![Show Menu](styles/mobile-menu.png)
![Page Background](./../common/page-substrates/page0044.jpg)
patient developed pneumonia and septic shock posto-
peratively that required broad-spectrum antibiotics and
vasopressors. The patient underwent emergent bron-
choscopy on postoperative day 2 for respiratory distress
and copious secretions. The patient was found to have
worsening right middle-lobe consolidation. By postopera-
tive day 7, the patient was successfully weaned to tra-
cheostomy collar and discharged home on postoperative
day 8.
The third patient was a 3-year-old girl, ASA 4, with
DiGeorge syndrome and subglottic stenosis who under-
went repair of type 1 laryngeal cleft and excision of
redundant glottic tissue (patient 16). The patient was
kept intubated postoperatively but failed extubation
under steroid coverage on postoperative day 3. The
patient was successfully extubated on postoperative day
6. The patient’s total hospital stay was 11 days.
The hospital duration for pediatric patients ranged
from 1 to 20 days. The longest hospital stay was the 14-
day-old patient, ASA 4E, with a right saccular laryngeal
cyst who underwent TORS-assisted excision of the sacc-
ular cyst (patient 5). The patient was kept intubated
after surgery, extubated on postoperative day 3, and
received 5 days of perioperative steroids. Although the
patient’s procedure and hospital course were uncompli-
cated, the patient was monitored in the neonatal inten-
sive care unit predominantly until per oral feeding
status could be assured.
Three of the 16 patients had previous traditional
surgical approaches prior to TORS. This includes a 2-
year-old patient with a type 2 laryngeal cleft and redun-
dant supraglottic tissue who has required no further
surgery after subsequent successful TORS repair
(patient 6); a 12-year-old patient with lymphangioma
involving the left hypopharynx and tongue base who has
undergone one additional TORS procedure (patient 11);
and a 12-year-old patient with history of caustic inges-
tion with resultant pharyngeal, supraglottic, and esoph-
ageal strictures who has required multiple endoscopic
procedures for dilation (patient 12).
To date, two of three patients who had a preexisting
tracheostomy tube were successfully decannulated fol-
lowing their TORS procedure, with only the patient with
a history of caustic ingestion and multiple levels of aero-
digestive scarring remaining tracheostomy dependent.
DISCUSSION
Since Rahbar et al. first published the robotic-
assisted repair of laryngeal clefts in pediatric patients,
the technology and its applications have been advancing
rapidly.
2
When analyzing robotic surgery in general, fac-
tors such as capital expense, instrument size, haptic
feedback loss, docking time, operative time, simulation
and training, complications, operative cost, and patient
outcomes are a few considerations which have been eval-
uated.
10
Following the current debate regarding adult
TORS, these same concerns regarding feasibility, teach-
ability, safety, efficacy, and outcomes will need to be
addressed for pediatric TORS.
11
Many early reports have appropriately focused on
safety, feasibility, operative time, and docking time.
3,5,6,8
Pediatric TORS is a clear example of early development
and exploration phases of surgical innovation in both its
application in the pediatric airway and description in
the literature.
12–16
In attempts to have more evidence-
based innovation, adopting the IDEAL model, as
described by McCulloch, is helpful and recommended.
12
The IDEAL model is a descriptive model of surgical tech-
nique delineating the stages of Innovation, Development,
Exploration, Assessment, and Long-term study. The
model includes descriptive guidance on the types of
expected studies in each stage, as well as the clinical
and scientific goals to be accomplished in each stage.
Our case series adds to the literature in several
ways. In representing one of the largest case series, it
nearly doubles the number of cases presented in the lit-
erature to date. A wide range of pathologies was success-
fully and safely addressed, including hypopharyngeal
and laryngeal lymphatic malformations, laryngeal clefts,
saccular cysts, pharyngeal strictures, tongue base
Fig. 4. Saccular cyst excision. (A) Visualization of the saccular cyst prior to excision; (B) intraoperative view after excision of saccular cyst.
[Color figure can be viewed in the online issue, which is available at
www.laryngoscope.com.]
Zdanski et al.: TORS in Pediatric Population
22