A Look at Transoral Robotic Surgery with Synchronous Neck Dissection

What is the incidence of pharyngocutaneous fistula associated with transoral robotic oropharyngectomy with concurrent neck dissection, and how can pharyngocutaneous fistula be prevented and treated?

Background: Transoral resection is emerging as a valuable modality to treat oropharyngeal squamous cell carcinoma. The surgical treatment frequently involves neck dissection, but many surgeons have been reluctant to perform the dissection at the time of primary tumor resection due to the potential of patients developing pharyngocutaneous fistula.

Study design: Retrospective review of single-institution patients.

Setting: Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minn.

Synopsis: A review of 148 patients with oropharyngeal carcinoma who underwent transoral robotic surgery with concomitant neck dissection included 42 patients (29 percent) who were identified intraoperatively as having an iatrogenic orocervical communication. Only six of these went on to develop a postoperative fistula. The authors described their surgical procedure and discussed fistulas that developed. No patients without an intraoperative communication went on to develop a postoperative fistula. Five of the patients who did had T2 tumors and one a T1 primary. Five of the patients had a tonsillar primary and one had a tongue base primary with extension to the tonsillar fossa. Fistulas developed in four patients who underwent cautery surgery and two patients with laser surgery. No other independent variable aside from tumor involving the tonsillar fossa could be associated with eventual fistula occurrence. Defects greater than 1 cm underwent suction drain placement and were then closed when feasible, reinforced with muscular coverage and bathed with Tisseel. Patients with defects greater than 1 cm underwent nasogastric feeding tube placement and were made NPO [nothing by mouth] for 24 to 48 hours. Intravenous antimicrobial coverage was initiated with either cefazolin/metronidazole or clindamycin.

Bottom line: Transoral robotic surgery with simultaneous neck dissection is safe and efficient for select patients with oropharyngeal malignancies.

Citation: Moore EJ, Olsen KD, Martin EJ. Concurrent neck dissection and transoral robotic surgery. Laryngoscope. 2011;121(3):541-544.

—Reviewed by Sue Pondrom