2017 Sec 1 Green Book

ogy continues to advance with smaller instruments, arms, and optics, the initial challenges lessen and the potential applications widen. Because all of the surgical instruments adapted for use in pediatric TORS airway surgery were designed for general and urologic surgical applications, it is essential for the future innovation and advancement of pediatric robotic airway surgery to have specialized airway instrumentation. As safety concerns diminish and indications are being developed, critical assessment of the future clinical value pediatric TORS for airway surgery should be assessed. 10 CONCLUSION Transoral robotic surgery can be safe and feasible, even in very small neonates. A wide array of pathologies and sites, including the hypopharynx, larynx, and proxi- mal trachea, can be successfully addressed. Whereas the diversity of procedures presented limits robust compari- son to traditional procedures, this study demonstrates advancements in application, feasibility, and safety. Future advancements in technology, smaller instru- ments, specialized instruments, and airway-specific optics can help broaden robotic applications. BIBLIOGRAPHY 1. Faust R, Kant A, Lorinez A, Younes A, Dawe E, Klein M. Robotic endo- scopic surgery in a porcine model of the infant neck. J Robotic Surg 2007;1:75–83 2. Rahbar R, Ferrari L, Borer J, Peters C. Robotic surgery in the pediatric airway: application and safety. Arch Otolaryngol Head Neck Surg 2007; 133:46–50. 3. Mehta D, Duvvuri U. Robotic Surgery in Pediatric Otolaryngology: Emerg- ing Trends. Laryngoscope 2012; 122:S105–S106. 4. Kayhan F, Kaya K, Koc A, Altintas A, Erdur O. Transoral Surgery for an infant thyroglossal duct cyst. Int J Pediatr Otorhinolaryngol 2013;77: 1620–1623. 5. Leonardis R, Duvvuri U, Mehta D. Transoral robotic-assisted lingual ton- sillectomy in the pediatric population. JAMA Otolaryngol Head Neck Surg 2013;139:1032–1036. 6. Wine T, Duvvuri U, Maurer S, Mehta D. Pediatric transoral robotic sur- gery for oropharyngeal malignancy: A case report. Int J Pediatr Otorhi- nolaryngol 2013;77:1222–1226. 7. Kokot N, Mazhar K, O’Dell K, Huang N, Lin A, Sinha UK. Transoral robotic resection of oropharyngeal synovial sarcoma in a pediatric patient. Int J Pediatr Otorhinolaryngol 2013;77:1042–1044. 8. Leonardis R, Duvvuri U, Mehta D. Transoral robotic-assisted laryngeal cleft repair in the pediatric patient. Laryngoscope 2014;124:2167–2169. 9. Ferrell J, Roy S, Karni R, Yuksel S. Applications for transoral robotic sur- gery in the pediatric airway. Laryngoscope 2014;124:2630–2635. 10. Cundy T, Marcus H, Hughes-Hallet A, Najmaldin A, Yang G, Darzi A. International attitudes of early adopters to current and future robotic technologies in pediatric surgery. J Pediatr Surg 2014;29:1522–1526. 11. Weinstein G, O’Malley B, Desai S, Quon H. Transoral robotic surgery: does the ends justify the means? Curr Opin Otolaryngol Head Neck Surg 2009;17:126–131. 12. McCulloch P, Altman D, Campell B; Balliol Collaboration, et al. No surgi- cal innovation without evaluation: the IDEAL recommendations. Lancet 2009;374:1105–1112. 13. Barkun JS, Aronson JK, Feldman LS; Balliol Collaboration, et al. Evalua- tion and stages of surgical innovations. Lancet 2009;374:1089–1096. 14. Ergina PL, Cook JA, Blazeby JM; Balliol Collaboration, et al. Challenges in evaluating surgical innovation. Lancet 2009;374:1097–1104. 15. Byrd JK, Leonardis RL, Bonawitz SC, Losee JE, Duvvuri U. Transoral robotic surgery for pharyngeal stenosis. Int J Med Robot 2014;10:418– 422. 16. Thottam PJ, Govil N, Duvvuri U, Mehta D. Transoral robotic surgery for sleep apnea in children: is it effective? Int J Pediatric Otorhinolaryngol 2015;79:2234–2237.

masses, and cysts. The generalizability of this series is novel in that it lies outside of the range of most of the published literature that includes lingual tonsillectomies and tongue-base reductions. It also demonstrates safety and feasibility in a wide range of patient ages and weights, including the carefully selected neonates (a 2.5- kg 26 day old and a 3.7-kg 10 day old). Because of the wide range of procedure types and pathologies addressed, a significant trend of decreased operative or surgical time is not to be expected. Our reported complications are within the expected complications for similar traditional transoral approaches in children with significant airway, respira- tory, and comorbid pathologies. It is difficult to draw strict comparison of open or traditional transoral proce- dures in all cases because many of the cases do not have appropriate counterpart comparative procedures or data. The complications seen in this series, although not directly from robotic instrumentation or surgery, could be the result of prolonged mouth gag suspension times, more extensive tissue manipulation, or tissue effects of noncompliant armored endotracheal tubes. However, the advantages of wristed instrument control, three- dimensional visualization, and more precise surgery were affirmed in our qualitative experience in this series. For example, we believe that use of the robot allowed more sutures to be placed in small spaces; more precise control of the laser; and in some cases, multi- layer closure with greater exposure than we typically experience in standard endoscopic procedures. We believe there are several critical elements for success in this case series. First, we had a team with two robotic surgery experienced attending surgeons. Sec- ondly, the experienced bedside surgeon facilitated patient safety, surgical access, and robotic surgeon. We also selected older, bigger children with relatively assessable pathology before attempting more challenging cases in younger, smaller children. We excluded patients with malignancy and vascular tumors (other than lym- phangioma). We were also prepared to convert to tradi- tional surgical methods if the procedure could not be safely and effectively addressed with the robot. With experience, we learned the importance of carefully selecting the appropriate endotracheal tube for the patient, resting the tongue (e.g., release from prolonged retraction), and consideration for overnight intubation in long surgical cases. We believe that surgeons can also decrease operative time with more experience. These data help solidify our understanding of key challenges and future development of TORS for pediatric airway surgery: 1) securing the airway with the appro- priate laser-safe endotracheal or tracheostomy tubes; 2) identifying the appropriate exposure; 3) obtaining surgi- cal access with the robotic arms allowing for unre- stricted mobility; 4) the critical role of the bedside surgeon in protecting the airway and the patient in addition to assisting the robotic surgeon. As the technol-

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