2017 Sec 1 Green Book

Reprinted by permission of Laryngoscope. 2017; 127(1):247-251.

The Laryngoscope V C 2016 The American Laryngological, Rhinological and Otological Society, Inc.

Transoral Robotic Surgery for Upper Airway Pathology in the Pediatric Population

Carlton J. Zdanski, MD; Grace K. Austin, MD; Jonathan M. Walsh, MD; Amelia F. Drake, MD; Austin S. Rose, MD; Trevor G. Hackman, MD; Adam M. Zanation, MD

Objectives/Hypothesis: The purpose of this study is to present one of the largest case series of pediatric transoral robotic surgery (TORS) in the upper airway demonstrating a wide range of ages and indications. Study Design: A retrospective case series at an academic tertiary referral center from August 2010 to September 2014. Methods: The da Vinci surgical robot (Intuitive Surgical, Inc., Sunnyvale, CA) was used on 16 pediatric patients for 18 procedures. A variety of upper airway pathologies and reconstructions in children with a wide range of ages and weights were treated. No lingual tonsillectomies or base-of-tongue reductions were included. Results: Sixteen children (6 males) underwent 18 TORS procedures, including resection of hamartoma (n 5 1), repair of laryngeal cleft (n 5 7), removal of saccular cyst (n 5 2), release of pharyngeal or esophageal strictures (n 5 2), and exci- sion of lymphatic malformations (n 5 4). Patient ages ranged from 14 days to 15 years. There were no intraoperative compli- cations. All patients had successful robotic access, and no patients had conversions to open or traditional endoscopic surgery. Hospital courses varied with duration ranging from 1 to 20 days. The median follow up was 22 months. Conclusion: Applying TORS to the pediatric population can be feasible and safe for appropriate airway pathologies. Because many patients are small in size, there is inherent risk in using robotic instruments and scopes transorally. Pearls in this series include a standardized two-robot experienced attending team and longitudinal airway follow-up. Key Words: Laryngeal cleft, saccular cyst, lymphatic malformation, pediatric airway, transoral robotic surgery (TORS). Level of Evidence: IV. Laryngoscope , 00:000–000, 2016

INTRODUCTION Transoral robotic surgery (TORS) for use in the pediatric airway is a recent application of this technol- ogy. Within a few years of descriptions of TORS in adults for head and neck surgery, animal studies investigating the feasibility of pediatric applications were published. 1 It was first described in human pediatric patients by Rahbar et al. with a case series of five patients in 2007. 2 Since that time, there have been seven case reports and case series presented in the literature; the largest describes 16 patients who underwent lingual tonsillec- tomy. 3–9 The role of TORS in the pediatric airway is still evolving. As the technology and tools advance, the indi- cations and applications of TORS in the pediatric airway From the Department of Otolaryngology/Head and Neck Surgery, University of North Carolina Hospitals ( C . J . Z ., G . K . A ., A . F . D ., A . S . R ., T . G . H ., A . M . Z .), Chapel Hill, North Carolina; and the Department of Otolaryngol- ogy/Head and Neck Surgery, Johns Hopkins University ( J . M . W .), Balti- more, Maryland, U.S.A. Editor’s Note: This Manuscript was accepted for publication April 25, 2016. This work was supported by a grant for the National Institute on Deafness and other Communicative Disorders, T32DC005360 (G.K.A.). The authors have no funding, financial relationships, or conflicts of interest to disclose. Send correspondence to Carlton J. Zdanski, MD, Associate Profes- sor, Department of Otolaryngology/Head and Neck Surgery, University of North Carolina, 170 Manning Drive, CB 7070, Physician’s Office Building, Room G-190, Chapel Hill, NC 27599-7070. E-mail: carlton_zdanski@med.unc.edu

are being developed. We present one of the largest case series of pediatric TORS, detailing our experience with a wide range of patient ages and pathologic processes. The purpose of this report is to illustrate the potential and feasibility of TORS in the pediatric airway and complex reconstructions. MATERIALS AND METHODS The da Vinci surgical robot (Intuitive Surgical, Inc., Sun- nyvale, CA) was used on 16 pediatric patients for 18 procedures at the University of North Carolina, Chapel Hill, North Caro- lina, from August 2010 to September 2014. Patients with pha- ryngeal and laryngeal pathology requiring either endoscopic or open surgical treatment were offered TORS as an alternative treatment option. For vascular malformations, this was limited to lymphangiomas for this series. Arteriovenous malformations, venous malformations, and other vascular tumors were excluded from consideration. The da Vinci surgical robot has been U.S. Food and Drug Administration-approved for resection of T1 and T2 oropharyn- geal cancers. We applied robotic technology for off-label use in pediatric airway procedures. Patients and families were offered traditional approaches and were also informed of the off-label application of TORS. All consent forms clearly stated that the robot would be utilized. The procedures were also preauthorized for insurance coverage. There are special considerations of the pediatric proce- dures. Because many patients are small in size, there is inher- ent higher risk in introducing and manipulating robotic instruments and scopes transorally compared to adult patients.

DOI: 10.1002/lary.26101

Zdanski et al.: TORS in Pediatric Population

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