ROBOTIC SURGERY IN ENT Presentation by Dr Salison Salim Panicker.pptx

Robotic Surgery In Ent by DR Salison Salim Panicker ENT surgeon , RelentCare ent centre thrissur , kerala, india.

1. ROBOTIC SURGERY Dr SALISON SALIM panicker Ent surgeon { relentcare ent centre Thrissur , kerala }

2. referenses Stellan maran 5 th edition Scott brown 8 th ediiton Robotic head and neck surgery[ david goldberg , neerav goyal]

3. The first surgical robot PUMA 560 [programmable universal machine for assembly]– used for stereotactic brain biopsy .T he field of surgical robotics started in the United Kingdom, where Brian Davies, JEA Wickham, and a team of urologists developed a six-axis PUMA robot device in 1987, aptly called the PROBOT , for prostate surgery. In the United States, the genesis of robotic surgery was driven by the National Aeronautics and Space Administration, in collaboration with surgeons from the Stanford Research Institute, who put forth the fundamentals of telepresence surgery. By combining dexterity-enhancing robotic manipulation with the 3-D audio-visual “virtual reality” system, the motions of the surgeon’s fingers could be digitally tracked via “data gloves” and reproduced at the remote robotic instruments. This later formed the basis for the team at Intuitive Surgical, that ultimately went on to develop the da Vinci robotic system in 1999. The first clinical trial using the da Vinci robot was performed on a series of 200 patients undergoing robotic cholecystectomy, which led to the Food and Drug Administration (FDA) approval for the robot in July 2000.

4. In 2oo7 ,the society of American Gastrointestinal and Endoscopic Surgeons and the Minimally Invasive Robotic Association defined robotic surgery “ a surgical procedure or technology that adds a computer technology –enhanced device to the interaction between a surgeon and a patient during a surgical operation and assumes some degree of control heretofore completely reserved for the surgeon.”

5. PUMA 560 in 1985 - used to perform a stereotactic brain biopsy. ROBODOC in 1992 to assist in total hip arthroplasty The PROBOT developed in 1988 -transurethral resection of the prostate. AESOP [automated endoscopic system for optimal positioning] -voice controlled endoscopic holder in 1994 In 1998 ZEUS gastrointestinal,cardiac and urological cases.

6. Surgical, Inc. (Mountain View, CA) was founded in 1995 and developed the da Vinci® Surgical System 1997 . FDA cleared da vinci system for laparoscopic use in 2000 Recently in December 2009 transoral otolaryngology surgical procedures restricted to benign and malignant tumors classified as T1 and T2. The first robotic surgery performed transorally in the head and neck was carried out in 2005 by Macleod and Melder – vallecular cyst excision

7. Advantage Improved accessibility Multi articulated instruments -that have 7 degrees of freedom that improves dexterity ,allowing maneuverability that approaches that of open surgery Enhanced visualisation-3D visualisation and tenfold magnification of operating field enhance the depth of the field and clarity of the tissue planes during dissection Better endoscopic control of operating tools Motion scaling and tremor reduction -large movements can be translated into micromovements inside the operative field allowing the surgeon more precision

8. Motion scaling, rather than tremor filtration, plays the major role in the enhanced accuracy seen in robotic surgical systems. Robotic assistance with MS significantly improved accuracy above laparoscopic instruments alone and robotic assistance with tremor filtration alone. MS also creates ambidexterity in an otherwise unidextrous population, optimizing the surgeon's ability to undertake tasks requiring microsurgical accuracy.

9. By markedly reducing tremor, microsurgical precision is improved to a level beyond present human capabilities. In conclusion, robotics offers potential advantages over free-hand microsurgery as it is currently performed during ophthalmic surgery

10. Fatigue reduction -surgeon sitting with his or her forearms resting comfortably on a pad and the head resting against the console ,therefore improving ergonomics Proper hand eye coordination Telesurgery -since the inception of robotic surgery,the wish to overcome geographical constraints and the availability of specialists was an important goal . 1 ST SURGERY –LINDENBERG SURGERY[ SEP 7 2001] laparoscopic cholecystectomy- surgeon –newyork patient-france [6000 KM] Telementoring

11. fewer blood transfusions shorter hospital stays faster recovery of preoperative functional ability and improved quality of life

12. Advantages of robotic surgery over traditional laparoscopic surgery Improved three-dimensional visualization Greater precision Improved dexterity with wristed instruments better ergonomics while operating from the surgeon’s console. Elimination of fulcrum effect Telesurgery Microanastomoses

13. Disadvantages Absence of tactile and haptic sensation Equipment size and weight Cost of the device Increased time of setup Monopoly New tech still unproven in many areas W

14. Currently the da Vinci Surgical System(intuitive Surgical Inc.,Sunnyvale , California,USA ) is the most widely used platform for robotic surgery

15. The da Vinci® Surgical System has four components: Surgeon console Patient side cart Endowrist ® instruments Vision system

16. SURGEONS CONSOLE The surgeons console consists of three dimensional display, a seat for the surgeon, foot pedals to control cautery and other instruments and hand controls linked to instruments in a virtual environment The console is fitted with a glove-like apparatus that translates the surgeon’s hand, wrist and finger movements into real time movements of the surgical instruments.

17. If a surgeon wishes to change instruments, it is necessary that an assistant remove the robotic arm from the patient or operative field, change the instrument and reinsert it into the surgeon’s line of sight. Seated at the console, the surgeon can then resume the operation with the new or different instrument. PATIENTS SIDE CART patient side cart is positioned next to the patient and utilizes four robotic arms to carry out the surgeon’s actions, with one arm holding the camera and the other arms holding theinstruments.

18. E NDOWRIST ® graspers forceps scissors retractors cautery devices

19. Each instrument has seven degrees of freedom : three translational (up and down, left and right, forward and backward ) three rotational ( roll, yaw and pitch ) one grip ( cutting, grasping, etc.). The tip of each instrument allows 90 degrees of articulation. When inserted into the patient, the Endowrist ® instruments mimic the surgeon’s hands operating in the patient.

20. VISION SYSTEM High definition, dual lens endoscope with two three-chip cameras that are integrated to provide the surgeon with a three-dimensional view of the operative field. Both a zero degree and 30 degree endoscope with either 12 mm or 8 mm diameter are available. Mounted touch screen- endoscope allignment , whitebalance, toggling between video inputs, telestration

21. These components are integrated such that the robot is controlled in a master-slave fashion to carry out the actions of the operating surgeon. The surgeon is provided with a feeling of standing inside the patient’s mouth and operating with his hands

22. NEW MODIFICATION Although robotic surgery provides multiple benefits in contrast to open surgery the relatively larger profile and rigidity of the current da vincis robotic systems instrument arms present certain challenges when used in head and neck surgery i.e when the robot is used transorally only 2 surgical arms and an endoscopic camera from the robot can be used limiting optimal surgical traction and countertraction And rigid instrumentation limits the ability to maneuver and operate around fixed bony anatomy within the pharynx

23. There fore in 2014-a novel and flexible single arm robotic system was approved

24. Holsinger used the single –instrument arm equipped with a 2cm cannula to introduce 3 separate 6 mm flexible instruments and a flexible stereoendoscopic binocular to perform oropharyngectomies He was able to manipulate three instrument arms transorally without collision and being able to visualise target anatomy with graduated angulation from 0 to 30 degree with the flexible endoscopic camera without the need for changing instruments

25. Transoral robotic surgery Bot neoplasm resection Tonsillar malignancy Obstructive sleep apnoea surgery Hypopharyngeal malignancy Laryngeal malignancy Transoral Robotic Retropharyngeal Node Dissection,cervical spine surgeriesh Robotic Supraglottic Anatomy and Laryngectomy Robotic thyroidectomy Robotic neck dissection Parapharyngeal space tumours[ Robotic skull base surgery]

26. Rationale for developing TORS Traditional treatment for aerodigestive tract carcinoma-open approach Allows direct visualisation Involves lip splitting mandibulotomies Free flap reconstruction Disadavantages Long operation hours tracheostomy /feeding tubes Prolonged period of rehabilitaion Variable recovery of speech and swallowing Non surgical organ preserving treatment Radiation and chemotherapy but was associated withsevere late pharyngeal or laryngeal toxicity

27. Minimaly invasive techniques that offer local control equal to standard therapy In 1970s-TLM (transoral laser microsurgery) was developed Ocologic and functional outcome of TLM for treatment of OPSCC have been excellent Limitations-access to oropharynx limited by laryngoscopes , retractrors that used in conjunction with operating microscopes Robotic surgery-potential to overcome limitations of TLM

28. TORS radical tonsillectomy THE MAIN INDICATION for TORS is primary resection of squamous cell carcinoma of the tonsillar fossa , specifically T1 and T2 tumors with selected T3 and T4a neoplasms. Contraindications TORS radical tonsillectomy include stage IVC cancer (with exception for curable, solitary, distant metastasis), T4a cancer (with exception of those involving only the extrinsic muscles of the tongue or minimal involvement of the medial pterygoid muscle) radiologic evidence of tumor adjacent to the common or internal carotid artery Other non– tumor-related contraindications include trismus that prevents adequate exposure, a retropharyngeal internal carotid artery, and any medical comorbidi- ties precluding the patient from general anesthesia

29. TORS Resection of tongue base tumours BENEFITS Binocular magnification at resection site Better resection due to wristed 3d grasping and cut ,Improve accuracy and manipulation of vessels andspecimens easier 2 surgeons can easily take part in surgery , As very fast interchanging of controls between 2 consoles is possible , also for training

30. OBSTRUCTIVE SLEEP APNOEA With TORS can adress the role of tongue base hypertrophy in osa in minimally invasive fashion with imporoived efficacy and minimal morbidity

31. TORS Trans oral robotic surgery

32. RETRACTORS Crowe davis Mclvor FK ,FK-WO ( Feyh-Kastenbauer Weinstein-O’Malley These modifications included widening of the aperture at the frame to allow for more room for instruments and the camera, as well as new blades for exposure of the supraglottis ) –best for supraglottic and hypopharyngeal Dingman LARS ( Laryngeal advanced retractor system)- vertical suspension system

33. THYROID SURGERY Earlier minimally invasive procedure – Small cervical incision surgeries Later video assisted endoscopic surgeries Incisions as small as 1.5 cm , Non cervical incicions , Endoscopic transaxillary [ disadvantage – time intensive and technically difficult – takes 3 -4 hrs for a lobectomy ] In 2005 first successful robotic axillary thyroidectomy was reported with an insufflation based technique

34. In 2009 gaseless robot assited transaxillary surgery [RATS] that uses a fixed retractor system to maintain the operative pocket , thus eliminating the need for gas insufflation

35. Criteria for robotic assisted thyroidectomy Patient selection criteria Motivated patient desiring absence of cervical scar Non morbidly obese <40 bmi American Society of Anaesthesiologist class 1 or 2 Absence of previous neck scar Disease criteria Anticipoated unilateral disease Dominant nodule less than 4 cm Absence of clinically apparent thyroiditis Absence of lymphadenopathy, substernal extension or extra thyroid extension

36. The arm and shoulder should be at the same vertical height, with proper padding of the forearm and elbow to prevent neu - ropraxia or stretch injury.The patient is positioned supine under gen - eral anesthesia and intubated with a Neural Integ - rity Monitor (NIM) endotracheal tube (Medtronic Xomed ) to allow intraoperative monitoring of recurrent laryngeal nerve (RLN) function. The neck is then slightly extended, and the arm ipsilateral to the lesion (ipsilateral to the larger lobe of the thyroid in cases of total thyroidectomy) is placed cephalad and flexed above the head (modified Ikeda’s arm position) (Fig. 7.1). Additionally, we routinely per- form monitoring for the median and ulnar nerves using somatosensory evoked potentials (SSEP) (Bio- tronic ) to avoid neuropraxia (Fig. 7.2).

37. During development of the working space, electrocautery, a vascular DeBakey forceps and various retractors (Army-Navy, right-angled, and lighted breast retractors) are used for subcutaneous flap dissection and elevation.

38. Using the Harmonic scalpel helps to develop a reasonable space between the sternal and clavicular heads of the SCM. The omohyoid muscle is a good landmark for the superior pole of the thyroid gland, and it can be either retracted or divided in cases with large thryoids. The strap muscles are then lifted anteriorly and suspended by inserting the Chung retractor or special modified robotic thyroidectomy retractor (Marina Medical) (Fig. 7.6), creating the working space and exposing the anterior surface of the thyroid gland .

39. Complication of rats Branchialm plexopathies Tracheal oesophageal injury Bleeding Recurrent laryngeal nerve injuries

40. Robotic Facelift Thyroidectomy Key Landmarks Sternocleidomastoid muscle Sternothyroid S ternohyoid , and O mohyoid muscles Key Vascular Structures Internal carotid artery Internal jugular vein External jugular vein Inferior and superior thyroid arteries Middle thyroid vein Key Nervous Structures Superior laryngeal nerve Recurrent laryngeal nerve Vagus nerve Great auricular nerve Selection criteria for patients1 under consideration for the robotic facelift thyroidectomy include: A motivated patient who is committed to eliminating a scar of the visible neck and who is willing to accept a lengthier surgical time, increased extent of dissection, and transient auricular hypoesthesia A body mass index of less than 40 The absence of substantial medical comorbidities with an American Society of Anesthesiologists class of 1 or 2 Absence of previous neck surgery The ability to understand the alternative surgical options, accept the possibility of conversion to an open anterior cervical approach, and capability to provide informed consent Selection criteria pertaining to disease characteristics are as follows: Anticipation of unilateral surgery for benign disease (for bilateral disease, patients may be candidates for staged bilateral RFT) Dominant nodule size less than 4 cm in greatest dimension Absence of clinically apparent thyroiditis Absence of lymphadenopathy, extrathyroidal extension, or substernal extension

41. The patient is marked preoperatively while sitting upright. The modified facelift incision is drawn in a position that will be concealed by the ear, beginning adjacent to the postauricular crease and extending into the occipital hairline. The incision is continued inferiorly, approximately 1 cm within the occipital hairline, to ensure it will be obscured by hair post- operatively (Fig. 8.1). No preauricular limb is used.2 A proposed anterior cervical incision is also marked[in case of any complication]

42. At the conclusion of the procedure, deep extubation is preferred to minimize coughing and bucking on emergence that could predispose to bleeding and seroma formation . ADVANTAGE Patient discharged on same day of surgery No risk of brachial plexopathies Shorter length of dissection Even in slight obese patients No drain required , no wound care is needed Approximately 3 weeks postoperatively, the skin glue and Steri-Strip may be gently removed by the patient. DISADVANTAGE Seroma formation Mild neck odema Transient hypothesia in GAN region

43. Parapharyngeal Space Tumours important to understand the anatomical relationships of this space when it is approached from the medial side. TORS may also be utilized to access the parapharyngeal space directly for removal of tumors in this area. Access to the parapharyngeal space is accomplished via incision of the pterygo- mandibular raphe and division of the musculature of the anterior tonsillar pillar and superior pharyngeal constrictor muscle. Intraoperative and postoperative hemorrhage are the most feared complications of TORS and can be life threatening. Two muscles, the stylopharyngeus and styloglos- sus, are critical landmarks for the vascular anatomy of this region. These 2 landmark form the posterior limit of surgery and its safe to stay anterior to parapharyngeal fat .

44. INDICATION PRESTYLOID PARAPHARYNGEAL TUMOURS-lipomas, salivary gland tumors, schwannomas, vascular lesions, and malignancies Relative indication -dumbbell tumours or tumours clearly arising in the parotid gland involving the deep lobe of the parotid gland CONTRAINDICATION TUMOUR INVOLVING CAROTID ADVANTAGE – completely avoid first bite syndrome seen with trans cervical approach

45. Robotic-Assisted Neck Dissection [RAND] Key Landmarks Sternocleidomastoid muscle Mandible angle Clavicle Key Vascular Structures External jugular vein Internal jugular vein Facial artery Key Nervous Structures Great auricular nerve Spinal accessory nerve Hypoglossal nerve INDICATION B iopsy-proven cancer of the head and neck requiring elective neck dissection (cN0) or therapeutic neck dissection (cN+), (2) no previous treatment for head and neck cancer. For experienced surgeon , the procedure can be competently performed on ther- apeutic neck dissection for the cN+ neck without overt extracapsular spread of the metastatic node.

46. Robot-Assisted Neck Dissection (RAND) Three robotic arms are used, which are all inserted via the retroauricular (RA) port. A 30° dual-channel endoscope (Intuitive Surgical) is placed in the center (camera arm), and Harmonic curved shears (Intuitive Surgical) or a 5-mm spatula monopolar coagulator and a 5-mm Maryland dissector (Intuitive Surgical) are placed in the instrument arms at either side of the central arm (Fig. 9.6). Additional aid from a fourth arm, such as a ProGrasp forceps, is not applicable but can be replaced by an endoscopic alligator forceps held by a patient-side assistant surgeon.

47. BENEFITS OF RAND - compared with conventional ND in functional aspects such as subcutaneous induration lymphedema sensory disturbance range of neck motion. No scar