Supraglottic Transoral Robotic Surgery

Introduction

Early supraglottic squamous cell carcinoma may be treated with either surgery or radiation as a single modality with equal results, based on retrospective evidence and extrapolation from larger studies comparing radiation to total laryngectomy. As treatment modalities shifted toward “organ preservation therapy” after the Veterans Affiars Larynx trial, both surgical innovation and a noted decrease in survival have prompted the resurgence of conservation surgical procedures, both open and endoscopic. Although open supraglottic partial laryngectomy (SGPL) is an excellent oncologic technique, it has been supplanted by endoscopic partial laryngectomy. Endoscopic laser partial laryngectomy has been shown to provide equivalent disease control compared with the open procedure , with good functional outcomes.

Transoral robotic surgery (TORS) was popularized in the mid-2000s by Weinstein and colleagues, who first reported TORS in a canine model and shortly thereafter published a series of three patients who underwent the procedure successfully. Since then, the technique has been widely adopted and reported in the literature with success rates comparable to both open surgery and laser microsurgery. Compared with open surgery, authors cite shorter operative times and lengths of hospitalization and avoidance or shortened duration of tracheostomy and enteral feeding. Compared with transoral laser microsurgery (TLM), TORS may also be associated with shorter operative times, provided that the patient’s anatomy allows adequate exposure with available retractors and instrumentation.

Key Operative Learning Points

• Superiorly based T1/T2 supraglottic tumors may be efficiently resected using TORS as an alternative to TLM, provided that the patient’s anatomy allows adequate exposure.

• Careful patient selection is important to ensure that swallowing and airway are not compromised by surgery.

• The superior laryngeal artery must be controlled with cautery or clips when dissecting in the lateral pre-epiglottic space.

• Dissection becomes more restricted inferiorly.

Preoperative Period

Candidates for TORS supraglottic laryngectomy should undergo preoperative in-office laryngoscopy to assess vocal cord mobility and mucosal extent of the cancer. Contrasted computed tomography (CT) may be helpful to evaluate the base of tongue, pre-epiglottic space, laryngeal framework, and cervical lymph nodes. The classification system proposed by Remacle et al. for the european laryngological society (ELS) endoscopic laser supraglottic laryngectomy is applicable for TORS SGPL. Patients with significant lung disease or poor performance status may be poor candidates for partial laryngeal surgery, especially more extensive ELS types, due to the probability of postoperative dysphagia and aspiration.

Robotic supraglottic laryngectomy is contraindicated in the presence of extralaryngeal spread, major invasion of the base of the tongue, and fixation of the arytenoid. Patients with significant involvement of the pre-epiglottic space or glottis may be better treated with an open approach to remove adjacent laryngeal framework as a margin and reposition the arytenoids, when necessary.

Patients should be counseled about the possible need for postoperative radiation or chemoradiation (CRT) due to cancer that may be found after neck dissection. In a large, multi-institutional European study, 51% of patients treated with TORS SGPL and neck dissection required adjuvant therapy. Patients with N2 or N3 metastasis or obvious extracapsular spread on imaging should be counseled that long-term swallowing outcomes will be poorer if concurrent chemoradiotherapy is necessary after SGPL. These patients may be better served with definitive chemoradiation, rather than surgery as a primary modality.