Journal of Anesthesia and Surgery
Management of the Airway in Transoral Robotic Surgery for Head and Neck Cancer
- 1Department of Otorhinolaryngology, Rey Juan Carlos University Hospital,
- 2Department of Anesthesiology, Rey Juan Carlos University Hospital, Madrid
- 3Intensive Care Unit, Rey Juan Carlos University Hospital, Madrid
Jose Granell, Rey Juan Carlos University Hospital,c/ Gladiolo s/n, 28933 Mostoles, Madrid, E-mail: firstname.lastname@example.org
Granell, J., et al. Management of the Airway in Transoral Robotic Surgery for Head and Neck Cancer. (2017) J Anesth Surg 4(1): 1- 6.
© 2017 Granell, J. This is an Open access article distributed under the terms of Creative Commons Attribution 4.0 International License.
KeywordsPostoperative intubation; Transoral robotic surgery; Oncological indications
Materials and Method:
Results: Thirty-six patients met the inclusion criteria; 72% were oropharyngeal tumors (most frequently, 13 cases, tumors of the base of the tongue). The most frequent local extension was T2 (18 cases) but almost two-thirds (64%) were classified as advanced tumors (stages III and IV) due to the N stage. Lymph node surgery and transoral primary tumor surgery were staged when required. The intervention was successful in all cases. After robotic surgery, the patients in risk remained intubated for 24 hours. All were managed without a tracheostomy except for a patient with a synchronous diagnosis of sleep apnea (who received a temporary prophylactic tracheostomy) and a case of combined transoral-transcervical surgery (who received a non-programmed tracheotomy). There were no relevant perioperative incidences related to the airway except for a case of delayed bleeding.
Conclusions: In our early experience, with a conservative management protocol with two-stage surgery and programmed postoperative intubation, transoral robotic surgery for oncological indications has been feasible and safe without a tracheotomy.
The introduction of technological innovations has become a constant of current clinical practice.
TransOral Robotic Surgery (TORS) is a new challenge for the
Figure 1: Transoral robotic approach. The exposure is obtained with the FKWO
TORS is in fair expansion. Although it is true that they are not particularly complex interventions from the
The primary objective of this study was to evaluate the feasibility and safety of conservative management of the airway without tracheotomy in patients undergoing TORS for head and neck cancer. As a secondary objective, we searched for possible risk factors that could condition airway management problems, defined as variations on the established protocol.
Materials and Methods
We designed a prospective observational study. A time horizon was proposed from the beginning of the program in July 2013, until July 2016. We included patients with a diagnosis of carcinoma of the oropharynx, hypopharynx or larynx undergoing TORS. Data were collected prospectively from diagnosis to completion of treatment.
The TORS-oncology program protocol is supervised by the institutional quality control system. Patients with tumors of the upper aerodigestive tract that can be surgically treated with functional preservation and are resectable by TORS are included, subject to agreement in the Multidisciplinary Committee on Head and Neck Cancer.
The anaesthetic management protocol includes a standard pre-anaesthetic assessment, with particular attention to the prediction of the difficult airway)[9,10]. Unless there is a reasonable contraindication, interventions are scheduled without a tracheotomy. The surgical position is supine, with
The management protocol contemplates the accomplishment of surgery in two times in case a neck dissection is required. Neck surgery is scheduled between one and two weeks prior to transoral surgery. Times given in the current study refer only to TORS itself.
For the present study, variables related to airway characteristics and management, and potential risk factors for complications were collected. Preoperatively, in addition to the oncological diagnosis (TNM staging), age, BMI and ASA classification, Mallampatti, difficulty in cervical extension, oral opening and teeth status were documented. Also Cormack-Lehane grade, type of intubation and eventually the existence of a difficult intubation, the quality of the exposure (insufficient, bad, moderate, good or excellent), type of surgery, surgical time, and
July 2013 to July 2016 were first 3 years of the TORS - oncology program at our centre. The study group consisted of 32 men and 3 women (one patient was operated twice because of two metachronous tumors). The mean age was 63.4 years (SD = 8.9 years). All tumors were epidermoid carcinomas except for one liposarcoma. Most tumors (72.2%) were located in the oropharynx (13 at the base of the tongue, 6 at the palatine tonsil, 1 at the tonsillar pillar, 3 at the lateral wall and 2 at the posterior wall); The rest were supraglottic tumors (9 cases), and a pyriform sinus tumor (hypopharynx). Two tumors belong to the same patient in whom a robotic supraglottic laryngectomy was performed for a pT2pN0, and 6 months later the robotic transoral excision of a second primary (pT1) of the posterior wall of the oropharynx. Half of the cases (18) were classified as T2. In order of frequency the rest were T1 (4), T4a (3) and T3 (1). Therefore, 11.1% were locally advanced tumors (T3 and T4), but due to the presence of lymph node metastases, the percentage of cases classified as advanced stages (III and IV) rose to 64%. As corresponds to a series with primarily surgical treatment, all cases were M0. Also, as per staging, 86% of the patients received a neck dissection. In half of the cases it was bilateral (all of the functional neck dissections, except for two necks with radical dissections),
All patients in whom TORS was indicated received
The mean time for the setup of the patient and the operating room was 55 minutes (SD = 11 minutes). The mean transoral surgery time was 59 minutes (SD = 29 minutes), with a minimum of 24 minutes and a maximum of 142 minutes.
Only one of the predicted difficult airways cases met difficult intubation criteria. However, in 5 other
Figure 2: Surgical bed at the end of robotic transoral resection of the base of the tongue and supraglottis (pT3pN2aM0 squamous cell carcinoma of the left
All of the patients were submitted to the Intensive Care Unit for
Complications were considered as prolongations in the time of intubation and a case of lingual oedema that motivated one of the prolonged intubations, besides pneumonia during the postoperative period in one of the laryngeal tumors. There were no intraoperative haemorrhagic complications, but two postoperative complications: diffuse haemorrhage of the tongue base surgical site the same afternoon of the intervention (with the patient intubated) and a bleeding after a week of a tongue base resection. Both required surgical revision and were resolved without further incidents. The patient with a
27% of patients received adjuvant radiotherapy and 33% received
Temporary elective tracheotomy is a safety measure in major head and neck surgical procedures; is a constant for certain approaches, such as the
Although transoral surgery (be it robotic or with other instrumentation) by definition implies a minimization of the damage associated with the approach, this risk of complications continues to exist. Even so, the expansion of transoral approaches
In the published series, the management of the airway in oncological patients operated by TORS is diverse. In one of the first ones, published by the authors who originally developed the technique, out of 27 patients, most of them remained intubated for 24 to 72 hours. In another series of 54 patients, 12 remained intubated 48 hours and 2 patients had tracheotomy. In a third early series of 45 cases, which mostly included
On a case-by-case basis, patients in whom the tube was maintained longer than initially scheduled, the first was a T2N2c tumor of the tongue base, the only case in which bilateral cervical lymph node dissection was performed simultaneously, in addition to bilateral resection with exposition of both lingual arteries, which, independently of the robotic instrumentation, placed us, in the absence of a tracheotomy, in an unprecedented postoperative situation that was handled with extreme caution. The second was a vertical
Neck surgery at a separate time is another option. In addition to decreasing postoperative
It is clear that the management of these patients involves care that goes beyond the robotic instrumentation itself, and that justifies the design of the transoral robotic surgery program. Regarding the intraoperative
Figure 3: Operating
Regarding the type of tube although the initial recommendations included that of using a laser-protected tube because of the risk of damaging it with the monopolar coagulation spatula commonly used in TORS. In clinical
We have to highlight some limitations of the study. It is an observational study on consecutive patients selected based on a surgical indication. The selection of patients who will undergo TORS might be different between
The concept of MIS is intimately linked to the very development of robotic surgery. From our point of view, the objective of minimizing morbidity includes in head and neck surgery the avoidance of
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