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Design and Study of a Next-Generation Computer-Assisted System for Transoral Laser Microsurgery.

ABSTRACT: Objective:To present a new computer-assisted system for improved usability, intuitiveness, efficiency, and controllability in transoral laser microsurgery (TLM). Study Design:Pilot technology feasibility study. Setting:A dedicated room with a simulated TLM surgical setup: surgical microscope, surgical laser system, instruments, ex vivo pig larynxes, and computer-assisted system. Subjects and Methods:The computer-assisted laser microsurgery (CALM) system consists of a novel motorized laser micromanipulator and a tablet- and stylus-based control interface. The system setup includes the Leica 2 surgical microscope and the DEKA HiScan Surgical laser system. The system was validated through a first-of-its-kind observational study with 57 international surgeons with varied experience in TLM. The subjects performed real surgical tasks on ex vivo pig larynxes in a simulated TLM scenario. The qualitative aspects were established with a newly devised questionnaire assessing the usability, efficiency, and suitability of the system. Results:The surgeons evaluated the CALM system with an average score of 6.29 (out of 7) in ease of use and ease of learning, while an average score of 5.96 was assigned for controllability and safety. A score of 1.51 indicated reduced workload for the subjects. Of 57 subjects, 41 stated that the CALM system allows better surgical quality than the existing TLM systems. Conclusions:The CALM system augments the usability, controllability, and efficiency in TLM. It enhances the ergonomics and accuracy beyond the current state of the art, potentially improving the surgical safety and quality. The system offers the intraoperative automated scanning of customized long incisions achieving uniform resections at the surgical site.

SUBMITTER: Deshpande N

PROVIDER: S-EPMC6239143 | biostudies-literature | 2018 Apr-Jun

REPOSITORIES: biostudies-literature

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Design and Study of a Next-Generation Computer-Assisted System for Transoral Laser Microsurgery.

Deshpande Nikhil N Peretti Giorgio G Mora Francesco F Guastini Luca L Lee Jinoh J Barresi Giacinto G Caldwell Darwin G DG Mattos Leonardo S LS

OTO open 20180401 2

<h4>Objective</h4>To present a new computer-assisted system for improved usability, intuitiveness, efficiency, and controllability in transoral laser microsurgery (TLM).<h4>Study design</h4>Pilot technology feasibility study.<h4>Setting</h4>A dedicated room with a simulated TLM surgical setup: surgical microscope, surgical laser system, instruments, ex vivo pig larynxes, and computer-assisted system.<h4>Subjects and methods</h4>The computer-assisted laser microsurgery (CALM) system consists of a ...[more]

PMID: 30480214

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Project description:Transoral laser microsurgery (TLM) is an accepted and effective treatment strategy for supraglottic carcinomas. Early supraglottic carcinoma has excellent outcomes independently of the treatment approach. The role of TLM for the treatment of locally advanced tumors is debated. Particularly, the functional outcomes after TLM have to be proven by functional assessment of large cohorts of patients. This study analyzes the oncologic and functional outcomes after TLM for supraglottic carcinomas.Ninety-one patients with pT1-pT4a supraglottic carcinomas treated between January 2002 and December 2012 were analyzed. Distribution of tumors (UICC 2010) was 11 patients with pT1, 31 patients with pT2, 36 patients with pT3, and 13 patients with pT4a tumors. Node status was positive in 40 (43.6%) patients; 61 (67.1%) patients had stage III or IVa disease. Local control and survival were estimated using the Kaplan-Meier method. For the assessment of functional outcomes, the MD Anderson Dysphagia Inventory (MDADI), the Voice Handicap Index-10 (VHI-10), and the performance status scale for head and neck cancer [Performance Status Scale for Head and Neck (PSS-HN)] were used.The median age was 62 years (range, 33-88 years). Fourteen (15.4%) patients developed a local or locoregional recurrence. The 5-year local control rate and 5-year ultimate local control rate were 72 and 92%, respectively. The 5-year overall survival rate was 63%. Twelve (13.2%) patients needed temporary tracheostomy. Sixty-eight (74.0%) patients had a nasogastric feeding tube post-operatively. At 1-year post-operative follow-up, only three patients were PEG dependent. The median VHI-10 score was 35, the median MDADI composite score was 80, and the median score of the domain "normalcy of diet" in the PSS-HN was 91.The oncologic outcomes are comparable to the results of open surgery for early and advanced supraglottic carcinomas. Functional swallowing outcome is superior to open surgery and to concomitant chemoradiation. Patients treated with TLM perceive low levels of voice- and swallowing-related quality of life impairment.

Project description:Laser microsurgery is the current gold standard surgical technique for the treatment of selected diseases in delicate organs such as the larynx. However, the operations require large surgical expertise and dexterity, and face significant limitations imposed by available technology, such as the requirement for direct line of sight to the surgical field, restricted access, and direct manual control of the surgical instruments. To change this status quo, the European project μRALP pioneered research towards a complete redesign of current laser microsurgery systems, focusing on the development of robotic micro-technologies to enable endoscopic operations. This has fostered awareness and interest in this field, which presents a unique set of needs, requirements and constraints, leading to research and technological developments beyond μRALP and its research consortium. This paper reviews the achievements and key contributions of such research, providing an overview of the current state of the art in robot-assisted endoscopic laser microsurgery. The primary target application considered is phonomicrosurgery, which is a representative use case involving highly challenging microsurgical techniques for the treatment of glottic diseases. The paper starts by presenting the motivations and rationale for endoscopic laser microsurgery, which leads to the introduction of robotics as an enabling technology for improved surgical field accessibility, visualization and management. Then, research goals, achievements, and current state of different technologies that can build-up to an effective robotic system for endoscopic laser microsurgery are presented. This includes research in micro-robotic laser steering, flexible robotic endoscopes, augmented imaging, assistive surgeon-robot interfaces, and cognitive surgical systems. Innovations in each of these areas are shown to provide sizable progress towards more precise, safer and higher quality endoscopic laser microsurgeries. Yet, major impact is really expected from the full integration of such individual contributions into a complete clinical surgical robotic system, as illustrated in the end of this paper with a description of preliminary cadaver trials conducted with the integrated μRALP system. Overall, the contribution of this paper lays in outlining the current state of the art and open challenges in the area of robot-assisted endoscopic laser microsurgery, which has important clinical applications even beyond laryngology.

Project description:ImportanceTransoral endoscopic head and neck surgery now plays an important role in the multidisciplinary management of oropharyngeal carcinoma. Previous generations of robotic surgical systems used a multiport system with a rigid stereo-endoscope and 2 wristed instruments that facilitated transoral robotic surgery.ObjectiveTo evaluate a new single-port robotic surgical system in head and neck surgery prospectively through concurrent nonrandomized clinical trials.Design, setting, and participantsTwo prospective clinical trials were conducted from December 16, 2016, to December 26, 2017, to assess the safety, feasibility, and performance of a flexible single-port robotic surgical system in 4 institutions, including 3 in the United States and 1 in Hong Kong. A total of 47 patients with tumors of the oropharynx were enrolled and underwent surgery. All patients were classified as having American Society of Anesthesiologists class I to III status and Eastern Cooperative Oncology Group status 0 to 1. An initial cohort of 7 patients underwent staging and endoscopic procedures for benign disease. The remaining 40 patients all had malignant tumors of the oropharynx.Main outcomes and measuresSafety was measured by the incidence of device-related serious adverse events. Feasibility and performance were measured by the conversion rate from the use of the single-port robotic surgical system to either open surgery or the use of any other transoral technology required to complete the planned procedure. Secondary end points of swallowing function and surgical margins were also measured.ResultsAll 47 patients (8 women and 39 men; mean [SD] age, 61 [8] years) safely underwent transoral resection with the single-port robotic surgical system without conversion to open surgery, laser surgery, or multiport robotic surgery. There were no intraoperative complications or device-related serious adverse events. Mean (SD) estimated intraoperative blood loss per procedure was 15.4 (23.9) mL; no patients received a transfusion. Two patients underwent a planned tracheotomy owing to medical comorbidity (previous chemoradiotherapy; obesity and severe sleep apnea). Two patients (4%) had grade III or IV postoperative hemorrhage, requiring a return to the operating room; however, both patients had medical comorbidities requiring the use of antithrombotic medication. The incidence of positive margins for patients with oropharyngeal malignancy was 3% (1 of 40). Within 30 days, 45 patients (96%) were eating by mouth and without the need for a percutaneous endoscopic gastrostomy tube.Conclusions and relevanceThis study describes the results of phase 2 clinical testing of a next-generation, robotic surgical system using a single-port architecture. The use of the device appears to be feasible, safe, and effective for transoral robotic surgery of oropharyngeal tumors.Trial registrationClinicalTrials.gov identifiers: NCT03010813 and NCT03049280.

Project description:BACKGROUND:The prognostic value of positive surgical margins after transoral laser microsurgery (TOLM) is still under debate. In case of positive superficial margins, some experts recommend a second-look surgery (SL) and some recommend wait and watch approach with close observation. Narrow band imaging (NBI) is an advanced imaging system used to enhance visualization of mucosal vascular pattern. In laryngology, NBI is used to improve the detection of premalignant, dysplastic and malignant lesions. AIM:To assess the usefulness of NBI imaging in guiding clinical decision making regarding follow-up plan and SL after TOLM. MATERIALS AND METHODS:A prospective cohort of 127 patients was divided into three groups based on the histology results and NBI vascular pattern of the mucosa. Group A (24/127, 18.90%) consisted of patients with suspicious vascular pattern in NBI or/and with positive deep margin. Group B (52/127, 40.94%) consisted of patients with positive or uncertain superficial margins and non-suspicious vascular pattern in NBI. Group C (51/127, 40.15%) had non-suspicious vascular NBI pattern and all negative margins. RESULTS:After the first TOLM procedure, 9/24 (37.5%) patients had positive deep margins, 1/24 (4.2%) had uncertain deep margin and 1/24 patient (4.2%) had both positive deep margin and suspicious vascular pattern in NBI. The remaining 13 cases in Group A had a suspicious NBI finding only during the first follow-up. All of the 24 patients (Group A) underwent a second look surgery. The final histology after SL showed squamous cell carcinoma in 10/24 (41.7%) patients. All 10 patients had suspicious vascular pattern in NBI and one patient had both a positive deep margins after the first TOLM and positive NBI finding. None of Group B and C subjects developed an early recurrence. CONCLUSIONS:Our study provides evidence that NBI imaging will be a useful adjunct to margin status after TOLM and will facilitate clinical decision-making regarding performing the SL in patients with positive or uncertain superficial surgical margins in the first TOLM procedure. However, additional investigation with more subjects is required at this time to further validate this technique and change the standard of care.

Dataset Information

Design and Study of a Next-Generation Computer-Assisted System for Transoral Laser Microsurgery.

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Design and Study of a Next-Generation Computer-Assisted System for Transoral Laser Microsurgery.

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