11/7/2014 Disclosure TORS & Supraglottic Laryngectomy TORS & Supraglottic Laryngectomy Dr. Walvekar, I have the following relationship(s) with commercial interests. Hood Laboratories – Rec. Royalties Cook Industries – Rec. Honoraria Medtronic – Rec. Honoraria RELATIONSHIP (Consultant) A commercial interest is any entity Rohan R Walvekar, MD Rohan R Walvekar, MD producing, marketing, re-selling, or Associate Professor Associate Professor distributing health care goods or services Department of Otolaryngology Head & Neck Surgery Department of Otolaryngology Head & Neck Surgery consumed by, or used on, patients. LSU Health Sciences Center, New Orleans LSU Health Sciences Center, New Orleans Access! The da Vinci Surgical System The da Vinci Surgical System Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870 1
11/7/2014 The Robotic Bedside Cart The Robotic Bedside Cart The Operating Room Setup The Operating Room Setup Otorhinolaryngology: Head and Neck Surgery at PENN Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870 Excellence in Patient Care, Education and Research since 1870 Feyh-Kastenbauer (FK) retractor OR FK-WO retractor 2
11/7/2014 Surgeon at Robotic Console Surgeon at Robotic Console Robotic Console Controls Robotic Console Controls Otorhinolaryngology: Head and Neck Surgery at PENN Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870 Excellence in Patient Care, Education and Research since 1870 “ as if the surgeon ’ s hands are miniaturized and working “ as if the surgeon ’ s hands are miniaturized and working in the mouth ” in the mouth ” TORS Base of Tongue Resection Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870 3
11/7/2014 Traditional Non-Robotic Transoral Surgery TORS - Advantages • Optics provide a three dimensional image • Can sometimes be awkward technically • Ability to magnify image from a distance to optimize • Tips of robotic instruments are “ wristed ” so • Microscopic optics are outside the oral cavity working space • Transoral laser offers a line of sight beam that cannot turn robotic instruments with “ tremor filtration ” corners surgeons hand movements are scaled down to the • Challenges of TLM are limited working space requiring multiple types of retractors to get exposure • This makes the experience similar to the feel of • Compartment surgery open surgical • Assistants can visualize and a participate more actively in the surgical experience. • Disadvantages: Lack of haptic feedback Value of TORS for the Patient: Value of TORS for the Patient: Efficacy / Invasiveness 2 Efficacy / Invasiveness 2 Indications • T1 T2 lesions of the oropharynx – T ongue base • TORS Open • – T onsil – Lat pharyngeal wall Surgery • Benign and malignant lesions of the oral cavity • Chemoradiation – Pathologic tonsils – Obstructive sleep apnea • Supraglottic and hypopharyngeal tumors • Robotic thyroid surgery • Para-pharyngeal space tumors • TORS Submandibular Stones and Ranula* - LSU Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870 4
11/7/2014 • Early stage SGL cancer – TLM comparable to Open Surgery • Late stage SGL cancer - concurrent CRT • In general, surgical modalities preferred for SGL tumors; pre-epiglottic space involvement • Robotic SGL feasible and safe • Robotic surgery could overcome some of the technical limitations of TLM • Potential advantages improved visualization and access Head Neck 2012 • 13 patients • Majority T2 tumors (8/13) • Negative margins in 100 % • Actual cost structure of Open – TLM and TOR SGL and TL • Tracheostomy and PEG dependence 1/13 • 17 primary activities to which direct cost related were identified • Adjuvant Radiation 2/13 • One-way sensitivity analysis on patient throughput, cost of equipment or op • Tumor sub-sites times was performed • Epiglottis • AE fold • TORS is more expensive than standard approaches; cost driven mainly by purchase, maintenance and use of proprietary instruments • This was true even when case loads were doubled per year, used shortest operative times. • TORS cost influenced by equipment Head Neck 2013 – Ohio State University Eur Arch Otorhinolaryngol (2014) 271:2825-2834 5
11/7/2014 In conclusion Future – defined by technology.. � TORS for Supraglottic tumors is feasible and oncologically sound � Success is dependent on patient selection and working within limits of surgeon expertise � Surgeons with experience in TLM would be better equipped to make the transition to TORS SGL surgery � Open, TLM and TORS approaches are all feasible, TLM and TORS Total Laryngectomy TORS have faster recovery and better functional outcomes Smith RV et al. � Factors impacting future applications of robotic surgery.. Otolaryngol Clin N Am 47 (2014) 379–395 � Cost of Equipment and Training � T echnology Thank You rwalve@lsuhsc.edu /412-251-8887 6
11/7/2014 we are not under water anymore! 7
11/7/2014 Thank You Questions?? 8
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