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J Reconstr Microsurg 2012; 28(07): 465-472
DOI: 10.1055/s-0032-1313762
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Reconstruction of Transoral Robotic Surgery Defects: Principles and Techniques

John Rukshan de Almeida
1   Department of Otolaryngology, Mount Sinai Medical Center, New York, New York
,
Richard Chan Woo Park
1   Department of Otolaryngology, Mount Sinai Medical Center, New York, New York
,
Eric M. Genden
1   Department of Otolaryngology, Mount Sinai Medical Center, New York, New York
› Author Affiliations
Further Information

Publication History

17 October 2011

09 February 2012

Publication Date:
28 June 2012 (online)

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Abstract

Early functional and oncological outcome studies suggest that transoral robotic surgery (TORS) may have a role for early stage cancers of the oropharynx. Unlike with traditional mandibular swing or pharyngotomy approaches, access to the oropharynx for reconstruction in TORS cases is limited. Maintaining a good functional result necessitates preserving physiological function where possible. The principles that should guide reconstructive surgeons include maintaining a velopharyngeal sphincter to prevent velopharyngeal insufficiency, maintaining sensate mucosa and restoring bulk in the tongue base to prevent aspiration, maintaining separation between the cervical and pharyngeal components, and covering exposed vessels in the pharynx. We present here principles and surgical techniques of TORS to reconstruct oropharyngeal defects using a subsite-based approach using secondary healing, local musculomucosal flaps, and free tissue transfer guided by the above principles.

Keywords

oropharyngeal cancer - transoral robotic surgery - reconstruction - radial forearms free flap
 

  • References

  • 1 Dai TS, Hao SP, Chang KP, Pan WL, Yeh HC, Tsang NM. Complications of mandibulotomy: midline versus paramidline. Otolaryngol Head Neck Surg 2003; 128: 137-141
    CrossrefPubMedGoogle Scholar
  • 2 Eisen MD, Weinstein GS, Chalian A , et al. Morbidity after midline mandibulotomy and radiation therapy. Am J Otolaryngol 2000; 21: 312-317
    CrossrefPubMedGoogle Scholar
  • 3 Wolf GT, Hong WK, Fischer SG , et al; The Department of Veterans Affairs Laryngeal Cancer Study Group. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med 1991; 324: 1685-1690
    CrossrefPubMedGoogle Scholar
  • 4 Pignon JP, Bourhis J, Domenge C, Designé L. Chemotherapy added to locoregional treatment for head and neck squamous-cell carcinoma: three meta-analyses of updated individual data. MACH-NC Collaborative Group. Meta-Analysis of Chemotherapy on Head and Neck Cancer. Lancet 2000; 355: 949-955
    CrossrefPubMedGoogle Scholar
  • 5 Machtay M, Moughan J, Trotti A , et al. Factors associated with severe late toxicity after concurrent chemoradiation for locally advanced head and neck cancer: an RTOG analysis. J Clin Oncol 2008; 26: 3582-3589
    CrossrefPubMedGoogle Scholar
  • 6 Satava RM. Surgical robotics: the early chronicles: a personal historical perspective. Surg Laparosc Endosc Percutan Tech 2002; 12: 6-16
    CrossrefPubMedGoogle Scholar
  • 7 Marescaux J, Leroy J, Rubino F , et al. Transcontinental robot-assisted remote telesurgery: feasibility and potential applications. Ann Surg 2002; 235: 487-492
    CrossrefPubMedGoogle Scholar
  • 8 Cheah WK, Lee B, Lenzi JE, Goh PM. Telesurgical laparoscopic cholecystectomy between two countries. Surg Endosc 2000; 14: 1085
    PubMedGoogle Scholar
  • 9 McLeod IK, Melder PC. Da Vinci robot-assisted excision of a vallecular cyst: a case report. Ear Nose Throat J 2005; 84: 170-172
    PubMedGoogle Scholar
  • 10 Hockstein NG, Nolan JP, O'malley Jr BW, Woo YJ. Robotic microlaryngeal surgery: a technical feasibility study using the daVinci surgical robot and an airway mannequin. Laryngoscope 2005; 115: 780-785
    CrossrefPubMedGoogle Scholar
  • 11 Hockstein NG, Nolan JP, O'Malley Jr BW, Woo YJ. Robot-assisted pharyngeal and laryngeal microsurgery: results of robotic cadaver dissections. Laryngoscope 2005; 115: 1003-1008
    PubMedGoogle Scholar
  • 12 Hockstein NG, Weinstein GS, O'malley Jr BW. Maintenance of hemostasis in transoral robotic surgery. ORL J Otorhinolaryngol Relat Spec 2005; 67: 220-224
    CrossrefPubMedGoogle Scholar
  • 13 Genden EM, Kotz T, Tong CC , et al. Transoral robotic resection and reconstruction for head and neck cancer. Laryngoscope 2011; 121: 1668-1674
    CrossrefPubMedGoogle Scholar
  • 14 Weinstein GS, O'Malley Jr BW, Cohen MA, Quon H. Transoral robotic surgery for advanced oropharyngeal carcinoma. Arch Otolaryngol Head Neck Surg 2010; 136: 1079-1085
    CrossrefPubMedGoogle Scholar
  • 15 Cohen MA, Weinstein GS, O'Malley Jr BW, Feldman M, Quon H. Transoral robotic surgery and human papillomavirus status: oncologic results. Head Neck 2011; 33: 573-580
    CrossrefPubMedGoogle Scholar
  • 16 White HN, Moore EJ, Rosenthal EL , et al. Transoral robotic-assisted surgery for head and neck squamous cell carcinoma: one- and 2-year survival analysis. Arch Otolaryngol Head Neck Surg 2010; 136: 1248-1252
    CrossrefPubMedGoogle Scholar
  • 17 Weinstein GS, O'Malley Jr BW, Snyder W, Sherman E, Quon H. Transoral robotic surgery: radical tonsillectomy. Arch Otolaryngol Head Neck Surg 2007; 133: 1220-1226
    CrossrefPubMedGoogle Scholar
  • 18 Genden EM, Desai S, Sung CK. Transoral robotic surgery for the management of head and neck cancer: a preliminary experience. Head Neck 2009; 31: 283-289
    CrossrefPubMedGoogle Scholar
  • 19 Iseli TA, Kulbersh BD, Iseli CE, Carroll WR, Rosenthal EL, Magnuson JS. Functional outcomes after transoral robotic surgery for head and neck cancer. Otolaryngol Head Neck Surg 2009; 141: 166-171
    CrossrefPubMedGoogle Scholar
  • 20 Moore EJ, Olsen KD, Kasperbauer JL. Transoral robotic surgery for oropharyngeal squamous cell carcinoma: a prospective study of feasibility and functional outcomes. Laryngoscope 2009; 119: 2156-2164
    CrossrefPubMedGoogle Scholar
  • 21 Givens DJ, Karnell LH, Gupta AK , et al. Adverse events associated with concurrent chemoradiation therapy in patients with head and neck cancer. Arch Otolaryngol Head Neck Surg 2009; 135: 1209-1217
    CrossrefPubMedGoogle Scholar
  • 22 Genden EM, Kotz T, Tong CC , et al. Transoral robotic resection and reconstruction for head and neck cancer. Laryngoscope 2011; 121: 1668-1674
    CrossrefPubMedGoogle Scholar
  • 23 Aviv JE. The normal swallow. In: Carrau RL, ed. Comprehensive Management of Swallowing Disorders. San Diego: Singular Publishing Group; 1999: 23-29
    Google Scholar
  • 24 Lew DH, Choi EC, Tark KC. Standardization of flap design for oropharyngeal reconstruction after cancer ablation surgery. Yonsei Med J 2003; 44: 1078-1082
    PubMedGoogle Scholar
  • 25 Jacobson MC, Franssen E, Fliss DM, Birt BD, Gilbert RW. Free forearm flap in oral reconstruction. Functional outcome. Arch Otolaryngol Head Neck Surg 1995; 121: 959-964
    CrossrefPubMedGoogle Scholar
  • 26 Chepeha DB, Sacco AG, Erickson VR , et al. Oropharyngoplasty with template-based reconstruction of oropharynx defects. Arch Otolaryngol Head Neck Surg 2009; 135: 887-894
    CrossrefPubMedGoogle Scholar
  • 27 Seikaly H, Rieger J, Zalmanowitz J , et al. Functional soft palate reconstruction: a comprehensive surgical approach. Head Neck 2008; 30: 1615-1623
    CrossrefPubMedGoogle Scholar
  • 28 Gehanno P, Guédon C, Véber F, Perreau P, Alalouf P, Moisy N. [Velopharyngeal rehabilitation after transmaxillary buccopharyngectomy extending to the soft palate]. Ann Otolaryngol Chir Cervicofac 1985; 102: 135-137
    PubMedGoogle Scholar
  • 29 Rieger J, Bohle Iii G, Huryn J, Tang JL, Harris J, Seikaly H. Surgical reconstruction versus prosthetic obturation of extensive soft palate defects: a comparison of speech outcomes. Int J Prosthodont 2009; 22: 566-572
    PubMedGoogle Scholar
  • 30 Chung EJ, Lee DJ, Kang HD, Park MI, Chung CH, Rho YS. Prospective speech outcome study in patients with soft palate reconstruction in tonsillar cancer. Oral Oncol 2011; 47: 988-992
    CrossrefPubMedGoogle Scholar
  • 31 Bohle III G, Rieger J, Huryn J, Verbel D, Hwang F, Zlotolow I. Efficacy of speech aid prostheses for acquired defects of the soft palate and velopharyngeal inadequacy—clinical assessments and cephalometric analysis: a Memorial Sloan-Kettering Study. Head Neck 2005; 27: 195-207
    CrossrefPubMedGoogle Scholar
  • 32 Yoshida H, Michi K, Yamashita Y, Ohno K. A comparison of surgical and prosthetic treatment for speech disorders attributable to surgically acquired soft palate defects. J Oral Maxillofac Surg 1993; 51: 361-365
    CrossrefPubMedGoogle Scholar
  • 33 Holsinger FC, McWhorter AJ, Ménard M, Garcia D, Laccourreye O. Transoral lateral oropharyngectomy for squamous cell carcinoma of the tonsillar region: I. Technique, complications, and functional results. Arch Otolaryngol Head Neck Surg 2005; 131: 583-591
    CrossrefPubMedGoogle Scholar
  • 34 Smith JE, Suh JD, Erman A, Nabili V, Chhetri DK, Blackwell KE. Risk factors predicting aspiration after free flap reconstruction of oral cavity and oropharyngeal defects. Arch Otolaryngol Head Neck Surg 2008; 134: 1205-1208
    CrossrefPubMedGoogle Scholar
  • 35 O'Connell DA, Rieger J, Harris JR , et al. Swallowing function in patients with base of tongue cancers treated with primary surgery and reconstructed with a modified radial forearm free flap. Arch Otolaryngol Head Neck Surg 2008; 134: 857-864
    CrossrefPubMedGoogle Scholar
  • 36 Winter SC, Cassell O, Corbridge RJ, Goodacre T, Cox GJ. Quality of life following resection, free flap reconstruction and postoperative external beam radiotherapy for squamous cell carcinoma of the base of tongue. Clin Otolaryngol Allied Sci 2004; 29: 274-278
    PubMedGoogle Scholar
  • 37 Laccourreye O, Ménard M, Behm E, Garcia D, Cauchois R, Holsinger FC. Sternocleidomastoid myofascial flap for reconstruction after composite resection of invasive squamous cell carcinoma of the tonsillar region: technique and outcome. Laryngoscope 2006; 116: 2001-2006
    CrossrefPubMedGoogle Scholar
  • 38 Ma S, Han Y, Wang W, Zhang M, Wang W, Zhou L. [Application of pectoralis major myocutaneous flap in repair of defect caused by resection of tonsillar cancer]. Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2010; 24: 556-558
    PubMedGoogle Scholar
  • 39 Mukhija VK, Sung CK, Desai SC, Wanna G, Genden EM. Transoral robotic assisted free flap reconstruction. Otolaryngol Head Neck Surg 2009; 140: 124-125
    CrossrefPubMedGoogle Scholar
  • 40 Genden EM, Park R, Smith C, Kotz T. The role of reconstruction for transoral robotic pharyngectomy and concomitant neck dissection. Arch Otolaryngol Head Neck Surg 2011; 137: 151-156
    CrossrefPubMedGoogle Scholar