Robotic microlaryngeal surgery: a new retractor that provides improved access to the glottis
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Robotic surgery has become the standard of care for many procedures outside of otolaryngology, and now is gaining momentum within our specialty. The robot has several advantages to human hands, including removal of tremor and better access to lesions due to increased degree of movement of the articulated instruments. The glottis has rarely been addressed using robotics because access was previously thought to be difficult. We present a case report using the modular oral retractor system to perform robotic microlaryngeal surgery.
KeywordsTongue Blade Redundant Mucosa Multiple Blade Glottic Airway Anterior Glottis
A 56 year-old man with a long history of smoking initially presented with progressive hoarseness and dysphagia for 8 months. He underwent direct laryngoscopy and biopsy at an outside facility which showed squamous hyperplasia of the bilateral true vocal folds and diffuse, severe supraglottic hypertrophy. Nasopharyngoscopy performed in our clinic revealed redundant supraglottic mucosa that prolapsed into the glottic airway with associated plicae ventricularis, retroflexed epiglottis and prolapsed aryepiglottic folds. It was not possible to view the glottis due to the redundant mucosa. The remainder of the head and neck exam was unremarkable. The patient was deemed a good candidate for robotic-assisted surgery using the MOR system. Informed consent was obtained for examination of the larynx and removal of the obstructing mucosa with a CO2 laser. He was consented for use of the MOR system under an IRB-approved protocol.
Few in vivo studies have been reported to investigate the efficacy of RMLS. Two studies used the Dingman mouthgag and a 30° scope to attain a working view of the larynx in a mannequin and cadaver, respectively (Hockstein et al. 2005a, b). Lalich et al. invented a retractor and conducted a study in cadavers with adequate access reported, but the retractor has not been trialed in an in vivo human model to date (Lalich et al. 2014). One study required the use of anterior tongue retraction with a 2.0 silk suture, malleable blade to retract the tongue base, and a Lindholm scope to retract the epiglottis. The robotic arms were inserted on either side of the Lindholm scope (Blanco et al. 2011). Resection of T1 glottic cancers have been successful in a small number of studies, but inadequate exposure was a recurrent theme (Park et al. 2009; Byrd and Duvvari 2013; Kayhan et al. 2012; Lallemant et al. 2013). An FK retractor was used in two studies, but the cumbersome nature of the retractor resulted in collision with the robotic arms and limited access to the anterior commissure in both studies. (Dogan et al. 2001; Blanco et al. 2011).
The senior author has used the Dingman, Crow Davis and FK retractor in the past and developed the MOR system as a simpler option with a wider range of applications. These previously described retractors are ideal to address the oropharynx particularly the palatine tonsil region but are limited in their exposure to other regions of the pharynx or larynx. The FK retractor is especially cumbersome in its use and its exposure of the larynx is very limited, especially in visualization of the anterior glottis. The MOR system was developed with two pivot points on the brace and a wide range of blade designs and can replicate the function of a Dingman or Crow Davis retractor. These features allow the user multiple set up options depending on the anatomical area being addressed. Our institution has not required use of the FK or any other retractor since the MOR became available. Unfortunately, direct comparisons between several retractors in a patient have not been performed due to the risk of unnecessary patient injury from insertion to removal of the retractor and significant operative time delay including use of the robot. A cadaver study in the future may have merit in this regard.
RMLS using the MOR system shows promise to allow for easy and effective resection of glottic and supraglottic lesions. We propose that by using this retractor, RMLS may improve upon traditional techniques. Technological advancements such as the new da Vinci Xi robotic system may make the MOR system a better option to perform laryngopharyngeal surgery. Areas of future analysis include a case series of multiple lesions that have been removed via RMLS using the MOR system.
NV made substantial contributions to conception and design, analysis and interpretation of data. He was involved in revising the manuscript critically for important intellectual content and has given final approval of the version to be published. He agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. JR made substantial contributions to conception and design, analysis and interpretation of data. She drafted the manuscript and has given final approval of the version to be published. She agrees to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Both authors read and approved the final manuscript.
Dr. Vasan is an Otolaryngologist—Head and Neck Surgeon in Oklahoma City at the University of Oklahoma Health Sciences Center (OUHSC). He was born and raised in New Zealand where he attended medical school and completed Residency. He is a Fellow of the Royal Australasian College of Surgeons. Dr. Vasan moved to Oklahoma City in 2002 where he completed a 2-year Head and Neck Fellowship at the OUHSC. He specializes in treating benign and malignant disease within the Head and Neck as well as General ENT disorders.
Dr. Vasan is the only physician in the state performing Head &Neck Robotic surgery and is active in the field of medical device innovation. Dr. Vasan is the Residency Program Director for the Department of Otorhinolaryngology.
Dr. Jennifer Rodney is a third year resident in the University of Oklahoma Department of Otorhinolaryngology. She is originally from Saint Petersburg, Florida. She completed her undergraduate training at The University of South Florida, double majoring in voice performance and biomedical science, with a minor in Spanish Language. She completed medical school at The University of Florida and moved to Oklahoma for residency training. She is a professional classical singer and has performed throughout the Southeast and in Europe prior to medical school.
She plans to combine her two passions by completing a fellowship in laryngology after her residency training. Her scholarly interests include robotic microlaryngeal surgery, care of the professional voice, and both benign and malignant vocal fold disorders.
Marina Medical Inc. (Sunrise, FL) provided assistance in engineering and production of the MOR system.
Intuitive Surgical Incorporated provided grant funding for this investigation. Intuitive Surgical has awarded $5000 for travel purposes for both authors to present research related to the MOR retractor. Intuitive Surgical Inc. did not have a role in the design, collection, analysis or interpretation of data.
This manuscript was presented at the Triological Society Combined Sections in Coronado Island, California, USA, 22–24 January 2015.
Nilesh Vasan, is the inventor of the retractor described in this case report with an International Patent application for the device filed in 2013 through the University of Oklahoma.
Jennifer Rodney does not have any conflicts of interest to disclose.
Consent to publish
Written consent to publish has been obtained from the participant to report individual patient data. The written consent is available for review by the Editor-in-Chief of this journal.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.
This case report did not require financial support. The authors have a clinical research grant from Intuitive Surgical, Inc. to continue to perform and present research using the MOR system.
Informed consent was obtained from all individual participants included in the study. Additional informed consent was obtained from the participant for whom identifying information is included in this article.
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