The robot’s camera offers a three-dimensional view, said Jeffrey Wolf, MD, associate professor of otorhinolaryngology-head and neck surgery at the University of Maryland Medical Center in Baltimore, “as if you’re standing on the base of the tongue.”
Explore This IssueApril 2014
While the visualization is great, practitioners say it can take some effort to understand the new perspective. “You need to relearn the anatomy from the inside out instead of the outside in,” Dr. Moore said.
Dr. Wolf and his partner Duane Sewell, MD, originally trained themselves on cadavers to become certified. Other head and neck surgeons travel to established training programs, such as the one at the University of Pennsylvania, which includes animal and cadaver practice as well as case observation.
For the NCI cooperative trials, study designers had to make sure a certain level of training was in place so that surgeons weren’t “learning on the trial,” Dr. Ferris said. Credentialing includes assessments of negative margins, bleeding, and surgical complications. It definitely takes time to learn and, as with any surgical procedure, some people pick it up faster than most. “Some take 10 to 15 cases to get really good,” he added. “Others may need more than 30.”
Although TORS shines compared with traditional open surgery, it still has some limitations. It’s difficult to extend the resection beyond the base of the tongue, said Dr. Moore. It depends on an individual’s anatomy, but generally the epiglottis, larynx, esophagus, and hypopharynx are out of reach. Tumors in these tissues might be accessible with laser microsurgery; otherwise, they remain candidates for chemotherapy and radiation.
The robot doesn’t have any haptic feedback, or “feel,” Dr. Wolf said. With many tumors, a surgeon will touch the tissue and can tell where a tumor is and where it’s not.
For now, the daVinci robot is the only one commercially available, but there are other companies working on their own versions. They are working to fill those gaps by including haptic feedback and by using smaller arms that can access more remote tumor sites.
Indications for TORS
Transoral surgery may be considered for patients with smaller T1 and T2 stage tumors in the oropharynx and is generally not favorable for larger T3 or T4 tumors, which may result in more destruction of normal tissue.
At the University of Pennsylvania, the procedure is a huge success. “We have a 96% cure rate when TORS is used for HPV-related cancers,” said Dr. Weinstein. “Negative margin surgery works.”