch his hands and also look on the screen there. And you can see the robotic instruments moving, so you can get a sense of the direct connection between the surgeon's actions and the robot's actions. This is me using the robot and I just want you to see how graceful it is to be able to use the robot. You have such freedom with your wrists in motion, and so it really allows for very fine and delicate surgery. This is a typical set up for transoral robotic surgery, and what you see here are the instruments and they're going through the patient's mouth. And the patient has padding and protection on them and a retractor that's holding everything open for me to get on in there. Another special aspect of robotic surgery is that I'll have an assistant. While I'm at the robotic console, I have my assistant here who's helping me right at the patient's head and neck. And so I have the two robotic hands in there, which are really an extension of my hands, but then also I have the resident's hands in there, so I'm able to get four instruments into the mouth, which really makes for a more efficient surgery. The DaVinci surgical system was approved by the Food and Drug Administration in 2009 for applications in the head and neck, based on the study here. And the key to see is the approval was specifically for tumors of the mouth, pharynx, and larynx. No bony tumors and nothing in kids. Specifically, they focused on what we call T1 and T2 malignancies, which are smaller tumors. However, many centers, including ours, will do larger tumors depending on the specific anatomy of the patient, and we also apply this technology to sleep apnea. This shows the publications by year of both transoral robotic surgery, or TORS, and another type of transoral procedure called transoral laser microsurgery. Now transoral laser microsurgery is very similar to TORS, except that it does not utilize a robot and has some distinct advantages and disadvantages, which we use in particular circumstances. But what this graph can show is that there's an increasing interest in transoral approaches, and that the level of evidence supporting their use in both head and neck cancer and sleep apnea is increasing. Comparing TORS to transoral laser microsurgery, the key advantages of TORS are the wristed instruments. So when I move my wrist, the robotic instruments are doing the same thing. Additionally, because of angled instrumentation and also angled scopes, I'm able to see kind of around the corner. So you can imagine if you're working with a base of tongue tumor and I'm trying to get around behind the tongue, I'm much more easily able to do that with wristed instruments and a scope that might be looking up. The disadvantages are that presently robotic technology has not developed the kind of super fine instruments that you might need for certain vocal cord tumors or other very, very precise types of microsurgery. The advantages of transoral laser microsurgery is that you get tactile feedback. When you're operating with the robot, when you push on something you get some visual feedback, but you don't get the same kind of tactile feedback that you'll get with a rigid instrument. Of course, the disadvantage being you're working with rigid instruments that can't get around the corner. So when we're approaching a patient for a particular type of disease, we try to customize our approach based on what they need. We give state-of-the-art cancer care here at the University of Chicago Medicine, and the right treatment for a patient depends on the site and stage of their disease, their anatomy and overall health status, and also their preferences for treatment. Sometimes it's equivocal, one treatment or another treatment could both work, and then we work with the patient to figure out the one that's going to be best for them. We have a multi-disciplinary team, and we don't hesitate to call upon each other and usually most of us collaborate on a patient if they have a complex disease. We have pioneered developments in surgery, radiation, and chemotherapy to best treat cancer and minimize the side effects. So I'm going to talk a little bit about tonsil and base of tongue cancer. This is an incredibly important cancer right now. There's a growing epidemic of human papilloma virus-associated head and neck cancer, and this has meant a sharp increase in the number of patients with these cancers in the base of tongue and tonsil. Now traditionally we had to use a large, open surgeries to get at many of these tumors, and these large surgeries had severe effects on swallowing and other functions. Now with transoral approaches, we're able to do a minimally invasive approach to these types of tumors. And with the development of transoral robotic surgery, we have even better access and better visualization. Here's an example of a CT scan where you can see that center that little black area and then the gray circle. What that is is that's a small tumor on base of the tongue. And here's a video of my taking off this part of the base of tongue here through the patient's mouth. And when you can really appreciate is the amazing visualization. You can see every muscle fiber there as I'm dividing it, and I can get good hemostasis. And there it is the resident's helping me with the suction and then my other hand's grabbing the tissue and I'm dividing some more of that tumor there. When the specimen comes out, we'll map it to the site specifically that it is in the tongue to make sure that our margins are perfect. And at a two-month post-operative result you have a very beautifully healed pharynx, and this patient has no swallowing problems. And the larger the operation, the more of a challenge it is to get a patient through that recovery period. But the advantage of transoral surgery is you minimize the collateral damage. You're only focusing on the site of disease. Here's a study demonstrating that even in patients who do not have HPV-associated head and neck cancer, transoral robotic surgery does offer an appropriate surgical treatment. So it's exciting for us to be able to apply this not only to patients with HPV but also patients with non-HPV-associated cancers. For larynx cancer, as I mentioned earlier, there are some small vocal cord tumors that might be not the right choice for robotic surgery, and those cases we'll use transoral laser microsurgery or other approaches that allow us to have those really fine instrumentation approaches. For superglottic cancers, so cancers that are above the voice box-- that includes in the epiglottis, in the arytenoid and in other areas-- robotic surgery is perfect. It's great access. As you start to get below the level of vocal cords, down into the deep throat, the hypopharynx, or in the subglottis, the robotic accesses is not typically good enough to be able to remove these tumors appropriately. Then again we use other approaches. Here's an example of the great visualization you can get just with a retractor system as you're starting to look through. Now I might have this view whether I'm doing transoral laser microsurgery or whether I'm doing a robotic surgery. Now this is in preparation for robotic case. One thing I want to highlight here is as you get deeper and deeper into the throat, you can see how the robotic arms need to come together a little bit, and that's that amber triangle there as you're going deeper. And so that can limit some of the access, and that's one of the key things to think about. Here's an example of a patient right after I removed a superglottic tumor. And the key thing to notice is that the vocal cords have absolutely no damage to them. They're going to function fine. We're able to carefully limit our dissection just to the area of the tumor. Another place the robotic surgeries actually had a very exciting utilization recently is for cancer of unknown primary. Now essentially what that means is a patient shows up with a neck mass, and you can see on the right side of the screen there the sort of funny, off-colored oval there that is not on the other side is the head and neck cancer. Now it's gone to a lymph node in the neck, and that's what you're seeing there, but the question is where did it come from? And often we will find these tumors in a tonsil or base of tongue, but if we can't find the tumor, then really we're obligated to radiate all of the head and neck, anywhere where that tumor may have come from in order to ensure adequate treatment. Well, what we've been doing with the robot is we have so much better visualization that we're actually able to, in a minimally invasive way, go in and remove all of the potential suspect sites. And if you do this in a stepwise approach, only taking what you need, sending it to the lab, you can actually minimize the amount of surgery the patient gets and even avoid that sort of drastic radiation that you have to do if you don't know where the primary is. So this has been a very exciting development. Now I'd like to review a little bit of the potential complications of transoral robotic surgery. With any surgery bleeding is always a risk. The key is to make sure that you prevent it while you're still on the operating room. Very rarely do we ever have to go back to the operating room for bleeding, but often in the operating room we have to specifically identify vessels and make sure that they're well controlled. Patients do, of course, have pain after surgery. We like to compare this to sort of a grand tonsillectomy. It is very sore. It hurts to swallow early on. However, we aggressively manage pain to ensure that patients will have a faster recovery. As you saw on some of the pictures, we do have retractors that hold the mouth open. That can result in some pain at the temporal mandibular joint, some jaw pain. It can also result in some compression of the nerve that helps with taste in the tongue, called the lingual nerve. And so in those situations, if we see it we typically know that it's going to resolve in a very short period of time. Rarely do patients have any kind of long-term problems with this. And then finally, any time you operate in an area, any time you retract something, you can have some swelling around that area. But it's important, this area's where you talk and breathe through. We make sure that we treat patients with steroids around the time of surgery. We keep our surgery only as long as it needs to be. And this usually solves the problem. Rarely, rarely do we ever need to put in any kind of temporary breathing tube for this reason. So now I'm going to shift gears a moment and talk about sleep apnea treatment. This has been a very exciting development for transoral robotic surgery and for head and neck surgery in general. Traditionally, sleep apnea is treated with a nighttime pressure mask, often referred to as CPAP for continuous positive airway pressure. However, for many patients wearing that mask every night is a challenge, and so we've tried to develop new ways to treat sleep apnea that don't require wearing a mask all the time. This new area of surgical treatment has been aided by two things. One is a better diagnosis of the causes of obstruction, and the other is less invasive, more effective surgical treatments. I'm going to go over both of these. So first better diagnosis. This is a patient I'm performing sleep endoscopy on. Now what this involves is this is a 15-minute procedure. An anesthesiologist helps the patient go to sleep. We turn off the lights. We try to get in sort of a comfortable area with a pillow. And then I place a camera down the patient's nose and then we observe the obstructive events that occur. We can get immediate diagnosis from this procedure on the soft palate, pharynx, tonsil, base of tongue, and epiglottis involvement in sleep apnea. Here's a little diagram is showing that gray scope with a little light attached to it at the end, and that's about where it sits as the patient's asleep. It allows us to see the soft palate, the base of tongue, and the epiglottis and pharynx. So let me show you an example of what a patient would look like perhaps awake. This patient is laying on their back. They're still awake. They haven't gone to sleep yet. And you can see at the top, there is the base of tongue. Along the sides coming down, that's the pharynx. That little half-moon in the middle is the epiglottis, and then just below that, that's the airway. That's where the patient breathes. Here's some examples of some abnormal airways. So you have the soft palate in the upper left that's collapsing. On the right, you have two slides showing the pharynx open and then pulling together when the patient has an obstructive event. And on the bottom you see the base of tongue coming down and collapsing. And then finally the last on the bottom right, you see the epiglottis independently obstructing. I actually of a video of that, because it's quite interesting. You can really appreciate the correlation of the obstruction with snoring and apnic events. So you see right there it's pulling. Right there again it's pulling, and that's a [SNORING SOUND] You get the snoring going on right there, and so you know that's the moment. And what we look for is not just, of course, the snoring, but actually the apnic event, which involves an obstruction and then an arousal. And that's really the problem with sleep apnea is that when you have these obstructive events, even though your brain doesn't realize it, your body wakes up ever so slightly. You get an arousal, and what that results in is a non-restful sleep and all sorts of medical problems, hypertension, and potential dangerous activity such as falling asleep while driving. So we really consider this a serious disease that we need to address. So surgical treatment for tongue-based collapse is what I want to focus on right now, because this is really a lecture about robotic surgery. There's actually a number of treatments that we offer, and we customize this again the patient. So for tongue-based collapse the sort of classic treatments were tongue-based suspension. That involves putting special sutures through the neck and the tongue, pulling the tongue base forward. We can also do that with bony advancement of the chin. There's radio-frequency tongue-base reduction, which involves using a special probe to eliminate some of the muscle of the tongue. And then there's a Submucosal Minimally Invasive Lingual Excision, or the SMILE procedure. It's really far from that. It's actually an uncomfortable procedure. But what it does is it takes out even more of the base of tongue, but also has a higher complication rate than other forms. Now those were sort of, I think, in the past. And what have is the future now where we're using transoral robotics to get a very precise reduction in the size of the base of tongue to better help our sleep apnea patients. And this is a correlation of some data from a number of published studies which essentially shows two things. At the top you have the reduction in apnea-hypopnea index. That's the sort of classic sleep apnea number. You can see it goes from a high number in pre op to a much lower number and post op. And many of the patients were what we consider to be cured, which is an AHI of less than 20 and a greater than 50% reduction in their total AHI value. Another important thing to look at is the Apworth Sleepiness Scale. And you can see that those numbers have dropped below 10, which is a good indication of a reduction in sleepiness symptoms. Here's an example of a kind of perfect candidate for transoral robotic base of tongue reduction for sleep apnea. Now I don't normally obtain CT scans. This patient's base of tongue was actually large enough that there was a concern initially that he might have a malignancy based on the outside referring physician. So he came in with the CT scan, and we were able to see clearly that there was a large base of tongue mass. But he had severe sleep apnea, and after a biopsy, again by the referring physician, we knew this wasn't a malignancy, so we were going after sleep apnea. Now here's a video of operating, and you can see with the robot that I'm able to precisely get at that plane between the lingual tonsils and the tongue muscle. So compared to the other procedures that I mentioned earlier, this procedure really spares a lot of the normal tongue but still gets a really good reduction in the base of tongue and a better pharyngeal airway. So here's an example of a pre- and post-operative result. And what you can see is that there's no longer that hooding where you can't quite see the airway, whereas in the slide on the right, the post-operative view, you can see the vocal cords. You can see right down into the airway. But also I want to highlight look how nice and smooth and clean that base of tongue is. It's really healed well, and that's the expectation for any of these cases that you have really nice mucosal healing. So in summary, for transoral robotic surgery for sleep apnea, TORS offers a potentially better outcome than other tongue base reductions in the right patients. Also, sleep endoscopy is really critical for preoperative workup. We're not going to go and do a tongue base reduction on every single patient. You have to focus in on only those patients that are needed. And sleep endoscopy is going to tell you who that is. And finally, multi-level surgery may be necessary. For some patients it's just the base of tongue. For other patients it might be the base of tongue and the tonsils and palate. In other patients it might just be the tonsils. And we need to figure out exactly what that's going to be. So thanks very much for attending the talk today. I appreciate it. And I just want to emphasize that the robot is a really wonderful tool, but the key is to pick the right treatment for the right patient, and that's what we can offer Thanks again.
