Daniel T. Friedrich

First use of a computer-assisted operator-controlled flexible endoscope for transoral surgery.

Transoral robotic surgery (TORS) has become an accepted treatment option for head and neck cancer. However, anatomical limitations and a relevant financial burden require alternative developments in this field. To this end, a patient presenting with a T2 squamous cell carcinoma of the lower lateral oropharyngeal wall was effectively treated with a new Conformité Européene–certified, computer‐assisted, operator‐controlled flexible endoscope (Flex). Intraoperative visualization and tissue handling were acceptable and safe. Transoral surgery with the flexible endoscope was safely conducted in a clinical setting. The introduction of alternative TORS systems will increase competition, drive scientific improvement, and reduce financial expenses. Laryngoscope, 125:645–648, 2015

Potential Advantages of a Single-Port, Operator-Controlled Flexible Endoscope System for Transoral Surgery of the Larynx

Introduction: Transoral surgery of the larynx is commonly performed with a rigid laryngoscope, a microscope, and a laser. We investigated the potential utility of a flexible, single-port, robot-assisted and physician-controlled endoscopic system to enable easy, transoral surgical access to the larynx. Methods: Transoral laryngeal surgery was performed in human cadavers (n = 4) using the Flex System and compatible flexible instruments. Anatomical landmarks were identified, and mock surgical procedures were performed. Results: Standard laryngeal surgical procedures were completed successfully in a human cadaver model. The built-in HD digital camera enabled high-quality visualization of the larynx. Epiglottectomy, as well as posterior cordectomy, were performed by laser and radio-frequency resection. The flexible design of the compatible tools enabled a nontraumatic approach. Conclusion: The Flex System has the potential to improve surgical access to the larynx, especially in patients with challenging anatomy. The associated flexible instruments enabled completion of surgical procedures in the larynx in a human cadaveric model. Further clinical studies, as well as the development of supplemental technology and tools, are recommended for future clinical applications.

Recent advances in robot-assisted head and neck surgery.

This article reviews current clinical applications and experimental developments for robotic surgery in the head and neck with special focus on financial challenges, current clinical trials, and the controversial aspect of haptic and tactile feedback.

Hybrid procedure for total laryngectomy with a flexible robot‐assisted surgical system

Total laryngectomy is a standard procedure in head‐and‐neck surgery for the treatment of cancer patients. Recent clinical experiences have indicated a clinical benefit for patients undergoing transoral robot‐assisted total laryngectomy (TORS‐TL) with commercially available systems. Here, a new hybrid procedure for total laryngectomy is presented.

Application of a computer-assisted flexible endoscope system for transoral surgery of the hypopharynx and upper esophagus

Zenker’s diverticulum is a common pathology in the transition zone of the posterior hypopharynx and esophagus. Surgical treatment is routinely performed by ENT and general surgeons. Besides the traditional open transcervical diverticulectomy, the introduction of transoral rigid treatment led to a paradigm change and is now the preferred treatment option for patients who are fit for general anesthesia. The implementation of interventional flexible endoscopy has opened another new micro-invasive approach for patients with high morbidity. Here, we present the potential utilization of a flexible, single port, robot-assisted, and physician-controlled endoscope system to facilitate transoral surgical access to the hypopharynx and upper esophagus. Transoral surgery of the hypopharynx and upper esophagus was performed in human cadavers (n = 5) using the Flex System (Medrobotics, Raynham, USA). Anatomical landmarks were identified, and posterior cricothyroid myotomy was performed with compatible flexible instruments in all cases. The approach to the hypopharynx and upper esophagus using the Flex system is feasible in a cadaveric model. Myotomy with a flexible tool and needle knife (from the perspective of treatment of Zenker´s diverticulum) was successful in all cases. Visualization of the surgical site with the system’s HD camera is suitable and the flexible instruments meet the special needs of a micro-invasive transoral approach. Zenker´s diverticulum can be potentially treated with a transoral minimally invasive approach using a computer-assisted flexible endoscope system. This setup could be of advantage in patients with reduced mobility of the cervical spine to prevent open transcervical surgery. In our study, the Flex system enabled advanced visualization of the surgical site and extended intervention options, compared to standard flexible endoscopic treatment. However, general anesthesia is mandatory for the presented approach. Application in live patients with actual pathologies of the hypopharynx and upper esophagus will have to prove suitability for the treatment of Zenker’s diverticulum. Further development of the system could include improved instrumentation and an adoption by other disciplines with challenging anatomy such as colorectal surgery.

An Innovate Robotic Endoscope Guidance System for Transnasal Sinus and Skull Base Surgery: Proof of Concept

Objective Advanced transnasal sinus and skull base surgery remains a challenging discipline for head and neck surgeons. Restricted access and space for instrumentation can impede advanced interventions. Thus, we present the combination of an innovative robotic endoscope guidance system and a specific endoscope with adjustable viewing angle to facilitate transnasal surgery in a human cadaver model. Materials and Methods The applicability of the robotic endoscope guidance system with custom foot pedal controller was tested for advanced transnasal surgery on a fresh frozen human cadaver head. Visualization was enabled using a commercially available endoscope with adjustable viewing angle (15‐90 degrees). Results Visualization and instrumentation of all paranasal sinuses, including the anterior and middle skull base, were feasible with the presented setup. Controlling the robotic endoscope guidance system was effectively precise, and the adjustable endoscope lens extended the view in the surgical field without the common change of fixed viewing angle endoscopes. Conclusion The combination of a robotic endoscope guidance system and an advanced endoscope with adjustable viewing angle enables bimanual surgery in transnasal interventions of the paranasal sinuses and the anterior skull base in a human cadaver model. The adjustable lens allows for the abandonment of fixed‐angle endoscopes, saving time and resources, without reducing the quality of imaging.

Teleoperated tubular continuum robots for transoral surgery - feasibility in a porcine larynx model

Evidence suggests that transoral robot‐assisted surgery is becoming increasingly common, yet current systems are incapable of sufficiently reaching the glottis or subglottic areas. This paper presents a teleoperated tubular continuum robot prototype for laryngeal surgery in a feasibility study.