Revisiting vascular contraindications for transoral robotic surgery for oropharyngeal cancer

Abstract

ObjectiveWe analyzed the outcomes for patients with a retropharyngeal internal carotid artery (ICA) who underwent a transoral robotic surgery (TORS) procedure involving a cervical‐transoral robotic oropharyngectomy course with free flap reconstruction.MethodsPatients were included in the prospective multicentric trial NCT02517125. These patients were scheduled to undergo surgery for an oropharyngeal localization. By pre‐operative CT scan and MRI it was determined that they had a retropharyngeal internal carotid artery.ResultsThree patients had a retropharyngeal ICA: a patient with a 35 mm synovial sarcoma of the tonsillar fossa, a patient with a T2N2b squamous‐cell carcinoma (SCC) of the glossotonsillar sulcus, and a patient with a T3N0 SCC of the tonsillar fossa in a previously irradiated field. These patients encountered neither preoperative nor postoperative complications.ConclusionsIn our experience, TORS for oropharyngeal cancers appears to be feasible in patients with a retropharyngeal ICA, provided that the procedure has been adapted for complex situations.Level of evidence4.

Cervical‐transoral robotic nasopharyngectomy: A preclinical study

“…29 More recently, in 2010, Wei et al, at the Queen Mary Hospital, University of Hong Kong, China, published the first live human clinical case of a robotic nasopharyngectomy, using a transoral (TORS) approach with a da Vinci Surgical System model S, after yet again a split of the soft palate for exposure. 36 However, the feasibility of this operative technique in nasopharyngeal cancer remained to be demonstrated in a preclinical study prior to being performed in patients in a prospective clinical trial. 35 Typical indications are salvage pharyngectomy for radiotherapy failure, or a second primary in a previously irradiated field.…”

“…It has proven to be feasible to date, with limited morbidity and without vascular complication, in oropharyngeal cancer. 36 However, the feasibility of this operative technique in nasopharyngeal cancer remained to be demonstrated in a preclinical study prior to being performed in patients in a prospective clinical trial. In our experience, complete transoral exposure of all of the nasopharyngeal anatomical structures is feasible without the need for a palatal split and without any conflict between instruments.…”

“…[27][28][29] Transpalatal approaches and combined endonasal endoscopic and transoral robotics have been developed by a very small number of teams to overcome these limitations. 35,36 Since the recent Xi generation of the da Vinci Surgical System offers better access to narrow spaces due to parallel movement of the arms, 37 we sought to investigate the anatomical and surgical specificities of this approach in parapharyngeal vascular dissection and transoral nasopharyngectomy procedures by means of a preclinical feasibility study. 35,36 Since the recent Xi generation of the da Vinci Surgical System offers better access to narrow spaces due to parallel movement of the arms, 37 we sought to investigate the anatomical and surgical specificities of this approach in parapharyngeal vascular dissection and transoral nasopharyngectomy procedures by means of a preclinical feasibility study.…”

“…[30][31][32][33][34] We have developed cervicaltransoral robotic pharyngectomy for salvage surgery in oropharyngeal carcinoma, to ensure vascular safety along with optimization of deep margins. 35,36 Since the recent Xi generation of the da Vinci Surgical System offers better access to narrow spaces due to parallel movement of the arms, 37 we sought to investigate the anatomical and surgical specificities of this approach in parapharyngeal vascular dissection and transoral nasopharyngectomy procedures by means of a preclinical feasibility study.…”

Transoral robotic surgery for head and neck malignancies: Imaging features in presurgical workup

“…During a pharyngeal resection, a patient with a medialized internal carotid artery would have a higher risk of vascular injury during resection. However, recent publications suggest TORS can still be feasible for this subset of patients . Finally, assessment of soft palate involvement (Figure C) is important as extensive involvement would be a relative contraindication as a large soft palate resection may result in a significant functional deficit with associated velopharyngeal insufficiency that would obviate the potential functional benefits of an upfront surgical approach and may also require more complex microvascular reconstructive methods to mitigate the risk of downstream functional deficit.…”