Lay Summary:
We present for the first time in the literature a description of a
successful transoral robotic surgical (TORS) resection of an esophageal
lipoma. The authors aimed to report on the feasibility of TORS cervical
esophageal surgery.
Introduction: Transoral robotic surgery (TORS) is a common,
minimally invasive surgical approach to treat benign and malignant head
and neck pathology. The ability to expose and operate on pharyngeal
pathology robotically has often mitigated the need for open, more morbid
approaches. Development in the field of surgical robotics has expanded
the geography of head and neck pathology that is routinely accessible,
particularly since the evolution of the da Vinci single-port (SP)
robotic system (Intuitive Surgical). A recent study, for example, found
that robotic surgical resection, versus transoral laser microsurgical
resection, of T1/T2 hypopharyngeal cancer was associated with improved
overall survival in the setting of a significantly lower rate of
positive surgical margins. This was theorized to be related to dynamic
tumor visualization and improved surgical ergonomics.1In spite of this emerging data, robotic surgery in the hypopharynx and
cervical esophagus (TORS-HE), is considered less frequently than in the
oropharynx. We present for the first time in the extant literature a
TORS resection of a post-cricoid and cervical esophageal lipoma. The
authors of this study aimed to report on the feasibility of cervical
esophageal transoral robotic surgery, so that surgeons might more
frequently consider the approach among patients with permitting anatomy
and pathology.
Report of a Case: We present a 74-year-old male who initially
arrived in the head and neck surgery clinic with dysphagia to solid
foodstuff, the sensation of food-sticking, and imaging demonstrating a
large upper esophageal lipoma. He previously underwent a debulking
procedure via rigid esophagoscopy with temporary improvement in his
symptoms approximately 2 years prior to his contemporary presentation;
pathology demonstrated a benign lipoma. A pre-operative barium
esophagram demonstrated mild hypopharyngeal stasis and evidence of lower
esophageal sphincter (LES) dysfunction. Computed tomography (Figure
1A/B/C) demonstrated a large fatty mass extending from the level of the
cricoid cranially into the cervical esophagus caudally (2.4 x 2.6 x 3.8
cm), with distal esophageal dilatation. The mass was well-circumscribed,
without calcifications or evidence of transmural infiltration. In-office
flexible laryngopharyngoscopy revealed mobile arytenoids, a clear
hypopharynx without retained secretions, and bulging of the post-cricoid
mucosa with submucosal nodularity. Given that his primary complaint was
food-sticking in his throat, we elected to proceed initially with
management of the lipoma. He was counseled regarding the option of a
standard transoral, microscopic approach to the lipoma using a
pharyngoscope, but was given the alternative option of a transoral
robotic approach using the daVinci single-port (SP) robot (Intuitive
Surgical) and Olympus Feyh–Kastenbauer (FK-WO) transoral retractor
system. The authors hypothesized that a robotic exposure might improve
visualization using the fully-articulating SP endoscope, and optimize
both the proximal and the distal working space, unrestricted by the
confines of a tubular scope.
Description of Surgery: The patient underwent general
endotracheal anesthesia with a 6-0 reinforced, laser-safe endotracheal
tube. He was placed into suspension with a curved tongue blade with the
distal tip situated posterior to the larynx using the Olympus FK-WO
retractor system. With the larynx suspended anteriorly, the lipoma was
readily apparent. The da Vinci SP robot was brought into dock, and the
procedure began with a carbon dioxide-laser assisted incision. A
flexible laser fiber fit with a red rubber catheter was passed through
the facet engaged with the Maryland retractor. A ~2.5 cm
incision in the post-cricoid mucosa was made with the laser, and fatty
lobules of the lipoma immediately became apparent. A combination of
blunt dissection and bipolar cautery was performed, separating lipoma
from the adjacent cricopharyngeal muscle fibers and post-cricoid and
proximal esophageal mucosa. (Figure 2A) All three robotic arms were
deployed, wherein one Maryland bipolar forceps was used to retract
mass/mucosa, and two other instruments were used to perform the
dissection. (Figure 2B) Most of the fatty mass was confluent and removed
en bloc. (Figure 3) A hemostatic agent was placed in the wound bed, and
the vertical mucosal defect closed using 3-0 barbed Monocryl suture in
simple running fashion. (Figure 2C) A post-operative day 1 barium
esophagram demonstrated an integral closure with no extraluminal
leakage. He resumed a regular diet with no precautions and reported
improvement in his dysphagia on post-operative follow-up.
Discussion: We describe for the first time in the literature a
TORS resection of a cervical esophageal mass. Although upper esophageal
lipomas are a relatively rare clinical entity (0.4% of all benign
gastrointestinal lesions, with vast majority of esophageal lipomas
[88.6%] manifesting as intraluminal stalked lesions), the authors
of this study primarily aimed to establish the feasibility of transoral
robotic cervical esophageal surgery with the report of this
case.2
A common concern with TORS is exposure. Cervical lordosis and prior
history of radiotherapy have been identified specifically as predictors
of difficult hypopharyngeal exposure for transoral robotic
surgery3, though any characteristic complicating the
displacement of oropharyngeal soft tissues (e.g. large tongue, narrow
mandible, compliance of the upper neck soft tissue, mandibular tori) or
the placement of robotic instrumentation (e.g. narrow interincisal
distance) should be considered prior to TORS-HE.4However, these same anatomic constraints apply to standard transoral
endoscopic techniques using a laryngoscope or
pharyngoscope.5
Contrarily, TORS-HE offers unique technical advantages when operating in
the post-cricoid and upper esophageal region. Using the da Vinci SP
system, the authors were able to use three robotic instruments through a
single cannula, permitting dynamic retraction of the adjacent, redundant
post-cricoid mucosa with one instrument, and bimanual dissection of the
lipoma with the others. The capability of distal, instrumented
retraction and the critical advantage of a flexible endoscope (unique to
the SP system), help the surgeon overcome the technical challenges of
static transoral exposure. The ability to engage three surgical
instruments while maintaining a wide-field, stereoscopic view of the
post-cricoid/cervical esophageal region trans orally is an important
technical advantage of robotic, versus the standard, transoral
microscopic, exposure.
Conclusion: TORS-HE should be considered a safe and effective
surgical option for cervical esophageal pathology. The da Vinci SP
system, allowing for distal instrumented retraction, dynamic
visualization with a flexible endoscope, and surgical maneuvering
unrestricted by the confines of a tubular scope, constitutes a
significant technical advantage in transoral hypopharyngeal and cervical
esophageal surgery.