Transoral robotic-assisted laryngeal cleft repair in the pediatric patient

Implementation of robotic systems in paediatric craniofacial and head and neck surgery: a narrative review of the literature

Surgical challenges in paediatric craniofacial and head and neck surgery can include operating in a small cavity, limited depth perception, restricted access with difficult angulations, and poor visualisation. Delicate tissue handling, muscle dissection, and suturing at depth require surgical access in congruence with the use of operative microscopes. Robotic assistance may aid surgeons in operating in confined spaces with minimal access incisions by improving the degree of freedom of operative instrumentation. In this study, we aim to review the use of robotic systems in paediatric head and neck and craniofacial surgery by focussing on total complications and length of surgery together with patient and surgeon experience. A literature search was conducted in June 2023 by two independent reviewers on Pubmed, Dynamed, DARE, EMBASE, Cochrane and British Medical Journal (BMJ) electronic databases for articles published between 1960-2024. Seventeen papers met the inclusion criteria. Seventy-nine patients were included. The success rate for head and neck and craniofacial cases that included robotic-assistance was 93.7% (n = 74) and the complication rate was 16.0% (n = 12). Robotic-assisted surgery demonstrates a low complication rate in treating a range of different pathologies in the head and neck in our included studies. Robotic-assistance in craniofacial surgery demonstrates promise in preventing iatrogenic injury from more traditional methods, and could allow for operations to proceed earlier in life in the management of midface distraction, however, more research in the area is necessary with limited research published at present.

Assessing robotic-assisted procedures in pediatric otolaryngology: A systematic review and meta-analysis

BACKGROUND

Robotic-assisted surgery is increasingly used in pediatric otolaryngology, offering potential benefits like improved cosmetic outcomes. However, challenges such as longer operative times, higher costs, and a steep learning curve remain.

OBJECTIVES

This systematic review and meta-analysis assess whether robotic-assisted surgery offers advantages in operative time, complication rates, hospital stay, and cosmetic outcomes compared to traditional methods in pediatric patients.

METHODS

A literature search identified 20 studies, with six focused on thyroidectomy. Data on operative time, complications, hospital stay, and cosmetic outcomes were extracted and analyzed.

RESULTS

No significant differences in operative time or complications were found for robotic-assisted thyroidectomy, but it showed superior cosmetic outcomes and, in some cases, shorter hospital stays. Additional analyses suggested feasibility and functional benefits of other robotic procedures.

CONCLUSIONS

Robotic-assisted surgery in pediatric otolaryngology is as safe and efficient as traditional methods, with added cosmetic and functional benefits. Further large-scale trials are needed.

Transoral robotic surgery for pediatric upper airway pathology: An institutional update

OBJECTIVE

Provide an update on our institution's experience with utilizing transoral robotic surgery (TORS) in pediatric airway surgery and compare these results to surgery by traditional methods.

METHODS

Pediatric patients who underwent TORS for treatment of upper airway pathology between 2010 and 2021 at our institution were retrospectively identified and compared to patients with the same or similar pathology who underwent a traditional (open or endoscopic) surgical approach over the same time period. Outcomes of interest included patient demographics, operative times, adverse events, hospital length of stay (LOS), and modified barium swallow (MBSS) results.

RESULTS

Forty children (19M, 21F) underwent 46 TORS procedures. Mean age was 6.4 years (range: 6 days-17 years). Most commonly treated pathology included: laryngeal clefts (LC) (n = 18), lymphatic malformations (n = 9), and base of tongue masses (n = 7). Surgical time was decreased in traditional type I LC repairs (mean: 111 vs 149 min, P = 0.04) and lymphatic malformation excisions (59 vs 120 min, p = 0.005). Hospital LOS was increased in TORS type I LC repairs (2.6 vs 1.2 days, P = 0.04). Adverse event rate was similar between TORS and traditional cohorts (17 % vs 16 % cases, P = 0.9). Postoperative MBSS results were improved for TORS type I LC repairs at 6 months (70 % vs 33 %, P = 0.09) and 12 months (82 % vs 43 %, P = 0.05).

CONCLUSIONS

Pediatric TORS is practical and safe and has comparable outcomes to traditional surgery. Robotic-assisted LC repair displayed improved postoperative swallow results versus traditional approaches and may be particularly useful in recurrent cases.

LEVEL OF EVIDENCE: 3

Pediatric Robotic Laryngeal Cleft Repair

OBJECTIVE

Compare surgical and swallow outcomes in robotic versus traditional laryngeal cleft (LC) repairs.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary care pediatric hospital.

METHODS

Pediatric patients who underwent robotic or traditional (open or endoscopic) LC repair between 2010 and 2021 were identified. Patient characteristics, operative times, adverse events, hospital length of stay (LOS), and modified barium swallow study (MBSS) results were compared.

RESULTS

Eighteen robotic and thirty traditional LC repairs were identified. Mean surgical (149 vs 111 min, P < .05) and OR times (207 vs 139 min, P < .002) were increased for robotic type I LC repairs, but were similar for type II and III LC. Mean hospital LOS was increased for robotic type I LC repairs (2.6 vs 1.2 days, P < .006), but was decreased for type II (4 vs 12.2 days) and type III (4.3 vs 94.5 days) LC. Postoperative MBSS results were improved for robotic type I LC repairs at 12 months (82% vs 43%, P = .05), and trended toward improvement at 6 months for type II (75% vs 22%), and type III (67% vs 50%) LC repairs, although significance was limited for type II and III LC due to the number of subjects. A robotic approach was used successfully to revise all recurrent LC that failed traditional repairs.

CONCLUSION

Robotic type 1 LC repairs demonstrated increased operative times and hospital LOS but improved postoperative swallow outcomes compared to traditional approaches may be particularly useful in cases of recurrent clefts.

Endoscopic Repair of Laryngeal Clefts: 8 Years' Experience

To emphasize the need for high clinical suspicion in the diagnosis of Laryngeal cleft in paediatric population, to catalogue the pattern of presentation, time to treatment and the evolution of surgical techniques for Laryngeal cleft repair at our center. A retrospective review of laryngeal cleft cases which presented over a period of 8 years (May 2012-May 2020), from a tertiary care center, was done. Data includes-patient demographics, preliminary investigations, diagnostic methods, type of cleft, surgical steps and post-operative follow up. Extensive literature search was done and we could not find similar studies from South East Asia and the Indian subcontinents. Of the 10 patients 7 were managed surgically and 3 conservatively. There was an equal distribution of type 1 (n = 5) and 2 (n = 5) clefts. 80% cases were males and 9 out of 10 patients had associated congenital anomalies. 80% cases had symptom resolution (75% were managed surgically and 25% managed medically). Surgical intervention should be based on the extent of anatomical defect and the functional impairment caused by cleft such as respiratory problems, persistence of feeding issues despite maximal medical management and feeding therapy. Early surgical management of type I and II clefts have satisfactory outcomes.

Can a flexible surgical robot be used in the pediatric population: A feasibility study

OBJECTIVES

Transoral robotic surgery in adults confers excellent results and decreased morbidity. Application of these techniques has not yet been rigorously investigated in children. The goal of this study is to evaluate the feasibility of a flexible robotic surgical system in a pediatric population.

METHODS

This was a non-randomized, non-blinded, prospective clinical trial. An Investigational Device Exemption was obtained from the FDA. Patients 8-12 years old scheduled for tonsillectomy and adenoidectomy between February and December 2019 at an academic tertiary care children's hospital were included. Exclusion criteria included pulmonary or vascular conditions posing risks for extended anesthesia, or a smaller mouth opening than the instrumentation (28 mm × 15 mm). Tonsillectomy was completed with standard monopolar cautery. After the surgery was complete, the robot was utilized for evaluation and assessment of exposure. A pediatric anesthesiologist screened patients for tolerance of additional anesthesia (up to 15 min). A flexible robotic surgical system, the MedRobotics Flex® Robotic System, was used to visualize and access the tonsillar fossa, posterior pharynx, base of tongue, epiglottis and false vocal folds. Visualization and access were graded on a five-point Likert scale.

RESULTS

A total of ten patients, eight males and two females, with obstructive sleep apnea (OSA) or sleep disordered breathing (SDB) were recruited in 2019. One patient did not complete the study due to equipment malfunction. The average patient demographics were: age 10.1 years (8.6-11.8 years), height 142.4 cm (127-164.9 cm), weight 47.5 kg (24.4-84.5 kg), and BMI 22.6 (13.9-31.0). Study time averaged 10.3 min (5-13 min). The tonsillar fossa, base of tongue, and posterior pharynx were visualized completely and easily accessed with the robotic instruments. The epiglottis and false vocal folds were visualized and accessed in 66% and 55% of patients, respectively. There were no adverse effects.

CONCLUSIONS

This study demonstrated that a flexible robotic surgical system is feasible for use in children 8-12 years of age when performing otolaryngology - head and neck surgery procedures of the oropharynx and larynx.

Laryngeal cleft: A literature review

INTRODUCTION

Laryngeal cleft is a congenital condition in which an opening in the posterior laryngotracheal wall allows food and liquid to pass from the esophageal lumen to the airway and causes aspiration. The severity of a laryngeal cleft is measured using the Benjamin-Inglis system, and can be managed conservatively or with a variety of surgical options With increased awareness, higher suspicion among primary physicians, advanced technology and improved intensive neonatal care services, more babies with laryngeal clefts survive in the modern era. Therefore, the focus has shifted from infant survival to treatment of laryngeal clefts and the challenging, complex medical conditions they create.

OBJECTIVE

To understand current laryngeal cleft management and post-operative outcomes.

METHODS

Literature review of laryngeal cleft studies from 2010 to 2021.

RESULTS

A total of 1033 patients were included. Based on 415 cases for whom sufficient classification data were available, the predominate symptom for patients with type I, III, and IV clefts is swallowing dysfunction, while the predominant symptoms for patients with type II clefts are stridor and aspiration. A wide variety of comorbidities involving several major organs has been reported with laryngeal clefts, which tend to impact clinical outcomes negatively. Approximately 19% of type I clefts have been treated conservatively successfully, but the majority was treated surgically. Most studies that used injection laryngoplasty for type I clefts reported highly successful repairs without complications or delays in additional procedures. Ninety-eight percent all type II clefts were treated with endoscopic repair; 87% of patients with type III clefts received endoscopic repair; and 66% of patients with type IV clefts underwent open surgery. Approximately 62% of resolved cases were reported within 12 months, while 50.87% of failed cases were reported within 6 weeks.

CONCLUSIONS

There are multiple treatment approaches, each of which may be applicable depending on factors such as laryngeal cleft type, severity of presentation, and comorbidities. Conservative approaches appear to be most useful for type I clefts or in patients with mild symptoms, while surgical management can be considered for any type of laryngeal cleft. The benefit of injection laryngoplasty, endoscopic repair and open surgery can also vary, but injection laryngoplasty and endoscopic repair are used most commonly. Open surgery should be to be considered if patients present with severe cleft types or if it is unsafe to perform other surgical techniques. Familiarity with this literature review should help clinicians understand clinical characteristics, direct medical management, and guide successful resolution of laryngeal clefts.

Experience in Transoral Robotic Surgery in Pediatric Subjects: A Systematic Literature Review

Pediatric transoral robotic surgery (TORS) has improved from 2007 to 2020, widening its indications and feasibility. This article aims to systematically analyze the procedures performed from the first use until the current year, observing their evolution over time. A systematic literature review was performed using PubMed, Scopus, Web of Science, and Cochrane databases between March 1, 2000, and April 1, 2020. We selected studies that were written only in English and were performed in live human subjects. About 16 studies were found with a total of 73 subjects treated, among them 41 were men and 32 were women with an average age of 6.8 ± 4.99 years. There have been four (5.47%) conversions. Both functional and benign-malignant diseases have been treated in the series. Eleven (15.06%) pre-operative tracheostomy and zero post-operative tracheostomy were performed. The bleeding data was only reported in 9 studies and was <50 ml. Only one (1.36%) intra-operative complication and 10 (12.32%) postoperative complications were reported. We consider the TORS procedures in pediatric subjects safe, feasible and with good surgical outcomes up to the laryngeal region.

Management of Type 1 Laryngeal Clefts: A Systematic Review and Meta-analysis

OBJECTIVE

Endoscopic surgical management or injection laryngoplasty of type 1 laryngeal clefts in pediatric patients is used in those who do not respond to conservative treatment. This study compares conservative treatment, endoscopic surgical repair, and injection laryngoplasty for the management of type 1 laryngeal clefts.

DATA SOURCES

PubMed, Web of Science, and Embase.

REVIEW METHODS

This systematic review included studies of patients with type 1 laryngeal clefts who were managed with conservative treatment, injection laryngoplasty, or endoscopic repair, and all studies reported postintervention outcomes. Two independent investigators assessed study eligibility, rated the quality, and extracted data for analysis. A random effects model was used for meta-analysis of pooled data.

RESULTS

Of the 1209 studies identified, 27 met inclusion criteria. There were 543 patients with type 1 laryngeal clefts represented in the studies, with outcomes reported for 537. Conservative therapy had a 52% (95% CI, 37%-66%; I² = 63%) success rate at improving symptoms, while endoscopic repair had a significantly higher percentage resolution of symptoms (70%; 95% CI, 59%-79%; I² = 62%, P < .001) as compared with conservative treatment (51%; 95% CI, 36%-65%; I² = 62%) or injection laryngoplasty (36%; 95% CI, 20%-57%; I² = 70%). The quality scores of the studies ranged from 7 to 12 out of 16.

CONCLUSION

Our systematic review demonstrated significant improvement and resolution of symptoms for patients with type 1 laryngeal clefts treated with endoscopic repair as compared with other modalities. More prospective and controlled studies comparing treatment strategies with validated instruments to measure outcomes are necessary to determine their efficacy in the management of type 1 laryngeal clefts.

Unusual presentation of a first Branchial cleft cyst associated with an abnormal bony canal -a case report

Background

First branchial cleft anomalies are rare, accounting for only 10% of all branchial cleft anomalies. We report an even more rare and unique case of a branchial cleft cyst with features of both first and second arch derivatives.

Case presentation

A 6-year-old boy presented to us with a left conductive hearing loss associated with pre-tympanic keratin debris and an ipsilateral painful cervical mass. He had a past medical history of left ear surgery for presumed cholesteatoma 2 years prior and left neck abscess drainage 6 months prior. CT and MRI revealed a lesion originating in the external auditory canal and extending cervically through a bony canal located medial to the facial nerve and terminating as a parapharyngeal cyst. The complete removal was accomplished in one surgical stage consisting of three distinct steps: robotic assisted transoral resection of the pharyngeal cyst, an endaural approach and a parotidectomy approach.

Conclusion

We believe that our detailed description of this rare first branchial cleft cyst with pharyngeal extension, possibly a hybrid case between a first and second branchial cyst, can serve as a valuable tool to Otolaryngologists – Head and Neck Surgeons who come across a similar unusual presentations.

Transoral Tubed Supraglottoplasty: A New Minimally Invasive Procedure for Aspiration

Objectives:

We describe a new procedure for aspiration called tubed supraglottoplasty (TS). TS is a transoral procedure that approximates the aryepiglottic (AE) folds and arytenoids. This narrows the laryngeal inlet. This procedure has been used to improve swallowing and reduce aspiration in patients with vocal fold paralysis. We describe the technical aspects of TS and report on 11 patients.

Methods:

TS is done by oral intubation followed by suspension laryngoscopy. An incision is made along the AE fold into the posterior commissure and then continued to the opposite AE fold. Dissection within this incision creates two mucosal flaps, one based on the laryngeal surface and the other on the pharyngeal surface. Two 1-cm releasing incisions are made at each end of the AE fold. The laryngeal mucosal flap is approximated using a 3-0 self-locking running suture. The pharyngeal mucosal flap is approximated as a second layer. This double-layered mucosal V-Y advancement flap builds up the posterior laryngeal height. It narrows and “tubes” the supraglottis.

Results:

All patients tolerated TS without airway complications. Ten of the 11 patients reported improved swallowing function with less aspiration. Six of the 8 patients with prior G-tubes had their gastrostomy tube removed. Postoperative laryngoscopy showed a narrowed “tubed” supraglottis with a higher posterior wall preventing spillover and aspiration. An improved Functional Oral Intake Scale was recorded in ten of eleven patients.

Conclusion:

TS is a minimally invasive procedure that can improve swallowing and reduce aspiration.

Utilization of Cable Guide Channels for Compact Articulation Within a Dexterous Three Degrees-of-Freedom Surgical Wrist Design

Pin-jointed wrist mechanisms provide compact articulation for surgical robotic applications, but are difficult to miniaturize at scales suitable for small body cavity surgery. Solid surface cable guide channels, which eliminate the need for pulleys and reduce overall length to facilitate miniaturization, were developed within a three-degree-of-freedom cable-driven pin-jointed wrist mechanism. A prototype was 3D printed in steel at 5 mm diameter. Friction generated by the guide channels was experimentally tested to determine increases in cable tension during constant cable velocity conditions. Cable tension increased exponentially from 0 to 37% when the wrist pitched from 0 deg to 90 deg. The shape of the guide channel groove and angle, where the cable exits the channel impacts the magnitude of cable tension. A spring tensioning and cam actuation mechanism were developed to account for changing cable circuit path lengths during wrist pitch. This work shows that pulley-free cable wrist mechanisms can facilitate miniaturization below current feasible sizes while retaining compact articulation at the expense of increases in friction under constant cable velocity conditions.

Beyond dilation: current concepts in endoscopic airway stenting and reconstruction

PURPOSE OF REVIEW

To discuss current modalities of endoscopic airway management beyond balloon dilation therapy.

RECENT FINDINGS

Advances continue to be made through technology and bioengineering with exciting potential in the pediatric airway. Smaller robots and instrumentation allow increased endoscopic surgical success. Biodegradable stents and bioengineered grafts are on the horizon for use in airway surgery. Dysphonia following airway reconstruction is of increasing recognition with new endoscopic treatments being performed. Supraglottoplasty is further recognized as a treatment for obstructive sleep apnea for laryngomalacia diagnosed on sleep endoscopy. Interarytenoid injection may be beneficial in the normal larynx for aspiration and dysphagia as well as diagnosing and treating type I laryngeal clefts.

SUMMARY

Endoscopic airway surgery continues to be a popular and effective method of treating the pediatric airway. Technological advances such as in robotics may have an increasing role in the future of endoscopic airway surgery in children. Bioengineered airway adjuncts including biodegradable airway stents look to be promising in the future treatment of airway stenosis.

Treatment of tongue base masses in children by transoral robotic surgery

The feasibility and effectiveness of transoral robotic surgery (TORS) in children with tongue base masses (TBMs) were evaluated. Eight pediatric patients who were treated with TORS for TBMs between January 2010 and January 2016 at a tertiary hospital included in the study. All pathologies were congenital lesions: four were lingual thyroglossal ductus cysts (LTGDCs), one was a minor salivary gland tumor, one was a vallecular cyst, one was a bronchogenic cyst, and one was an ectopic thyroid tissue. TORS was performed successfully in all cases. The mean robotic set-up and exposure time was 13.0 ± 2.1 min (range 10-16 min) and the mean robotic surgery time was 8.8 ± 6.9 min (range 4-25 min). Estimated blood loss was lower than 5 ml for one patient and lower than 50 ml for another one. The remaining patients' estimated blood loss was lower than 10 ml. No patient required tracheostomy intra- or post-operatively. Only one minor complication occurred on day 10 after surgery (minor bleeding), which was resolved without intervention. No major complications or recurrence were observed. Better visualization and small, flexible arms allow surgeons to treat TBM faster and easily using TORS. This leads to decreased morbidity compared to open and transoral endoscopic/microscopic surgical methods. In the future, we believe that TORS may become the gold standard method for the treatment of pediatric TBM with continued development of robotic technology.

Transoral robotic surgery for upper airway pathology in the pediatric population

OBJECTIVES/HYPOTHESIS

The purpose of this study is to present one of the largest case series of pediatric transoral robotic surgery (TORS) in the upper airway demonstrating a wide range of ages and indications.

STUDY DESIGN

A retrospective case series at an academic tertiary referral center from August 2010 to September 2014.

METHODS

The da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) was used on 16 pediatric patients for 18 procedures. A variety of upper airway pathologies and reconstructions in children with a wide range of ages and weights were treated. No lingual tonsillectomies or base-of-tongue reductions were included.

RESULTS

Sixteen children (6 males) underwent 18 TORS procedures, including resection of hamartoma (n = 1), repair of laryngeal cleft (n = 7), removal of saccular cyst (n = 2), release of pharyngeal or esophageal strictures (n = 2), and excision of lymphatic malformations (n = 4). Patient ages ranged from 14 days to 15 years. There were no intraoperative complications. All patients had successful robotic access, and no patients had conversions to open or traditional endoscopic surgery. Hospital courses varied with duration ranging from 1 to 20 days. The median follow up was 22 months.

CONCLUSION

Applying TORS to the pediatric population can be feasible and safe for appropriate airway pathologies. Because many patients are small in size, there is inherent risk in using robotic instruments and scopes transorally. Pearls in this series include a standardized two-robot experienced attending team and longitudinal airway follow-up.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:247-251, 2017.

Laryngotracheoesophageal clefts

Laryngotracheoesophageal clefts are rare congenital anomalies of the aerodigestive tract. Patients may present with airway and/or swallowing impairments. An approach to evaluation and management is presented. Important pearls for conservative and surgical management are discussed. Open versus endoscopic surgical techniques are reviewed.