Pure Robotic Surgery for Odontoid Tumor: First Case

Accepted Manuscript Pure Robotic Surgery for Odontoid Tumor: First Case Umit Eroglu PII: S1878-8750(18)31058-1 DOI: 10.1016/j.wneu.2018.05.105 Reference: WNEU 8166 To appear in: World Neurosurgery Received Date: 23 February 2018 Revised Date: 14 May 2018 Accepted Date: 15 May 2018 Please cite this article as: Eroglu, U, Pure Robotic Surgery for Odontoid Tumor: First Case, World Neurosurgery (2018), doi: 10.1016/j.wneu.2018.05.105. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. ACCEPTED MANUSCRIPT Pure Robotic Surgery for Odontoid Tumor: First Case RI PT Key words: da Vinci surgery, robotic, transoral robotic surgery Abbreviations AC C EP TE D M AN US C TORS, transoral robotic surgery ACCEPTED MANUSCRIPT Abstract Background: Transoral robotic surgery has been used successfully to assist many surgical procedures. Here, we report its first use as pure robotic surgery, applied to excise an RI PT odontoid metastatic mass. Introduction Robotic surgery is used effectively across many surgical fields, including urology, general M AN US C surgery, cardiovascular surgery and gynecology. This approach has significant advantages: it is minimally invasive, it can provide three-dimensional access to locations where the surgeon cannot reach and/or see, it allows greater freedom of hand and wrist movements in confined areas, it enables faster healing, and it can offer a tremor filtration feature. In 2009, the U.S. Food and Drug Administration approved the use of transoral robotic surgery (TORS) D for specified cases. Since then, TORS has been actively used in otorhinolaryngology clinics for TE various pathologies e.g. sleep apnea and tongue-base tumors. Several cases of its use in brain surgery have also been reported. However, all these cases involved robot-assisted EP surgeries; the robotic systems lack of a drill tip necessitated the sequential use of endoscopic AC C and robotic surgery. Here, we report the first use of pure robotic TORS, applied to excise an odontoid metastatic mass. Case Description: A 48-year-old woman was admitted to our clinic with a complaint of long-term pain in her neck and both arms. Her medical history noted rapid weight loss. On examination, she showed no notable loss of motor strength, but she had difficulty in swallowing. Laboratory ACCEPTED MANUSCRIPT tests showed no remarkable results except for the height level of acute phase reactants. Magnetic resonance imaging (MRI) revealed that the border of the anterior longitudinal ligament had disappeared. It also showed a lesion consistent with metastasis that extended to the pharyngeal constrictor muscles and that had completely destroyed the odontoid RI PT bone. (Figure 1). Because the patient was unstable, occipitocervical fixation was performed initially (Figure 2), and the transoral surgery took place 5 days later. Intraoperative neurophysiological imaging M AN US C was used during the procedure. Under general anesthesia, the patient was placed in a supine position in the horseshoe cap. Her neck was extended as far as possible; however, it could not be fully extended because of the earlier fixation from the posterior. After fiberoptic orotracheal intubation, self-retaining retractors were used to pull both cheeks to the sides to increase the oral opening as much as possible. Petroleum jelly (Vaseline) was D applied to the patient’s lips to avoid possible trauma and drying. The uvula was pulled up by TE hanging the nasogastric feeding tube inserted in both nostrils. The interdental opening was set at 4 cm (Figure 3). Using Karl Storz Electromagnetic navigation system EP (Karl Storz company, Tuttlingen, Germany), the region where the incision was to be made AC C was confirmed on axial, sagittal, and coronal images of the pharyngeal region and marked using a monopolar dissector (Figure 4). The da Vinci Surgical System Robot XI (Intuitive Surgical, Sunnyvale, Calif., USA) was moved closer to the surgical field. The assistant surgeon took position on the right side of the patient for aspiration, with a nurse at the head of the patient and an anesthetist in a separate sterile field closer to the patient’s feet. A 5-mm Maryland monopolar dissector was placed in the left hand, with a forceps arm in the right hand, and the camera arm centered on the previously marked location in the mouth. The assistant surgeon holding the aspirator intermittently aspirated when necessary. ACCEPTED MANUSCRIPT An incision was made by the forceps in the soft palate vertically at the midline. The localization of incision was checked with the navigation probe. The muscles and soft mucosa were passed with the help of a forceps cautery and spatula, and the navigation probe was used to confirm the position within the odontoid tumor tissue. The forceps was changed to a RI PT cadiere forceps, and tumor fragments were subtotally resected; these had a soft consistency, with occasional cartilage and bone fragments (Figure 5). A specimen was examined intraoperatively compatible with a mucinous-type tumor metastasis and diffuse M AN US C necrosis. Hemostasis was performed carefully and attentively, and the patient’s neurophysiologic responses were checked with intraoperative neuromonitoring at each stage of the surgery. Both arms of the robot were then changed to wristed needle driver handles. Muscles and mucous membranes were sutured full-thickness with interrupted 4-0 Vicryl sutures (Figure 6). The surgery lasted approximately 55 min, and the robotic system D remained in the surgical field throughout. Prior to extubation, the patient was given TE intravenous prednisolone to avoid possible tongue and soft palate edema, and she was extubated without any problems. No tongue or lip trauma was observed. Postoperative EP tomography and MRI images were taken (Figure 7; Figure 8) AC C The patient’s oral nutrition was stopped for 3 days and fed parenterally. On the third postoperative day, her soft palate, muscle, and deglutition were reevaluated by the otorhinolaryngologist. The patient started oral feeding with a liquid diet after 3 days. The patient was discharged with a very good general condition. Discussion The use of TORS is increasing worldwide, and many studies have demonstrated its high reliability for head and neck surgery.1,2 The transoral approach is the most direct way to ACCEPTED MANUSCRIPT reach the anterior base of the skull and for accessing odontoid lesions. However, this approach is associated with some serious complications, including cerebrospinal fluid leakage and sepsis. There have been previous reports of cadaver studies using TORS for the skull base and odontoid approach.3,4 There have been three case reports of TORS used to RI PT attempt; osteodystrophic tissue in the C1 corpus vertebra, basilar invagination and the C2 osteolytic lesion.5,6 In these examples, an endoscope and the da Vinci robotic system were used sequentially in the surgical field, according to the nature and localization of the lesion, M AN US C and both procedures were performed under C-arm fluoroscopy. Because the da Vinci robotic system has no drill, curette, or Kerrison rongeur, these auxiliary items are introduced into the surgical field as necessary. However, in the present case, bone integrity had been lost, the anterior longitudinal ligament boundary had disappeared, and the tumor had invaded the posterior pharyngeal constrictor muscles. This D allowed the tumor to be removed with the aid of robotic forceps without the need to drill. TE Intraoperative frozen section diagnosis was tumor metastasis. Tumor excision was performed safely because the navigation probe showed the location of the forceps in the EP axial, sagittal, and coronal planes. In soft tumors such as this case, where bone integrity has AC C been lost, it is difficult to start the surgery by feeling the bone tissue, as classically described. In addition, C-arm fluoroscopy cannot show the bone structure well when bone integrity has been lost. Our recommendation is to use navigation in such cases. Intraoperative neurophysiologic imaging was used during the surgery, and no problems were encountered. A mouth opening of about 4 cm was sufficient for the two robotic working arms, a camera, and the aspirator used by the assistant surgeon. However, uplifting the uvula and, especially, pulling both cheeks back laterally with retractors created a wide gap. The closure was sutured interrupted with 4-0 Vicryl sutures. The articulated robotic arms achieved this ACCEPTED MANUSCRIPT quite well in a narrow, deep, and small field. We observed that this suturing process was easier than in cadaver and simulation exercises. The suture knots were tight, and there was no loosening. The occipitocervical fixation of the patient prior to the procedure made it difficult for the neck to be fully extended, however during the surgery, this did not cause a RI PT problem. M AN US C Conclusion This article presents the first pure robotic surgery for odontoid. da Vinci robotic system worked very well due to the location and nature of the pathology. Endoscopy and similar surgical tools were initially used in other surgical branches, but when they began to be used in neurosurgery, the neurosurgical adaptations of these devices accelerated. Innovation is needed for robotic systems, such as the da Vinci system, to be used effectively D in neurosurgery. The increasing number of robot-assisted cases will demonstrate the EP TE necessity of this evolution and should accelerate the process. AC C Declarations of interest: The authors declare no conflict of interest, including employment, consultancies, grands or other funding. Acknowledgements Operation was performed at the Ankara University Hospital Neurosurgery Department. Disclosure ACCEPTED MANUSCRIPT RI PT No financial or material support. Highlight 1- This article presents the first pure robotic odontoid tumor surgery M AN US C 2- This approach offered enough visual field for lesion resection References 1. Tsang RK, To VS, Ho AC, Ho WK, Chan JY, Wei WI. Early results of robotic assisted D nasopharyngectomy for recurrent nasopharyngeal carcinoma. Head Neck. 2015;37:788–793. TE 2. Hockstein NG, O’Malley BW Jr, Weinstein GS. Assessment of intraoperative safety in EP transoral robotic surgery. Laryngoscope. 2006;116:165–168. 3. Lee JY, O’Malley BW Jr, Newman JG, Weinstein GS, Lega B, Diaz J, Grady MS. Transoral AC C robotic surgery of cranio cervical junction and atlantoaxial spine: a cadaveric study. J Neurosurg Spine. 2010;12:13–18. 4. Yang MS, Yoon TH, Yoon DH, Kim KN, Pennant W, Ha Y. Robot-assisted transoral odontoidectomy: experiment in new minimally invasive technology, a cadaveric study. J Korean Neurosurg Soc. 2011;49:248–251. 5. Molteni G, Greco MG, Presutti L. Transoral robotic-assisted surgery for the approach to ACCEPTED MANUSCRIPT anterior cervical spine lesions. Eur Arch Otorhinolaryngol. 2017;274:4011–4016. 6. Lee JY, Lega B, Bhowmick D, Newman JG, O’Malley BW Jr, Weinstein GS, Grady MS, Welch WC. Da Vinci Robot-assisted transoral odontoidectomy for basilar invagination. ORL J M AN US C RI PT Otorhinolaryngol Relat Spec. 2010;72:91–95. Figure captions Figure 1. The destructive lesion seen on magnetic resonance and tomography images Figure 2. Postoperative cervical graph of the occipitocervical fixation performed prior to the D main procedure TE Figure 3. Self-retaining retractors were used to pull the cheeks back laterally to achieve the maximum oral opening and positioning of the robotic arms in the mouth monopolar EP Figure 4. The area to be incised was identified using the navigation probe and marked with a AC C Figure 5. Performing the incision with robotic arms, passing the mucosa and muscle structures and excision of the dirty yellow bulk that was compatible with a tumor Figure 6. Suture of the mucosal flap Figure 7. Postoperative tomography Figure 8. Postoperative MR images ACCEPTED MANUSCRIPT Highlight 1- This article presents the first pure robotic odontoid tumor surgery AC C EP TE D M AN US C RI PT 2- This approach offered enough visual field for lesion resection AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT AC C EP TE D M AN US C RI PT ACCEPTED MANUSCRIPT ACCEPTED MANUSCRIPT Abbreviations AC C EP TE D M AN US C RI PT TORS, transoral robotic surgery ACCEPTED MANUSCRIPT I certify that this manuscript is a unique submission and is not being considered for publication, in part or in full, with any other source in any medium. I have approved the manuscript and agree with submission to World Neurosurgery. There are no conflicts of interest to declare. Declarations of interest: RI PT All the authors declared no conflict of interest, including employment, consultancies, grands or other funding. M AN US C Acknowledgements Operation was performed at the Neurosurgical Department of the University Hospital Ankara. Disclosure D No financial or material support. AC C EP TE Umit Eroglu Ankara University Neurosurgery Department 06230 Phone No: +90 312 580 23 00 Email Address: umitkovikeroglu@hotmail.com