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Robotic surgery a paradigm shift for head and neck cancers
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Patients may have a better quality of life after robotic surgery compared with conventional surgery or treatment with chemotherapy and radiation, according to physicians at the University of Pennsylvania.
Earlier this year, the FDA approved a minimally invasive surgical procedure for use in treating head and neck tumors, both malignant and benign. Without the persistence of otorhinolaryngologists at the University of Pennsylvania, this procedure may not have made it this far.
Robotic surgery began evolving in the area of prostate surgery. With the advent of this system, other specialties became interested in whether or not the procedure had potential. It found a place in cardiac surgery, GYN surgery and gastrointestinal surgery. In 2004, it began to infiltrate into head and neck surgery.
In November 2004, Bert W. O’Malley, Jr. MD, co-founder of the TransOral Robotic Surgery (TORS) program at the University of Pennsylvania, attended a symposium at the American Academy of Otolaryngology, where scientists had concluded that robotic surgery for head and neck cancer was impossible. But O’Malley, now the Gabriel Tucker Professor of Otorhinolaryngology at Penn, refused to accept that.
“I had seen an early prototype of robotic surgery when I was at Johns Hopkins around 1995, and it was interesting, but not ready for practice,” O’Malley said. “When I went to this symposium, 10 years later, it opened my eyes to the potential of using this procedure for head and neck cancers.”
O’Malley, along with Gregory S. Weinstein, MD, also a co-founder of TORS, began to approach TORS as a scientific experiment, using the da Vinci Surgical System that was already part of Penn. They decided to develop the procedure themselves before concluding it was not feasible.
Innovative surgeries
Approximately 50,000 people in the United States develop head and neck cancer each year, O’Malley said. Treatment for these cancers usually involves a combination of surgery, radiation therapy and chemotherapy. Surgery usually offers the greatest chance at a cure.
However, conventional surgery is an extremely invasive procedure that requires making a large incision up the neck, splitting the lip and splitting the jaw bone to remove a tumor at the back of the throat. Then, tissue is borrowed from the arm or thigh to repair the area. Patients require the placement of a tube to breathe and a feeding tube.
“This is a 14-hour procedure that requires a 7- to 10-day stay in the hospital, and leaves the patient disfigured,” O’Malley said. “If they didn’t have surgery, then they had primary chemotherapy and radiation at such high levels that they had swallowing problems and dependence on feeding tubes. Either way, the procedures left the patients dysfunctional and with a poor quality of life.”
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Photo courtesy of the University of Pennsylvania Department of Otorhinolaryngology–Head and Neck Surgery |
O’Malley and Weinstein initiated a prospective research plan to look at the potential of robotic surgery for the treatment of head and neck tumors. First, it was tested in mannequins, then they moved on to cadavers, and then live animal procedures. Finally, they initiated human trials. This all took place from November 2004 to May 2005. Since 2005, approximately 410 patients have participated in the first prospective clinical trial of TORS.
Remote surgery
The minimally invasive TORS accesses the surgical site through the mouth. The surgeon performs the procedure remotely at a console, viewing the operating field on a high definition, three-dimensional video screen. Using handheld manipulators, the surgeon can access the limited space of the back of the mouth and throat using miniaturized surgical instruments, such as forceps, elecrocautery and lasers. With TORS, surgeons can overcome some of the limitations of traditional surgery and even a previously developed minimally invasive procedure called transoral laser microsurgery.
Unlike traditional surgery, TORS improves long-term swallowing function, reduces the risk of infection, reduces blood loss and morbidity, and speeds recovery time. After the cancers are removed, patients regain swallowing function sooner and can leave the hospital earlier.
The approval of TORS came down from the FDA in January 2010. Drs. O’Malley and Weinstein are training surgeons from all over the world on the TORS system.
“This procedure represents a paradigm shift in the way we treat patients with head and neck cancers,” O’Malley said. – by Emily Shafer