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masses, and cysts. The generalizability of this series is
novel in that it lies outside of the range of most of the
published literature that includes lingual tonsillectomies
and tongue-base reductions. It also demonstrates safety
and feasibility in a wide range of patient ages and
weights, including the carefully selected neonates (a 2.5-
kg 26 day old and a 3.7-kg 10 day old). Because of the
wide range of procedure types and pathologies
addressed, a significant trend of decreased operative or
surgical time is not to be expected.
Our reported complications are within the expected
complications for similar traditional
transoral
approaches in children with significant airway, respira-
tory, and comorbid pathologies. It is difficult to draw
strict comparison of open or traditional transoral proce-
dures in all cases because many of the cases do not have
appropriate counterpart comparative procedures or data.
The complications seen in this series, although not
directly from robotic instrumentation or surgery, could
be the result of prolonged mouth gag suspension times,
more extensive tissue manipulation, or tissue effects of
noncompliant armored endotracheal tubes. However, the
advantages of wristed instrument control, three-
dimensional visualization, and more precise surgery
were affirmed in our qualitative experience in this
series. For example, we believe that use of the robot
allowed more sutures to be placed in small spaces; more
precise control of the laser; and in some cases, multi-
layer closure with greater exposure than we typically
experience in standard endoscopic procedures.
We believe there are several critical elements for
success in this case series. First, we had a team with
two robotic surgery experienced attending surgeons. Sec-
ondly, the experienced bedside surgeon facilitated
patient safety, surgical access, and robotic surgeon. We
also selected older, bigger children with relatively
assessable pathology before attempting more challenging
cases in younger, smaller children. We excluded patients
with malignancy and vascular tumors (other than lym-
phangioma). We were also prepared to convert to tradi-
tional surgical methods if the procedure could not be
safely and effectively addressed with the robot. With
experience, we learned the importance of carefully
selecting the appropriate endotracheal tube for the
patient, resting the tongue (e.g., release from prolonged
retraction), and consideration for overnight intubation in
long surgical cases. We believe that surgeons can also
decrease operative time with more experience.
These data help solidify our understanding of key
challenges and future development of TORS for pediatric
airway surgery: 1) securing the airway with the appro-
priate laser-safe endotracheal or tracheostomy tubes; 2)
identifying the appropriate exposure; 3) obtaining surgi-
cal access with the robotic arms allowing for unre-
stricted mobility; 4) the critical role of the bedside
surgeon in protecting the airway and the patient in
addition to assisting the robotic surgeon. As the technol-
ogy continues to advance with smaller instruments,
arms, and optics, the initial challenges lessen and the
potential applications widen. Because all of the surgical
instruments adapted for use in pediatric TORS airway
surgery were designed for general and urologic surgical
applications, it is essential for the future innovation and
advancement of pediatric robotic airway surgery to have
specialized airway instrumentation. As safety concerns
diminish and indications are being developed, critical
assessment of the future clinical value pediatric TORS
for airway surgery should be assessed.
10
CONCLUSION
Transoral robotic surgery can be safe and feasible,
even in very small neonates. A wide array of pathologies
and sites, including the hypopharynx, larynx, and proxi-
mal trachea, can be successfully addressed. Whereas the
diversity of procedures presented limits robust compari-
son to traditional procedures, this study demonstrates
advancements in application, feasibility, and safety.
Future advancements in technology, smaller instru-
ments, specialized instruments, and airway-specific
optics can help broaden robotic applications.
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