Transoral ultrasonic total laryngectomy (TOUSS-TL): description of a new endoscopic approach and report of two cases

Abstract

The minimally invasive total laryngectomy avoids a wide surgical field and so it has the potential benefit of reducing the local morbidity, especially on radiated patients. This approach has been previously described on a robotic basis, the transoral robotic total laryngectomy (TORS-TL). We have designed a minimally invasive approach for total laryngectomy (TL) using the transoral ultrasonic surgery technique (TOUSS). TOUSS is a transoral, endoscopic, non-robotic approach for laryngeal and pharyngeal tumors, based on the ultrasonic scalpel as a resection tool. Two patients with a laryngeal squamous cell carcinoma with indication for total laryngectomy were surgically treated: one primary TL for a subglottic carcinoma and one salvage TL with partial pharyngectomy for a local relapse after chemoradiotherapy of a glottic carcinoma. The tumors were completely removed with free surgical margin in both patients. The functional recovery was satisfactory in terms of swallowing and speech (a tracheoesophageal puncture and voice prosthesis placement were done in the same procedure). No intraoperative complications were observed. The patient with previous chemoradiotherapy had a pharyngocutaneous fistula which closed spontaneously without additional surgery. We have demonstrated that transoral endoscopic approach to the larynx and pharynx is feasible without a robotic platform. TOUSS-TL can easily spread the transoral endoscopic philosophy as well as the benefits of a minimally invasive way to remove the entire larynx. Further research will show the advantages in terms of complications and functional outcomes.

Total laryngectomy: A new lateral cervical approach

“…Over the last few years, the trend in sparing healthy tissue during head and neck surgery has also attracted the laryngeal field. In 2013, Lawson et al 3 described the transoral robotic total laryngectomy procedure and, in 2016, Fernandez-Fernandez et al 4 published the transoral endoscopic approach. These techniques demonstrated the feasibility of total laryngectomy via a minimally invasive approach to accomplish faster recovery at the same time reducing morbidity.…”

“…Transoral total laryngectomy performed with minimally invasive approach has recently been proposed to preserve as much tissue as possible. 3,4 These techniques require dedicated instruments and the need of staged neck dissection. The idea of a new lateral surgical approach for the treatment of both the larynx and the neck nodes through the same skin incision allows a minimally invasive technique using standard equipment, avoiding any delay of neck treatment involving the removal of the larynx and nodes during the same procedure.…”

Lateral cervical approach for open laryngeal surgery: Technical notes

“…The National Comprehensive Cancer Network (NCCN) 2017 guidelines confirmed the use of endoscopic resection/ open partial resections for T1, T2, and selected T3 tumors. Some authors proposed transoral laser microsurgery especially for early stage laryngeal tumors, [1][2][3] whereas others reported the feasibility of transoral robotic surgery even for candidates undergoing total laryngectomy (TL), 4,5 obtaining faster rehabilitation and reduced morbidity. Nevertheless, open transcervical approach for partial laryngectomy/TL is still widely used for intermediate and advanced laryngeal/ hypopharyngeal cancers.…”

Reply to Letter to the Editor regarding “Robotic or non‐robotic transoral laryngectomy”

“…The authors also discuss a prior publication regarding the use of rigid endoscopes both transcervically and transorally as well as an ultrasonic scalpel for total laryngectomy. 2 We appreciate this discussion, but also note the benefit of evaluating several techniques for minimally invasive supraglottic and total laryngectomy. Specifically, head and neck surgeons may find value to having a flexible endoscope and flexible, wristed instrumentation for the transoral work that is otherwise not available in a traditional, rigid endoscope system.…”