FRCA Notes

Trans-Oral Robotic Surgery

This topic is included in light of a fairly recent BJA education article on the topic (see below) and because the inclusion of a CRQ on robotic (general) surgery in September 2022 has opened Pandora's robotic box.

Resources

  • Trans-oral robotic surgery (TORS) is used for treating both benign and neoplastic conditions of the head and neck in a minimally invasive fashion, most commonly:
    • Lateral oropharyngectomy
    • Tongue base hemiglossectomy
    • Supraglottic laryngectomy
    • Tongue base mucosectomy

  • It benefits from reducing the need for trans-facial or trans-mandibular surgical approaches and their associated morbidity
  • Furthermore it facilitates greater surgical precision, more delicate tissue handling, greater access and greater instrument flexibility
  • Conversely, it adds complexity to an already complex, sharing-the-airway surgical cohort

Advantages Disadvantages
↓ blood loss (& thus transfusion req'ment) Cost (initial + ongoing)
↓ Post-operative pain (& thus opioid req'ment) Extra training
↓ LOS Time delay to undock in case of complication
↓ Need for tracheostomy Loss of surgical tactile feedback
Improved cosmetic outcome & QoL Bulky equipment needs extra storage space
Faster recovery of safe swallowing and normal speech Any patient movement can have disastrous consequences
Shorter duration of surgery Potential ethical issues training surgeons on unwitting patients
↓Post-operative wound infections
↓VTE
Less NG/PEG feeding required
↓ Requirements for neoadjuvant chemo-/radio-therapy


  • TORS is being used for a variable and growing list of head and neck surgeries
  • There are some contraindications, however, such as:
    • Trismus or other limitations to mouth opening
    • Limited (or total lack of) neck extension e.g. due to spinal pathology, previous radiotherapy
    • Macroglossia
    • Lesions infiltrating bone e.g. mandible or maxilla
    • Lesions involving the carotid artery
    • Large lymph nodes not suitable for TORS (even if primary cancer is)
    • Lack of suitable equipment and staff

Perioperative management of the patient undergoing TORS


  • Pre-operative assessment follows a similar pattern for the patient with the same pathology undergoing non-robotic surgery e.g. those with head and neck cancer

Airway assessment and planning

  • Meticulous airway assessment as a difficult airway is likely in view of:
    • Supra-, sub- or glottic lesion(s)
    • Previous airway surgery
    • Head/neck chemo-/radio-therapy
  • It should take the form of a clinical assessment and review of imaging including FNE, panendoscopy and cross-sectional imaging
  • Existing dentition should be carefully documented owing to the risk of dental damage
  • Airway plans should be clearly communicated in advance between anaesthetic and surgical teams
  • Difficult intubation increases the risk of conversion from TORS to an open procedure as a result of poor surgical access

Monitoring

  • AAGBI as standard
  • Cannulae in the arm contralateral to the robot
  • ± A-line
  • ± CVC (femoral)
  • Depth of anaesthesia monitoring, certainly if TIVA technique
  • Long breathing circuit
  • ± NG tube for enteral feeding post-operatively

Induction

  • Induction in theatre may be preferable to limit transfers and issues associated with them
  • Surgeons should be present during induction/extubation with tracheostomy equipment available in case of complications
  • Airway choice should be discussed with surgeon, e.g.:
    • Armoured tube
    • Nasal North-facing RAE
    • LASER tube
  • Ensure the tube is inserted deep enough so as not to be dislodged when the head is extended during surgical positioning and when the surgical instruments are being placed
  • Ensure cuff properly inflated (20 - 30cmH2O) to reduce aspiration of debris/blood from surgery

Maintenance

  • TIVA or volatile + remi is suitable; TIVA benefits from uncoupling the airway from the mode of anaesthesia
  • Remifentanil comes with the standard benefits associated with head and neck surgery
  • Clonidine, IV lidocaine and magnesium can be used to further blunt the hypertensive responses to airway manipulation e.g. gag or instrument insertion
  • Full, qToF-guided (tibial nerve) neuromuscular blockade throughout is recommended to optimise surgical conditions and minimise risk of disastrous patient movement
  • Aim FiO2 <0.3 if LASER surgery

Positioning

  • Meticulous eye protection and padding inc. goggles
  • Ensure pressure points protected and arms properly wrapped
  • Ensure properly positioned as once robot is docked there should be no movement of, and limited access to, patient

Homeostatic bundle

  • Temperature control/warming
  • Mechanical VTE prophylaxis
  • Multi-modal anti-emetic prophylaxis including dexamethasone
  • Judicious use of fluids to avoid airway oedema

Extubation

  • Careful extubation
  • Avoid Guedel airways as bite blocks as may damage tissue and cause bleeding
  • Follow (enhanced recovery) post-operative plan

Analgesia

  • Often less sore than open surgical counterparts
  • Multi-modal analgesia with:
    • Regular simple analgesics
    • PRN short-acting opioid e.g. fentanyl in PCA or patch form
    • Consider opioid-sparing agents inc. gabapentinoids
    • Post-operative dexamethasone has anti-emetic and analgesic properties whilst improving swallowing and reducing length of stay
    • Enteral analgesia should be liquid owing to high risk of dysphagia; SALT input invariably required

Post-operative bleeding

  • Significant bleeding occurs in up to 9.8%
  • Most common on day 10 post-operatively
  • Mostly self-limiting, minor, venous bleeding
  • Can be catastrophic due to arterial erosion or vasodilation
  • More likely if higher-grade tumour, recurrent disease or larger resection
  • Mortality via aspiration and asphyxiation

  • Minor bleeding e.g. blood in saliva occurs in up to 27%

Airway and respiratory

  • Airway oedema e.g. larynx, uvular, face
  • Tongue oedema (14%)
  • Airway obstruction of any cause (9%)
  • Airway infection (2-3%)
  • Aspiration ± LRTI (up to 15%)
  • Need for tracheostomy (up to 5% in complex cases)
  • Sore throat (common, severe in up to 10%)
  • Altered phonation (4%)

Neurological

  • Pain
  • Hypoglossal nerve injury (1%)
  • Lingual nerve injury (1-3%)
  • Ocular injury

Gastrointestinal

  • Pharyngo-cutaneous fistula formation
  • Dehydration
  • Dysphagia and long-term (>6 months) PEG dependency
  • Dysgeusia
  • Nasopharyngeal reflux
  • Velopharyngeal insufficiently

MSK

  • Skin lacerations
  • Dental damage (1-2%)
  • Mucosal lacerations
  • Bony injury inc. mandible, C-spine
  • Neck pain (severe in 1%)