Head-and-neck surgeons at the University of Maryland Medical Center are now using the da Vinci surgical robot to remove hard-to-reach cancers of the throat, tongue and tonsils in a minimally invasive way. It is called “transoral robotic surgery,” and doctors are able to access the tumor site through the mouth without having to make a large incision. They say the technique significantly reduces patients’ recovery time, helps to preserve their ability to speak and swallow normally and produces fewer complications.
“Using the da Vinci robot gives us unprecedented access to the back of the throat with really good 3-D visualization – it’s like you’re standing on the patient’s tongue. We’re now able to perform intricate surgeries in a very small space with great dexterity,” says Jeffrey S. Wolf, M.D., a head-and-neck surgeon at the medical center and associate professor of otorhinolaryngology-head and neck surgery at the University of Maryland School of Medicine.
The da Vinci surgical robot system is commonly used to treat gynecologic and prostate cancers as well as to perform heart bypass and other cardiac surgeries. The U.S. Food and Drug Administration recently approved its use to treat certain head-and-neck cancers.
Dr. Wolf and Duane A. Sewell, M.D., a head-and-neck surgeon and an associate professor of otorhinolaryngology-head and neck surgery at the University of Maryland School of Medicine who was instrumental in starting the transoral robotic surgery program, have performed four of these robotic surgeries for head-and-neck cancer since June.
According to Dr. Wolf, patients who may benefit the most from robotic surgery are those with cancers at the base of the tongue or of the soft palate and tonsils who experience a recurrence after being treated with chemotherapy and radiation. He says the procedure also may be used for early-stage primary cancers that have not spread.
In a traditional “open” surgery, doctors would make a large incision and split the patient’s jaw, which would require performing a tracheotomy to alleviate breathing problems caused by swelling and may also require extensive reconstruction. Typically, the patient would remain in the hospital for more than a week. With the robotic surgery, surgeons don’t need to cut bones for access, and patients can leave the hospital in two to three days.
“Patients get out of the hospital much sooner, and preliminary data indicate that they swallow better and have fewer problems with speech after surgery,” Dr. Wolf says. After traditional surgery, it can take months for patients to regain their ability to swallow normally.
During the procedure, the surgeon operates the robot while sitting at a console in the operating room. Binocular cameras provide three-dimensional images magnified 10 times greater than what can be seen by the human eye, and the surgeon has great flexibility to move the robotic arms in different directions with sophisticated hand controls. The arms have tiny tools attached to them, including a laser and cauterizing device that can be used to remove the cancer.
E. Albert Reece, M.D., Ph.D., M.B.A., vice president of medical affairs at the University of Maryland and dean of the School of Medicine, says, “This new technique using the surgical robot offers patients with certain head-and-neck cancers an effective, minimally invasive treatment option that spares them from having to undergo an ‘open’ surgical procedure. Our faculty members are always looking for new ways to minimize possible side effects for patients.”
Cancers of the base of the tongue, throat and tonsils (the oropharynx) are often difficult to treat with surgery because of their location. Many of these cancers are caused by infection with the human papillomavirus (HPV), a sexually transmitted virus. Other risk factors are smoking and chewing tobacco and heavy alcohol use. The most common symptoms are pain, a lump in the neck and difficulty in swallowing. Patients are treated with chemotherapy, radiation and surgery, or a combination of these therapies.
“We know that people whose cancers are HPV-positive respond much better to chemotherapy and radiation than those who are HPV-negative,” Dr. Wolf notes, adding that the exact reason for this is unclear. “About 20 percent of patients with advanced disease who are HPV-positive have a recurrence or metastasis of their cancer while the recurrence rate for advanced non-HPV-related cancers is much higher – 60 percent to 80 percent.”
Dr. Wolf says he doesn’t expect surgery with the da Vinci robot to replace chemotherapy and radiation as a first-line treatment option for many patients with advanced disease, but it is an excellent option for some. “It’s revolutionary in that it gives us unprecedented access to the oropharanx,” he says. Dr. Wolf adds that head-and-neck surgeons at the medical center also plan to use the da Vinci robot to treat thyroid cancer in the near future.
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