Treatment of tongue base masses in children by transoral robotic surgery

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.

Excision of tongue base lesions in children: The frenuloplasty mini-rake technique

OBJECTIVES

We developed a new approach of exposing the tongue base using frenuloplasty and mini-rakes (FMR) to resect lesions directly with microbipolar cautery. The purpose of this study is to review the patients who underwent this procedure at our center.

METHODS

A medical chart review was conducted from January 2011 to June 2023 looking for children under 18 years of age who had a base of tongue lesion resected using the FMR technique. Age at time of surgery, lesion type, intubation, number of days until eating, and length of hospital stay were recorded.

RESULTS

We identified 16 patients who underwent excision of a tongue base lesion using the FMR technique. The median (IQR) age was 1.9 (0.9-7.9) years. The diagnosis on pathology of the lesions were 13 lingual thyroglossal duct cysts, 1 lingual thyroid goiter, 1 dermoid cyst and 1 vallecular cyst excised. Nine (57 %) patients were extubated immediately after the procedure on the operating table, 6 (38 %) were extubated on the first postoperative day, and 1 (6 %) was extubated on the second postoperative day. The median (IQR) number of days until starting a normal oral diet was 1.0 (0-1.0) and the median (IQR) length of hospital stay was 2.5 (1.8-3.3) days. There were no complications from this technique.

CONCLUSION

Excision of tongue base lesions is feasible in children using the FMR technique. This may obviate the need for suspension microlaryngoscopy and laser resection and decrease risks associated with that technique.

The Role of TORS in the Management of Benign Pathology of the Base of Tongue: A Systematic Review

OBJECTIVE

Transoral robotic surgery (TORS) is becoming increasingly popular in head and neck surgery. Its applications have expanded beyond oncologic indications to obstructive sleep apnea syndrome (OSAS) and, more recently, to benign pathologies.

DATA SOURCES

A systematic search for articles published in the PubMed and Google Scholar databases between January 2003 and December 2023 was performed using the following combined search query (robot OR sleep OR apnea OR syndrome) AND (robot OR tongue OR base).

REVIEW METHODS

Given the limited literature, we conducted a systematic review focusing on the outcomes of TORS for benign pathologies of the base of the tongue. Our search methodology followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

We found 16 articles that met our inclusion criteria. These were mainly case reports and a few case series.

CONCLUSIONS

Compared to other transoral techniques, TORS offers better exposure, visualization, and access to the oropharynx, especially the base of the tongue, even in benign pathology. TORS should be considered a feasible, safe, and effective technique. Several more studies are needed to effectively evaluate the role of TORS in benign pathology that does not correlate with OSAS.

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

Adverse Events and Morbidity in a Multidisciplinary Pediatric Robotic Surgery Program. A prospective, Observational Study

OBJECTIVE

To report one-year morbidity of robotic-assisted laparoscopic surgery (RALS) in a dedicated, multidisciplinary, pediatric robotic surgery program. Summary Background Data. RALS in pediatric surgery is expanding, but data on morbidity in children is limited.

METHODS

All children who underwent RALS (Da Vinci Xi, Intuitive Surgical, USA) were prospectively included (October 2016 to May 2020; follow-up ≥1 year). Analyzed data: patient characteristics, surgical indication/procedure, intraoperative adverse events (ClassIntra classification), blood transfusion, hospital stay, postoperative complications (Clavien-Dindo).

RESULTS

Three hundred consecutive surgeries were included: urology/gynecology (n=105), digestive surgery (n=83), oncology (n=66), ENT surgery (n=28), thoracic surgery (n=18). Median age and weight at surgery were 9.5 [interquartile range (IQR)=8.8] years and 31 [IQR=29.3] kg, respectively. Over one year, 65 (22%) children presented with ≥1 complication, with Clavien-Dindo ≥III in 14/300 (5%) children at ≤30 days, 7/300 (2%) at 30-90 days, and 12/300 (4%) at >90 days. Perioperative transfusion was necessary in 15 (5%) children, mostly oncological (n=8). Eight (3%) robotic malfunctions were noted, one leading to conversion (laparotomy). Overall conversion rate was 4%. ASA ≥3, weight ≤15 kg, and surgical oncology did not significantly increase the conversion rate, complications, or intraoperative adverse events (ClassIntra ≥2). ASA score was significantly higher in children with complications (Clavien-Dindo ≥III) than without (p=0.01). Median hospital stay was 2 [IQR=3] days. Three children died after a median follow-up of 20 [IQR=16] months.

CONCLUSIONS

RALS is safe, even in the most vulnerable children with a wide scope of indications, age, and weight. Robot-specific complications or malfunctions are scarce.

Paediatric robotic surgery: a narrative review

The benefits of minimally invasive surgery (MIS) compared with traditional open surgery, including reduced postoperative pain and a reduced length of stay, are well recognised. A significant barrier for MIS in paediatric populations has been the technical challenge posed by laparoscopic surgery in small working spaces, where rigid instruments and restrictive working angles act as barriers to safe dissection. Thus, open surgery remains commonplace in paediatrics, particularly for complex major surgery and for surgical oncology. Robotic surgical platforms have been designed to overcome the limitations of laparoscopic surgery by offering a stable 3-dimensional view, improved ergonomics and greater range of motion. Such advantages may be particularly beneficial in paediatric surgery by empowering the surgeon to perform MIS in the smaller working spaces found in children, particularly in cases that may demand intracorporeal suturing and anastomosis. However, some reservations have been raised regarding the utilisation of robotic platforms in children, including elevated cost, an increased operative time and a lack of dedicated paediatric equipment. This article aims to review the current role of robotics within the field of paediatric surgery.

Endoscopic management of intralingual thyroglossal duct cysts: Case series and systematic review

OBJECTIVE

To discuss our institutional experience with endoscopic management of intralingual thyroglossal duct cyst (TGDC) and review cases in the published literature in a systematic review.

METHODS

Pediatric patients with intralingual TGDC treated with endoscopic surgery at our institution from 2009-2019 were identified. Metrics from our case series were then compared to those in the literature in a systematic review to assess pooled outcomes of endoscopic or transoral management. Patient demographics, age of presentation, presenting symptomatology, size of cyst on imaging, type of surgery, and post-operative outcomes were assessed.

RESULTS

We identified 5 institutional cases of intralingual TGDC and 48 cases of intralingual TGDC described in the literature. The average age of presentation was 20.36 months. 69.8% (N=37) of patients presented with at least one respiratory symptom, 22.6% (N=12) presented with dysphagia, 9.4% (N=5) presented with an identified mass in the oropharynx, and 15.1% (N=8) had the cyst discovered as an incidental finding. Three patients required revision surgeries due to prior incomplete TGDC excisions and one patient experienced a recurrence >6 months after primary excision requiring a second procedure. Our data pooled with published case series in systematic review confirms that endoscopic or transoral management are excellent options for definitive management of intralingual TGDC.

CONCLUSIONS

Intralingual TDGC is a potentially life-threatening variant of TGDC. Our results pooled with published series in a systematic review suggest that endoscopic or transoral management of intralingual TGDC are excellent minimally invasive treatments with a low risk of recurrence. Postoperative surveillance up to one year is recommended.

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.

Robotic-Assisted Minimally Invasive Surgery in Children

Currently, minimally invasive surgery (MIS) includes conventional laparo-thoracoscopic surgery and robot-assisted surgery (RAS) or robotic surgery. Robotic surgery is performed with robotic devices, for example the Da Vinci system from Intuitive Surgical, which has a miniaturized camera capable of image magnification, a three-dimensional image of the surgical field, and the instruments are articulated with 7 degrees of freedom of movement, and the surgeon operates in a sitting position at a surgical console near the patient. Robotic surgery has gained an enormous surge in use on adults, but it has been slowly accepted for children, although it offers important advantages in complex surgeries. The areas of application of robotic surgery in the pediatric population include urological, general surgery, thoracic, oncological, and otorhinolaryngology, the largest application has been in urological surgery. There is evidence that robotic surgery in children is safe and it is important to offer its benefits. Intraoperative complications are rare, and the frequency of postoperative complications ranges from 0–15%. Recommendations for the implementation of a pediatric robotic surgery program are included. The future will be fascinating with upcoming advancements in robotic surgical systems, the use of artificial intelligence, and digital surgery.

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.

Is Transoral Robotic Surgery the Best Surgical Treatment for Lingual Thyroid?: A Case-Report and Literature Review

OBJECTIVES

To highlight the specific outcomes of the current surgical procedures for lingual thyroid excision, for benign and malignant lesions.

METHODS

We carried out a systematic review of surgical treatments of lingual thyroid, according to the PRISMA method. We conducted our literature search in PubMed and Ovid. Data was collected concerning patient demographics, tumor characteristics, types of surgery performed, and specific intra- and postoperative outcomes of each procedure. Surgical procedures were classified in 4 categories: transcervical approaches, "invasive" transoral approaches (transmandibular and/or tongue splitting), "non-invasive" transoral approaches, and transoral robotic surgery. We detailed the transoral robotic surgical technique through a case report, along with a surgical video.

RESULTS

Of 373 peer-reviewed articles found, 40 provided adequate information on surgical management and outcomes for patients with lingual thyroid. "Non-invasive" transoral approaches and transoral robotic surgeries required significantly fewer tracheostomies than "invasive" transoral and transcervical approaches (P < .001), while there was no statistical difference in the rate of surgical complications between each procedure.

CONCLUSIONS

Transoral robotic surgery appears to be a feasible, effective, and fast solution for lingual thyroid excision, with excellent short- and long-term surgical outcomes.

Minimally invasive procedure for diagnosis and treatment of vallecular cysts in children: review of 156 cases

PURPOSE

Vallecular cyst is an uncommon but potentially life-threatening disease. The aim of this study was to review the presentation, evaluation, and treatment of vallecular cysts in children.

METHODS

Medical records of 156 patients treated for vallecular cysts between 2013 and 2016 were retrospectively reviewed. The patients were divided into four age groups for comparison of clinical data: A, < 1 month; B, 1-6 months; C, 7-12 months; and D, > 1 year.

RESULTS

The median age of all patients (98 males and 58 females) was 12.1 months (range 1 day-11 years), including 21, 86, 21, and 28 patients in group A, B, C, and D, respectively. A diagnosis of vallecular cysts was made for 135 patients using a combination of flexible laryngoscopy and ultrasound, and ten patients (all in group A) required pre-surgery ventilation support. The most common symptoms were wheezing (59.6%) and stridor (36.5%). Ten patients experienced difficulty with intubation. Endoscopic-assisted transoral coblation marsupialization was performed for all patients, combined with supraglottoplasty for 41 out of 68 patients with concurrent laryngomalacia. Patients in group D had a longer operation time and higher incidence of intraoperative bleeding, two of whom experienced post-operation recurrence, and symptoms resolved after a second operation in both cases.

CONCLUSIONS

Flexible laryngoscopy and ultrasound are recommended for a diagnosis in suspected cases of vallecular cysts. Coblation marsupialization has advantages of minor damage, low recurrence rate, and suitability for all age groups.

Robotic Surgery in Head and Neck in Pediatric Population: Our Experience

Robot assisted surgery of the head and neck is a relatively novel approach in the management of head and neck tumors. There are very few reported cases of robot-assisted surgery of the head and neck in pediatric population in the world literature and no report of such procedures in the Indian subcontinent. In this article we present three such cases we performed for the first time in the country. The first case is that of second branchial cleft cyst, the second is a 4-year-old boy with a tongue base cyst and the third patient is a 12-year-old girl with left parotid gland tumor. All the patients underwent successful Robotic surgeries. Case 1 underwent robotic excision of the cyst through a retroauricular hairline incision. Case 2 underwent transoral robotic excision of the tongue base cyst. Case 3 underwent robotic excision of the tumor through a modified facelift incision. The mean docking time for the robot was 12.33 min and approximate blood loss was less than 10 ml in all cases. The patient and their parents were extremely satisfied with the cosmetic outcomes of the scarless surgery. Robot assisted surgery has the advantage of performing minimally invasive procedures within constrained spaces especially in children. The multiarticulated endowrist movements of the robotic arms combined with higher magnification and three-dimensional depth perception allows a precise surgery with better visualization in otherwise inaccessible areas resulting in better surgical outcome. With exceptional advantages of scarless surgery, minimal blood loss and postoperative pain and better surgeon ergonomics, robotic technique is an effective and feasible option in Pediatric Head and neck Surgery.

Totally robotic soave pull-through procedure for Hirschsprung's disease: lessons learned from 11 consecutive pediatric patients

INTRODUCTION

Since Hirschsprung's disease (HSCR) already proved to benefit from robotic surgery, we aimed at describing a wider series of patients with this rare disease who were operated on with a robotic approach.

PATIENTS AND METHODS

All consecutive HSCR patients who underwent totally robotic soave pull-through (TRSPT), between October 2015 and June 2019, have been included. Ethical Committee approval was obtained. Data regarding clinical features, technical details, complications, hospital stay, and functional outcome have been prospectively collected for each patient.

RESULTS

Eleven patients have been included. Mean age at surgery was 29 months. Median length of surgery was 420 min. Median console time was 180 min. Six patients suffered from rectosigmoid aganglionosis, three from long HSCR (extending up to the hepatic flexure), two from total colonic aganglionosis. No major intraoperative complications occurred. Four patients (three of whom carrying a stoma) experienced minor mucosal tearing during dissection. One anastomotic stricture required dilatation under general anesthesia and two cuff strictures required cuff release (both occurring in patients who experienced intraoperative mucosal tearing). Follow-up lasted a median of 12 months. One patient experienced mild postoperative enterocolitis. Continence scored excellent-to-good in all patients who could be assessed on that regard (7 out of 11).

CONCLUSIONS

Provided a number of technical key points are respected, the outcome of TRSPT for HSCR is promising. Younger patients, particularly those carrying a stoma, proved to be technically demanding and deserve a longer learning curve. Accurate preoperative bowel preparation, correct trocar placement and patient positioning proved to be crucial aspects of treatment. To conclude, TRSPT is particularly suitable for older HSCR patients, even those requiring a redo, and represents a valid alternative to available surgical option for this delicate subgroup of HSCR patients.