2017 Sec 1 Green Book

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The operating room setup was similar to adult patients.
All patients were placed in the supine position with the table
top 180 degrees from the normal position; that is, the patient’s
head was placed at the foot of the bed. This allows for place-
ment of the robot to be placed underneath the table and closer
to the patient after rotating the bed (Fig. 1). The patients were
induced by pediatric anesthesiologists, the airway was topically
anesthetized with lidocaine, and the operating table was then
rotated 90 degrees away from the anesthesiologist’s field to
deliver the patients toward the surgeon. The operating table is
rotated a total of 90 degrees.
Direct laryngoscopy and bronchoscopy were performed
prior to each procedure under the same anesthetic. When
patients had existing tracheostomy tubes, these were replaced
with laser-safe Jackson tracheostomy tubes for the duration of
the procedure. In patients without tracheostomies, an appropri-
ate laser-safe endotracheal tube (i.e., cuffless Mallinckrodt laser
oral endotracheal tube, Magill tip; Covidien plc, Dublin, Ire-
land) was sized and placed when feasible.
A tooth guard was individually created and placed when
teeth were present utilizing Aquaplast (Medline, Mundelein,
IL). A variety of mouth gags were available for selecting appro-
priate fit. We found that a McIvor gag with a flat blade pro-
duced the best exposure of the posterior larynx for laryngeal
cleft repair in most patients. A tongue stitch was utilized for
retraction when a mouth gag was not necessary.
The articulating robotic arms were positioned intraorally
with camera, typically utilizing a 30-degree anterior facing
scope for hypopharyngeal and laryngeal pathology and a 0-
degree scope for tongue base pathology. In all cases, 5-mm
working ports and instruments were used.
There were two attending surgeons that were robot-
credentialed during these cases. There is an internal hospital
pathway for robotic surgery credentialing. Attending surgeons,
as well as residents and fellows, have access to a robotic simula-
tor and are at the console with simulation prior to participating
in robotic surgery cases in general. However, the surgeons did
not practice on a robot simulator for each patient immediately
prior to surgery.
Two experienced robot-credentialed attending surgeons
alternated positions between the robot console (i.e., the robotic
surgeon) and the bedside (i.e., the bedside surgeon), as needed.
A bedside surgeon participated in every case, utilizing a variety
of standard laryngeal and pharyngeal surgical instruments
including suction and cautery (Fig. 2). In addition, the bedside
surgeon had the critical role of protecting the patient and main-
taining the airway during the procedure.
RESULTS
Sixteen children (6 males) underwent 18 TORS pro-
cedures including resection of hamartoma (base of
tongue) (n 5 1), repair of laryngeal cleft (n 5 7) (Fig. 3),
removal of saccular cyst (n 5 2), release of pharyngeal
or esophageal strictures (n 5 2), and excision of lym-
phatic malformations in the base of tongue (n 5 1) or
hypopharynx/supraglottis (n 5 3) (Table I). Of the
patients with lymphatic malformations, two patients
received subsequent TORS procedures. Patients with lin-
gual tonsillectomies or tongue base reductions were not
included. The median follow-up from surgery was 22
months (range, 56 days to 44 months).
At the time of surgery, the median age of children
was 4 years old (range, 14 days to 15 years). The median
weight was 18.4 kg (range, 2.5 kg to 93.7 kg). The
youngest patient was 14 days old and weighed 3.7 kg.
The smallest patient was 26 days old and weighed 2.5
kg. Both had saccular cysts and successfully underwent
robotic-assisted removal of these lesions (Fig. 4).
The median operating room (OR) elapsed time (time
from patient entering the OR room to exiting the OR
room, including time of anesthesia care and robot setup)
was 3 hours, 17 minutes (range: 2 hours, 27 minutes to
5 hours, 37 minutes). The median surgery elapsed time
(time for surgical procedure including laryngoscopy and
bronchoscopy) was 2 hours and 24 minutes (range: 1
hour, 3 minutes to 4 hours, 38 minutes). The median
setup time (patient release from anesthesia team to time
out) was 8 minutes. The docking time, that is, the time
used to position the robot, could not be determined or
calculated from the retrospective review of the data.
Fig. 1. Positioning of the robot and the patient. [Color figure can
be viewed in the online issue, which is available at www.laryngo-
]
Fig. 2. The bedside surgeon utilizes standard laryngeal and pha-
ryngeal surgical instruments, as well as having the critical role of
protecting the patient and the airway. [Color figure can be viewed
in the online issue, which is available at .]
Zdanski et al.: TORS in Pediatric Population
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