Robot-assisted, volumetric tongue base reduction and pharyngeal surgery for obstructive sleep apnea

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A structured approach to Surgery for OSA has been clearly defined and accepted by the American Academy of Sleep Medicine. The aim of surgery is to address the collapsibility of structures of the upper airway. The da Vinci Robot (Intuitive Surgical, Sunnyvale, California, USA) has been validated and now approved by the Food and Drug Administration as an adjunct to transoral surgery. Trans Oral Robotic Surgery (TORS) has been proved to be useful in resection of oropharyngeal malignancy and some benign tumours of the parapharyngeal space. This is due to the excellent visual and instrument access, as well as the loss of tremor. The application of TORS for a variety of surgical procedures for sleep apnea is described.

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... 14 Transoral robotic surgery (TORS) is the optimal technique for reducing tongue size and excision of the lingual tonsil; it reduces the duration of surgery, peri-operative complications and the length of the hospital stay. 91,92 Expansion of the maxillofacial skeleton using mandibular or bi-maxillary osteotomies is an invasive and highly effective technique for treating intractable OSA. 70 Multidetector CT has an integral role in surgical planning using dedicated protocols and software programs. ...
Obstructive sleep apnoea (OSA) is a serious worldwide health problem. Moderate‐to‐severe OSA has been found in up to 50% of men and 25% of women in the middle‐aged population. It results in a fourfold increase in all causes of mortality. The prevalence of OSA is underestimated, partly due to absence of symptoms but also lack of knowledge amongst the population at large as well as sectors of the medical profession. Imaging, performed predominantly by clinicians and research scientists, has been integral to evaluating the anatomical basis of OSA. Increased nasal resistance and a narrowed and elongated oropharynx lead to increased collapsibility of the upper airway, predisposing to airway collapse and apnoea during sleep when there is reduction in tone of the pharyngeal dilator muscles. Unfortunately, a significantly narrowed upper airway is usually ignored by radiologists: it is not part of their reporting ‘check‐list’. The imaging findings in the upper airway that are strongly associated with OSA and its sequelae in various organ systems are discussed. Imaging can strongly suggest OSA; the diagnosis requires a polysomnogram for confirmation. Treatment of moderate‐to‐severe disease is primarily with positive airway pressure applied by a nasal or oral mask which splints the upper airway. Although highly effective, compliance is limited and other treatment modalities are increasingly being utilized.
Current surgical management of obstructive sleep apnea (OSA) is most successfully achieved by multilevel surgery. This was confirmed after thorough understanding of the complexity of airway obstruction by drug-induced sleep endoscopy (DISE) that showed that the hypopharynx and base of tongue, not only the palate, are important anatomic components of obstruction in OSA. Vicini et al. have performed 160 cases of TORS for OSA between May 2008 and April 2014. In the beginning, all the palate surgeries were treated performing a classic UPPP. Since June 2010, the UPPP palate technique has in most cases been replaced by a modified expansion sphincter pharyngoplasty (ESP) and barbed reposition pharyngoplasty (BRP) later on. The authors were able to show the functional and objective superiority of ESP and BRP when compared to the traditional UPPP as a multilevel procedure. So, the associated palate procedure should not be under-evaluated as it may impact the final outcomes of TORS.
Tongue base hypertrophy is an obstructive condition in many if not most cases of obstructive sleep apnea–hypopnea syndrome (OSAHS). Base of tongue is difficult to manage surgically, and its surgery remains a great challenge for both surgeon and patient. The 3-D array of the tongue base associated with its complex relationships to surrounding structures and its critical physiological functions make tongue base surgery technically demanding and encumbered with complications that are not insignificant. In this chapter, we try to present different surgical techniques other than TORS for management of tongue base hypertrophy together with comparing the results with that of TORS. These techniques range from minimally invasive approaches through more technically demanding open approaches and finally recent advances in the area of tongue stimulation using implantable devices.
In 2010 approximately 4.7 % of the Australian population overall were affected by OSA; 6.4 % of males and 3.6 % of females. The importance of sleep health is gaining increased recognition as both the personal and societal costs are better understood. Sleep disorders cost the hospital system around $96.2 million but imposes a burden that extends far beyond the diagnosis and treatment of the disorders themselves.
Obstructive sleep apnea (OSA) is a chronic disease with the risks of secondary cardiovascular or metabolic diseases. Continuous positive airway pressure (CPAP) is the first line treatment for OSA, but patients who fail the treatment with CPAP or other conservative treatment, should be considered for surgery. The early target of sleep surgery was the oropharynx by tonsils, uvula, and soft palate. However, a better understanding of the pathophysiology of OSA and improvement of diagnostic methods has revealed multi-level obstruction in the upper airway. The base of tongue is one of major contributors to OSA and many surgical methods have been developed to resolve the compromise of retroglossal area. Careful examinations of obstruction site and its structured approach to surgery with less morbidity should be evaluated and understood for the better outcome by sleep surgery.
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To develop a minimally invasive surgical technique for the treatment of base of tongue neoplasms using the optical and technical advantages of robotic surgical instrumentation. Ten experimental procedures including tongue base exposure and dissections were performed on three cadavers and two mongrel dogs. Transoral robotic surgery (TORS) was then performed on three human patients with tongue base cancers in a prospective human trial. Using the da Vinci Surgical Robot (Intuitive Surgical, Inc., Sunnyvale, CA), we performed a total of 10 base of tongue resections on edentulous and dentate cadavers as well as live mongrel dogs. In the cadaver models, exposure was evaluated using three different retractors, the Dingman, Crowe Davis, and FK retractors. The three human patients underwent TORS surgery of their tongue base cancers under an institutional review board approved prospective clinical trial. The ability to identify and preserve or resect key anatomic structures such as the glossopharyngeal, hypoglossal, and lingual nerves as well as techniques for identifying the lingual artery and achieving hemostasis were developed. The da Vinci Surgical Robot provided excellent visualization and enabled removal of the posterior one third to one half of the oral tongue in cadavers, dogs, and human patients. Among the three retractors evaluated, the FK retractor offered the greatest versatility and overall exposure for robotic instrument maneuverability. Complete resection to negative surgical margins with excellent hemostasis and no complications was achieved in the live patient surgeries. TORS provided excellent three-dimensional visualization and instrument access that allowed successful surgical resections from cadaver models to human patients. TORS is a novel and minimally invasive approach to tongue neoplasms that has significant advantages over classic open surgery or endoscopic transoral laser surgery.
Velopharyngeal incompetence (VPI) is a recognized complication of uvulopalatopharyngoplasty (UPPP) for obstructive sleep apnea. A new uvulopalatal flap (UPF) technique that modifies the UPPP and reduces this risk is presented. The technique achieves the same anatomic results as the UPPP but is reversible. To evaluate clinical outcomes of this new procedure, selected variables were compared in patients who underwent UPPP and UPF procedures. Eighty patients were examined (59/80 UPF, 21/80 UPPP) in a prospective and consecutive manner. Subjects underwent polysomnography and extensive airway evaluations. The characteristics of all patients, at baseline, were evaluated. The study variables included age, sex, body mass index (BMI), palatal length (PNS P) in millimeters, respiratory disturbance index (RDI), lowest oxygen saturation during sleep and a subjective snoring scale. Sixty-seven of the 80 patients underwent simultaneous hypopharyngeal surgery. Data were analyzed with a SAS program. No statistical difference existed between groups. The postoperative character of the palate and the change in snoring scores were the same in all patients (p = 0.584). A positive correlation existed between improvement in the snoring score and the amount of tissue removed or repositioned in the patients treated with UPF (correlation coefficient = 0.370, p = 0.004). In contrast, there was a negative correlation in the UPPP group for the same parameters (correlation coefficient = -0.195, P = 0.409). This suggests there was a difference between these two groups despite the fact that the baseline and postoperative lengths, as well as tissue removed or repositioned, were equivalent. This further suggests that the UPF may reduce snoring to a greater extent than the UPPP. No significant complications were seen in either group. There was no evidence of VPI, even in the early postoperative period. The new reported procedure is reversible and conservative and reduces the risk of VPI. Snoring is improved, which is consistent with a decrease in airway resistance or obstruction.
Uvulopalatopharyngoplasty is widely used to treat obstructive sleep apnea, and many techniques are described in the literature. However, complications and failures remain a problem. We describe a new imbrication technique that reduces pain, minimizes bleeding, and serves to realign muscle tension, thereby reducing palatal bulk. The imbrication technique has become the standard procedure at our clinic.
Robotic surgery has significant potential in pharyngeal and microlaryngeal surgery. We demonstrate the use of a surgical robot in pharyngeal and microlaryngeal surgery in a cadaver. Six experimental surgical dissections, modeled after commonly performed pharyngeal and microlaryngeal procedures, were performed in a cadaver with a commercially available surgical robot in an operating room suite to demonstrate proof of concept. Using the daVinci Surgical Robot (Intuitive Surgical, Sunnyvale, CA), surgical procedures were performed on an edentulous, female cadaver. The procedures included 1) bilateral true vocal cord stripping, 2) rotation of a mucosal flap from the epiglottis to the anterior commissure, 3) partial vocal cordectomy, 4) arytenoidectomy, 5) partial epiglottectomy and thyrohyoid dissection and 6) partial resection of the base of tongue with primary closure. All procedures were timed and documented with still and video photography. The daVinci Surgical Robot, with currently available instruments, enabled performance of several laryngeal and pharyngeal surgical procedures on a cadaver. Laryngeal and pharyngeal exposure was excellent, instruments movement was unimpeded, tissue handling was delicate and precise, and endolaryngeal suturing was relatively easily performed. The duration of the different robotic cadaver dissections was comparable to procedure duration using conventional techniques. Using the daVinci Surgical Robot, six different pharyngeal and microlaryngeal dissections were successfully performed in a cadaver. The recent development of surgical robotics has a potential role in pharyngeal and microlaryngeal surgery. Surgical robots offer the ability to manipulate instruments at their distal ends with increased freedom of movement, scaled movement, tremor buffering, and under stereoscopic three-dimensional visualization. Surgical robots may increase the precision with which we perform currently described procedures; additionally, surgical robots may advance the field of endoscopic laryngeal and pharyngeal surgery.
Robot-assisted pha-ryngeal and laryngeal microsurgery: results of robotic cadaver dissec-tions
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Hockstein NG, Nolan JP, O'Malley BW, Jr, et al: Robot-assisted pha-ryngeal and laryngeal microsurgery: results of robotic cadaver dissec-tions. Laryngoscope 115:1003-1008, 2005
Expansion Sphincter pharyngoplasty. chapter 37 Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy
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Pang K, Woodson BT: Expansion Sphincter pharyngoplasty. chapter 37, in Friedman M (ed): Sleep Apnea and Snoring: Surgical and Non-Surgical Therapy. Elsevier, 2009