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How To: Exoscopic Transoral Supraglottic Laryngectomy

by Alberto Deganello, MD, PhD, Tommaso Gualtieri, MD, Gabriele Testa, MD, Vittorio Rampinelli, MD, PhD, Giulia Berretti, MD, Alberto Paderno, MD, PhD, and Cesare Piazza, MD •

INTRODUCTION

A substantial turning point in the surgical management of laryngeal squamous cell carcinomas (SCC) was the introduction of carbon dioxide transoral laser microsurgery (CO2 TOLMS), which involves the use of an operating microscope that provides an excellent magnified view of the surgical field.

Recently, the refinement of exoscopic systems has provided the head and neck surgeon with a new magnification tool, potentially competing with the operative microscope in various procedures, from microvascular free flap anastomosis to transoral surgery. In particular, coupling between a 4K-3D exoscopic system and CO2 laser micromanipulator when performing transoral laser laryngeal surgery seems to be noninferior to the operative microscope in terms of surgical time, resection radicality, and precision, with some advantages in terms of intuitivism, maneuverability, ergonomics, and ease of alignment. In this setting, the surgeon is in close contact with the laryngoscope inlet, looking at the surgical field in a 3D high-definition screen, without bulky instruments obstructing the space of maneuver, and without the need to keep the head constantly in contact with the microscope eyepieces. This subjectively improves the surgeon’s comfort and ergonomics, favoring bimanual tissue manipulation while maintaining an optimal magnified stereoscopic visualization of the larynx. Moreover, using 3D glasses, the surgeon’s assistant(s), as well as all the operatory room staff, can easily follow the entire procedure with the same surgical field of view as the first operator. This improves the possibility for assistants to help during some crucial parts of the procedure. The significant magnification capability (up to 15× zoom) is particularly useful to approach supraglottic, glottic, and subglottic regions, keeping optimal illumination even at high depth of field. Furthermore, during magnification, it is possible to digitally move the field of view using a separate control joystick, without the need to physically move and adjust the exoscope. On the other hand, the robotic arm (ARTip cruise robotic system, Karl Storz, Tuttlingen, Germany), on which the exoscope is mounted in the most recent version of the VITOM 3D, makes it possible for the surgeon to easily modify the observant’s perspective using a dedicated joystick (IMAGE1 PILOT, Karl Storz, Tuttlingen, Germany).

To date, no clinical video report has been published regarding the application of CO2 transoral laser exoscopic surgery (TOLES) for the treatment of laryngeal SCC. In this case video, the authors sought to point out the feasibility and strengths of this technology in transoral surgery.

METHODS

In this case video (scan the QR code for the full article and video), the authors sought to highlight the feasibility and strengths of transoral exoscopic laser resection for the treatment of supraglottic laryngeal carcinoma. The exoscopic visualization guaranteed a bright and wide view of the surgical field during the entire procedure, simplifying the zooming process during the most challenging steps. In this setting, the surgeon is in close contact with the laryngoscope inlet, looking at the surgical field in a 3D high-definition screen, without bulky instruments obstructing the space of maneuver.

The patient who underwent this procedure signed an informed consent to publication through Wiley standard form.

RESULTS

Figure 1. Operative theatre setup during TOLES, with the position of the surgeon and his team (letters) and the TOLES tools (numbers). (A) surgeon; (B) assistant surgeon; (C) scrub nurse; (D) anesthesiologist; (E) patient; 1, ARTip Cruise robotic arm; 2, VITOM 3D-HD Exoscope coupled to the laser micromanipulator; 3, VITOM IMAGINE1 PILOT; 4, suspension system with Zeitels Suspension Gallows (Endocraft LLC, Boston, Mass.) and DEDO laryngoscope (Karl Storz, Tuttlingen, Germany); 5, 3D monitor. TOLES = transoral laser exoscopic surgery.

We proposed the employment of CO2 TOLES as an alternative to CO2 TOLMS in the treatment of supraglottic cancer located in the supra-hyoid portion of the epiglottis and extended to the infra-hyoid epiglottis and to the left aryepiglottic fold (cT2N0). Endoscopic results, evaluated during follow-up (the latest control has been performed two years after surgery), showed excellent healing of the surgical field without any macroscopic evidence of residual disease. Laryngeal phonatory and swallowing functions were completely preserved.

In our experience, CO2 TOLES proved feasible for early intermediate laryngeal SCC and represents a valuable alternative to TOLMS. The 3D visualization helped the surgeon and assistant to dominate the tumor at 360° and achieve en bloc removal within free resection margins and with optimal post-operative results. Moreover, CO2 TOLES provides a didactic gain, with the subjective benefits of ergonomics and optimal intra-operative visualization being well perceived throughout the entire surgical procedure (Fig 1).