2017 Sec 1 Green Book

as well as residents and fellows, have access to a robotic simula- tor and are at the console with simulation prior to participating in robotic surgery cases in general. However, the surgeons did not practice on a robot simulator for each patient immediately prior to surgery. Two experienced robot-credentialed attending surgeons alternated positions between the robot console (i.e., the robotic surgeon) and the bedside (i.e., the bedside surgeon), as needed. A bedside surgeon participated in every case, utilizing a variety of standard laryngeal and pharyngeal surgical instruments including suction and cautery (Fig. 2). In addition, the bedside surgeon had the critical role of protecting the patient and main- taining the airway during the procedure. RESULTS Sixteen children (6 males) underwent 18 TORS pro- cedures including resection of hamartoma (base of tongue) (n 5 1), repair of laryngeal cleft (n 5 7) (Fig. 3), removal of saccular cyst (n 5 2), release of pharyngeal or esophageal strictures (n 5 2), and excision of lym- phatic malformations in the base of tongue (n 5 1) or hypopharynx/supraglottis (n 5 3) (Table I). Of the patients with lymphatic malformations, two patients received subsequent TORS procedures. Patients with lin- gual tonsillectomies or tongue base reductions were not included. The median follow-up from surgery was 22 months (range, 56 days to 44 months). At the time of surgery, the median age of children was 4 years old (range, 14 days to 15 years). The median weight was 18.4 kg (range, 2.5 kg to 93.7 kg). The youngest patient was 14 days old and weighed 3.7 kg. The smallest patient was 26 days old and weighed 2.5 kg. Both had saccular cysts and successfully underwent robotic-assisted removal of these lesions (Fig. 4). The median operating room (OR) elapsed time (time from patient entering the OR room to exiting the OR room, including time of anesthesia care and robot setup) was 3 hours, 17 minutes (range: 2 hours, 27 minutes to 5 hours, 37 minutes). The median surgery elapsed time (time for surgical procedure including laryngoscopy and bronchoscopy) was 2 hours and 24 minutes (range: 1 hour, 3 minutes to 4 hours, 38 minutes). The median setup time (patient release from anesthesia team to time out) was 8 minutes. The docking time, that is, the time used to position the robot, could not be determined or calculated from the retrospective review of the data.

Fig. 1. Positioning of the robot and the patient. [Color figure can be viewed in the online issue, which is available at www.laryngo- scope.com.]

The operating room setup was similar to adult patients. All patients were placed in the supine position with the table top 180 degrees from the normal position; that is, the patient’s head was placed at the foot of the bed. This allows for place- ment of the robot to be placed underneath the table and closer to the patient after rotating the bed (Fig. 1). The patients were induced by pediatric anesthesiologists, the airway was topically anesthetized with lidocaine, and the operating table was then rotated 90 degrees away from the anesthesiologist’s field to deliver the patients toward the surgeon. The operating table is rotated a total of 90 degrees. Direct laryngoscopy and bronchoscopy were performed prior to each procedure under the same anesthetic. When patients had existing tracheostomy tubes, these were replaced with laser-safe Jackson tracheostomy tubes for the duration of the procedure. In patients without tracheostomies, an appropri- ate laser-safe endotracheal tube (i.e., cuffless Mallinckrodt laser oral endotracheal tube, Magill tip; Covidien plc, Dublin, Ire- land) was sized and placed when feasible. A tooth guard was individually created and placed when teeth were present utilizing Aquaplast (Medline, Mundelein, IL). A variety of mouth gags were available for selecting appro- priate fit. We found that a McIvor gag with a flat blade pro- duced the best exposure of the posterior larynx for laryngeal cleft repair in most patients. A tongue stitch was utilized for retraction when a mouth gag was not necessary. The articulating robotic arms were positioned intraorally with camera, typically utilizing a 30-degree anterior facing scope for hypopharyngeal and laryngeal pathology and a 0- degree scope for tongue base pathology. In all cases, 5-mm working ports and instruments were used. There were two attending surgeons that were robot- credentialed during these cases. There is an internal hospital pathway for robotic surgery credentialing. Attending surgeons,

Fig. 2. The bedside surgeon utilizes standard laryngeal and pha- ryngeal surgical instruments, as well as having the critical role of protecting the patient and the airway. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

Zdanski et al.: TORS in Pediatric Population

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