Trans-Oral Robotic Surgery for Hypopharyngeal & Laryngeal cancers

1. 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

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

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

4. TORS- UADT Transoral robotic surgery (TORS)

5. Step 1: Mouth opening with retractor LARS FK retractor

6. About 3.5 to 4.0 cm height

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

8. 3-D telescope Maryland dissector Spatula tip monopolar cautery

9. Step 3: Surgery at Console

10. 1 Hypopharyngeal ca

11. 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

13. Disease free 51 months after op Good voice and swallowing function

14. 2016 retrospectively review first 10 cases

15. 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

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

17. 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 92% Organ preservation rate 96% No tracheostomy, no tube feeding 100%

18. Bigger tumors? TORS IC No RT 14 months FU

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

21. 75 y/o male , glottic ca cT1aN0M0 with ant. Commissure involvement 2012-07-06 TORS after surgery

24. 3. TORS – total laryngectomy

25. Case 1 : 64 y/o male • Glottic cancer after TLM & R/T at other hospital • 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

26. Played in 4x speed

28. 2014 May FEES

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

30. Experienes of 7 cases

31. Advantages of TORS WHY?

32. More panoramic view Direct laryngoscope TORS

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

34. Better hemostasis Endo Clip by assistant

35. 2 men 4 hands endoscopic surgery

36. 2 men 4 hands endoscopic surgery

37. No need of tracheostomy Tracheostomy Open surgery TORS

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

39. Thank you for your attention!