2017 Sec 1 Green Book

Fig. 3. Laryngeal cleft repair. (A) Palpation of the laryngeal cleft prior to repair; (B) close-up intraoperative view of the laryngeal cleft closure during repair; (C) intraoperative view of the luminal side of laryngeal cleft after repair. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

central apneas, and 2 hypopneas). The patient was not treated surgically for the sleep-disordered breathing. The patient underwent a TORS-assisted laryngeal cleft repair and removal of supraglottic tissue using CO2 laser with FlexGuide ULTRA conduit (Omniguide, Lex- ington, MA). The patient had no intraoperative compli- cations, but required immediate reintubation in the operating room at the end of the case due to copious secretions. The patient was extubated successfully in the PICU and discharged home on postoperative day 5. The second patient was a 12-year-old girl who had a history of caustic ingestion and resultant pharyngeal, supraglottic, and esophageal strictures (patient 12). The patient had an existent tracheostomy tube in place and underwent multiple previous procedures addressing strictures at the oral aperture, hypopharynx, and esoph- agus. The patient underwent a TORS approach that included pharyngectomy, supraglottic laryngectomy, and base-of-tongue release. The surgical wound site was allowed to heal by granulation. The patient had no intraoperative complications but had poor tidal volumes after surgery. Despite perioperative antibiotics, the

There were no intraoperative complications. The overall TORS completion rate was 100%. No procedures were converted to open or traditional endoscopic surgery. Estimated blood loss ranged from 0 to 25 mL. The majority of patients had high-grade American Society of Anesthesiologists (ASA) classification: ASA I (n 5 2), ASA 2 (n 5 1), ASA 3 (n 5 7), and ASA 4 (n 5 6) (Table I). The reason many patients in this series had a high-grade ASA classification is related to their com- plex medical conditions, but ASA grade was not a crite- rion for eligibility. Three of 16 patients had a tracheostomy tube in place prior to the operative case. None of the patients required a new tracheostomy intra- operatively or postoperatively. Five patients were kept intubated after the procedure and were observed in the pediatric intensive care unit (PICU) (1–4 days) for pro- tection of the airway. There were three postoperative complications. The first patient was a 5-year old girl, ASA 3, who had a type 1 laryngeal cleft and sleep-disordered breathing (patient 8). On polysomnogram, the patient had an apnea-hypopnea index of 0.3 (no obstructive apneas, 2

TABLE I. Patient Characteristics.

Patient

Gender

Weight (kg)

ASA

Indication

1 2 3 4 5 6 7 8 9

F F F

23.7

4 3 3 1 4 3 3 4 1 3 4 3 3 2 4

Supraglottic lymphatic malformation

44 10 30

Hypopharyngeal and supraglottic lymphatic malformation

Type I laryngeal cleft

M M M

Pharyngeal and esophageal stricture

3.7

4E

Saccular cyst

13.1 10.8 29.4 27.6 52.5 34.2 2.5

Type II laryngeal cleft Type I laryngeal cleft Type I laryngeal cleft

F F

M

Saccular cyst

10 11 12 13 14 15 16

F F F

Base of tongue hamartoma

Hypopharyngeal lymphatic malformation Pharyngeal and esophageal stricture

M M

8

Type III laryngeal cleft Type II laryngeal cleft

7.03

F F

93.7 11.2

Base of tongue lymphatic malformation

Type I laryngeal cleft

ASA 5 American Society of Anesthesiologists; F 5 female; M 5 male.

Zdanski et al.: TORS in Pediatric Population

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