TORS Dramatically Improves Surgical Treatment for Head & Neck Cancer
May / June 2006
New surgical technique pioneered in Philadelphia offers patient benefits.
Penn surgeons have pioneered the use of transoral robotic
surgery (TORS), completing the largest and most comprehensive
study regarding the effectiveness of TORS for oral and laryngopharyngeal
benign and malignant lesions. Penn's Center for Head
and Neck Surgery is the only center in the world with an Institutional
Review Board-approved study and the only center currently reporting on TORS.
“In the last decade, we've seen a tremendous growth
in robotic surgery, especially in cardiac and urologic procedures.
It made us consider how robotics could be applied to surgical
treatment for head and neck cancer,” says
Bert
O'Malley, MD, chair, Department of Otorhinolaryngology at the Hospital
of the University of Pennsylvania and co-director, Penn's Center for Head
and Neck Cancer.
“Surgical treatment for cancers of the mouth and
throat can involve breaking the jawbone, ear-to-ear incisions,
tracheotomy, speech and swallowing difficulties and cosmetic
scarring. For some patients, TORS can mean less surgery,
less deformity and a faster rehabilitation in functional
recovery,” says Gregory
Weinstein, MD, vice chairman,
Department of Otorhinolaryngology: Head and Neck Surgery
at the Hospital of the University of Pennsylvania; director,
Head and Neck Surgery Division and Head and Neck Surgery
Clinic and co-director, Penn’s Center for Head and
Neck Cancer.
How it Works
The Penn da Vinci surgical robotic system
has three main components: a mechanical robot with four multi-jointed
arms (three are used for TORS: one with an endoscope and
two with instruments), a computer command center several
feet from the patient and a 3D video monitor that provides
a magnified view of the surgical site inside the patient.
Equipped with a special, double-telescopic endoscope, the
viewfinder allows surgeons to see the surgical site more
closely than human vision allows and to work at a smaller
scale of detail than conventional surgery permits.
“The end of the instrument basically moves exactly
like your hand,” says Dr. Weinstein. “It is as
if your hands are miniaturized in whatever small cavity you
are operating. In standard laproscopic surgery, you're still
about 20 inches away from the surgical site, if you consider
the instruments you're holding and the depth of the area
in which you're operating. That distance prevents you from
achieving full wrist motion but the difficulty is non-existent
in TORS. The system has perfect movement with six degrees
of freedom so it actually completely reflects the wrist.”
In addition, “TORS provides superb visualization
of the operative field as well as three-dimensional vision,” says
Dr. O'Malley. “Those who criticize the technique say
that it does not provide any sense of tactile feeling. But
the visualization it provides transcends the true sense of
touch. Nonetheless, mechanical resistance provided by the
instrumentation gives you a sense of touch that is linked
directly to the surgeon's hand. It allows for very fine and
delicate surgery.”
Contraindications and Risks
At this time, Penn
researchers have found no specific contraindications for
TORS. If a patient is a good surgical candidate, he or she
may be a good candidate for TORS. “The only exceptions,
so far, have been patients who have an anatomy that interferes
with the success of the procedure,” says Dr. Weinstein. “For
example, if a patient has a very tiny jaw, it may not be
realistic to operate transorally.”
The safety and risk profile appears to be similar to conventional
transoral surgery. Initial studies regarding management of
hemostasis during TORS showed that there are no additional
difficulties with the robotic technique. Researchers found
effective hemostasis of both large and small vessels could
be maintained using surgical hemoclips and electrocautery. “We're
using the same blood management techniques used in open surgery,” says
Dr. Weinstein. “We have not found any risk of increased
bleeding or difficulty controlling bleeding.”
Clinical Impressions
In some cases, robotic surgical
resection is used in combination with radiation and chemotherapy.
The study focuses primarily on the surgeons' ability to access
the lesion for resection with TORS and secondarily on issues
such as safety and quality of life. “The entire TORS
procedure is typically performed in about one to two hours,
compared to six to 12 hours for standard open procedures,” says
Dr. O'Malley. “The
shorter surgery, smaller incisions and reduced bleeding may
improve overall recovery rates for patients.”
Penn researchers are speaking both nationally and internationally
about the technique they've pioneered. “We've received
an amazing response,” says Dr. O'Malley.
Currently, patients who may benefit from TORS can only
receive the surgery by participating in Penn's IRB-approved
clinical trial. Eligible participants must be at least 18
years old and present with indications for diagnostic and
therapeutic approaches for benign and malignant diseases
of the oral cavity or laryngopharynx. Exclusion criteria
include unexplained fever and/or treated, active infection;
pregnancy; previous head and neck surgery preventing transoral/robotic
procedures; and the presence of medical conditions contraindicating
general anesthesia or transoral surgical approaches.
Online Consultation
Penn otorhinolaryngologists are available for consultation
on any case. For more information, please call PENNHealth at
1-800-789-PENN. You can also visit ENTconsult.org,
the referring health care professional's
online connection to the University of Pennsylvania Health
System's Department of Otorhinolaryngology – Head
and Neck Surgery.
After registering for a secure account, physicians and advanced
health care practitioners can:
- Request Patient Referrals
- Consult with Internationally Renowned Subspecialists
- Electronically submit X-rays, photos and office notes
Prompt attention and rapid communication can be expected
from our team. Click
here to set-up your account today.
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Referring Physicians: To speak with a Penn physician
or refer a patient, contact PennHealth through the secure online
referral form or by calling
1-800-789-PENN
(7366). |
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