2017 Sec 1 Green Book

Fig. 4. Saccular cyst excision. (A) Visualization of the saccular cyst prior to excision; (B) intraoperative view after excision of saccular cyst. [Color figure can be viewed in the online issue, which is available at www.laryngoscope.com.]

patient developed pneumonia and septic shock posto- peratively that required broad-spectrum antibiotics and vasopressors. The patient underwent emergent bron- choscopy on postoperative day 2 for respiratory distress and copious secretions. The patient was found to have worsening right middle-lobe consolidation. By postopera- tive day 7, the patient was successfully weaned to tra- cheostomy collar and discharged home on postoperative day 8. The third patient was a 3-year-old girl, ASA 4, with DiGeorge syndrome and subglottic stenosis who under- went repair of type 1 laryngeal cleft and excision of redundant glottic tissue (patient 16). The patient was kept intubated postoperatively but failed extubation under steroid coverage on postoperative day 3. The patient was successfully extubated on postoperative day 6. The patient’s total hospital stay was 11 days. The hospital duration for pediatric patients ranged from 1 to 20 days. The longest hospital stay was the 14- day-old patient, ASA 4E, with a right saccular laryngeal cyst who underwent TORS-assisted excision of the sacc- ular cyst (patient 5). The patient was kept intubated after surgery, extubated on postoperative day 3, and received 5 days of perioperative steroids. Although the patient’s procedure and hospital course were uncompli- cated, the patient was monitored in the neonatal inten- sive care unit predominantly until per oral feeding status could be assured. Three of the 16 patients had previous traditional surgical approaches prior to TORS. This includes a 2- year-old patient with a type 2 laryngeal cleft and redun- dant supraglottic tissue who has required no further surgery after subsequent successful TORS repair (patient 6); a 12-year-old patient with lymphangioma involving the left hypopharynx and tongue base who has undergone one additional TORS procedure (patient 11); and a 12-year-old patient with history of caustic inges- tion with resultant pharyngeal, supraglottic, and esoph- ageal strictures who has required multiple endoscopic procedures for dilation (patient 12).

To date, two of three patients who had a preexisting tracheostomy tube were successfully decannulated fol- lowing their TORS procedure, with only the patient with a history of caustic ingestion and multiple levels of aero- digestive scarring remaining tracheostomy dependent. DISCUSSION Since Rahbar et al. first published the robotic- assisted repair of laryngeal clefts in pediatric patients, the technology and its applications have been advancing rapidly. 2 When analyzing robotic surgery in general, fac- tors such as capital expense, instrument size, haptic feedback loss, docking time, operative time, simulation and training, complications, operative cost, and patient outcomes are a few considerations which have been eval- uated. 10 Following the current debate regarding adult TORS, these same concerns regarding feasibility, teach- ability, safety, efficacy, and outcomes will need to be addressed for pediatric TORS. 11 Many early reports have appropriately focused on safety, feasibility, operative time, and docking time. 3,5,6,8 Pediatric TORS is a clear example of early development and exploration phases of surgical innovation in both its application in the pediatric airway and description in the literature. 12–16 In attempts to have more evidence- based innovation, adopting the IDEAL model, as described by McCulloch, is helpful and recommended. 12 The IDEAL model is a descriptive model of surgical tech- nique delineating the stages of Innovation, Development, Exploration, Assessment, and Long-term study. The model includes descriptive guidance on the types of expected studies in each stage, as well as the clinical and scientific goals to be accomplished in each stage. Our case series adds to the literature in several ways. In representing one of the largest case series, it nearly doubles the number of cases presented in the lit- erature to date. A wide range of pathologies was success- fully and safely addressed, including hypopharyngeal and laryngeal lymphatic malformations, laryngeal clefts, saccular cysts, pharyngeal strictures, tongue base

Zdanski et al.: TORS in Pediatric Population

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