Preoperative predictors of difficult hypopharyngeal exposure by retractor for transoral robotic surgery

Abstract

Introduction Transoral endoscopic surgeries provide excellent oncologic outcomes while preserving speech and swallowing ability. However, feasibility has been a major concern about transoral surgery. Therefore, ensuring visualization of the surgical field and sufficient working space is required. The aim of this study was to evaluate the parameters in the preoperative assessment that affect hypopharyngeal exposure. Methods Before transoral surgery, parameters regarding the patient's neck and face such as modified Mallampati index, thyroid-mental distance (TMD), and ability to fully open the mouth were evaluated. Cephalometry and cervical spine radiography were performed preoperatively to evaluate the size of the mandible bone, mouth opening, and cervical spine extension. Mandibular bone parameters such as intergonion distance, mental-gonion distance, articulare-gonion distance, and aperture angle were measured. According to hypopharyngeal exposure using FKWO retractor, patients were divided into difficult hypopharyngeal exposure group (DHE) and non-difficult hypopharyngeal exposure group (non-DHE). Parameters were enrolled to evaluate the relationship between these parameters and DHE status. Results This study included 51 patients, 37 in the non-DHE group and 14 in the DHE group. On radiographic evaluation, there was a significant difference in the degree of cervical lordosis between non-DHE and DHE patients. A significantly higher proportion of DHE patients had a history of radiotherapy compared with non-DHE patients. Conclusion Patients with limited cervical extension and a history of previous radiotherapy might have difficult hypopharyngeal exposure during transoral surgery. This is the first report to suggest a classification system for hypopharyngeal exposure during transoral surgery.

Preoperative predictors of difficult oropharyngeal exposure for transoral robotic surgery: The Pharyngoscore

“…The frequency of difficult exposure for TORS is 25% in the literature, which is similar to the 21.2% rate of DOE found in our series, confirming that difficult exposure is a significant issue which must be addressed when planning TORS. So far, no definitive indications regarding predictive factors for GOE and DOE have been reported in previous clinical trials 35,39,42,44–46 . The reported rate of TORS termination or conversion to TLM or open surgery is around 14% in the literature 27,35–40 .…”

“…According to the prevalence of difficult exposure for transoral procedures of the pharynx and larynx in the literature, 35,38,41,42,[44][45][46] and estimating a maximum of 10 variables for the creation of the Pharyngoscore, a sample size of 300 subjects was deemed sufficient for the study, considering 30 patients for each variable. Categorical variables were described as absolute frequency and percentage, and continuous variables were described as mean and standard deviation.…”

“…Among all causes, unpredicted insufficient exposure due to patient‐related characteristics accounts for termination or conversion of 9% of all TORS procedures 27,35–40 . Some authors have tried to select the best candidates for transoral surgeries, identifying patient‐related preoperative parameters which could predict difficult exposure of the larynx and hypopharynx 41–43 . Some authors systematically plan an examination under general anesthesia to judge accessibility and help in treatment selection 44 .…”

“…27,[35][36][37][38][39][40] Some authors have tried to select the best candidates for transoral surgeries, identifying patient-related preoperative parameters which could predict difficult exposure of the larynx and hypopharynx. [41][42][43] Some authors systematically plan an examination under general anesthesia to judge accessibility and help in treatment selection. 44 One group proposed cephalometric analysis to predict oropharyngeal exposure for TORS, but the study was restricted to base of tongue cancer, and further, it required preoperative Computed Tomography (CT) scan.…”

Distribution by physical status ASA and Mallampati Scale of patients submitted to inguinal herniorrhapiers by laparoscopy

“…), it is known that there is a close relationship between the classification of physical status ASA and mortality in surgery. So many other authors, such as Davenport et al (2006), Schwartzman et al (2014 and 2011), Santos et al (2017) and Wolters et al (1996), made the relationship between preanesthetic evaluation and physical status with complications in surgery and anesthesia, which places these factors as important objects of study for a better medical practice (FUJIWARA et al, 2019).…”