Concurrent neck dissection and transoral robotic surgery

Abstract

Transoral robotic surgery is emerging as a primary treatment modality for oropharyngeal malignancies. Neck dissection is a required portion of operative therapy in many of these patients, and many surgeons delay neck dissection to prevent pharyngocutaneous fistula. Pharyngeal communication with the neck is a common occurrence during transoral surgery when it is combined concurrently with neck dissection, but persistent fistula formation is an uncommon, preventable, but potentially problematic, complication resulting from this operative technique. Prompt recognition and intervention are of paramount importance in preventing acute, long-term functional impairment.

Transoral Robotic Surgery using the Thulium‐YAG Laser: A Prospective Study

“…Interestingly, the incidence of intraoperative pharyngotomy (IP) in patients undergoing concomitant neck dissection was significantly higher in the EC:TORS group (42.3%; 8 tonsil, 3 BOT) when compared to the TY:TORS group (7.7%; 1 tonsil) (p = 0.03). The incidence in our control group was similar to the 29 -40% previously described in patients undergoing EC:TORS for OPSCC 3,18 . We hypothesize that decreased collateral thermal damage and improved tissue visualization in addition to the relatively small spot size of the laser in TY:TORS may allow for more precise cutting and preservation of the buccopharyngeal fascia.…”

Surgical Management of Oropharyngeal Squamous Cell Carcinoma

“…Although some surgeons stage the neck dissection to prevent a communication between the oropharynx and neck, we have not found this to be necessary. The advantages of simultaneous neck dissection are multiple, including access to the vessels supplying the oropharynx during the operation, cost and time savings [34]. After neck dissection, suction drains are placed and the mouth is flooded with saline to rigorously investigate the parapharynx for oral communication.…”

Role of primary closure after transoral robotic surgery for tonsillar cancer

“…However, if neck dissection is performed concomitantly, the risk of making a communication defect increases, which in turn increases the risk of developing a pharyngocutaneous fistula. In one study, the rate of pharyngocutaneous fistula formation was as high as 29% intraoperatively when neck dissection was performed concomitant with TORS [8]. Therefore, proponents of TORS have advocated staged neck dissection in an effort to prevent pharyngocutaneous fistula development.…”

“…However, due to the size limitation of the local flap, this technique can be applied only to small defects. Moore et al developed an algorithm for reconstruction of the communication defect using the primary closure technique [8]. Defects less than 1 cm in diameter were managed via transoral or transcervical primary closure of the constrictor muscles.…”

“…Therefore, proper reconstruction of the communication defect is necessary after TORS. Several reconstruction methods are available for this defect, including primary closure, musculomucosal adjacent tissue flaps, and free flap reconstruction [7,8]. Although primary closure is a simple, easy, and reliable method, it can be applied only in limited cases with small defects.…”