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Da Vinci SP robot provides better outcomes for removal of deep lobe tumors

Dr. Josh Kain is leading the evolution in treating deep lobe and parapharyngeal space tumors with recent successful surgeries using the Da Vinci single port (SP) robot at Houston Methodist’s Department of Otolaryngology — Head & Neck Surgery. Surgery to remove deep lobe tumors or parapharyngeal tumors has long been a complicated procedure with often considerable risks for patients. Because the parapharyngeal space is well hidden behind the jaw, these tumors are difficult to detect and complicated to remove.
Joshua Kain, MD
“The latest iteration of the (Da Vinci SP) robot provides something fresh and new that can break the sound barrier so to speak to bring this technique into more mainstream usage for these tumors,” said Kain, Assistant Professor of Otolaryngology Houston Methodist Academic Institution and Weill Cornell Medical College, specializing in head and neck surgical oncology and microvascular reconstructive surgery. “The flexible camera really adds quite a bit of an element of safety,” he said. Kain believes the new robot will bring this procedure into more common use so that more patients can be helped with better outcomes. “The SP robot serves this purpose really well because it has a flexible camera that allows us to continually change the angle of visualization in ways you could never do standing at the side of the patient or with a traditional robot that only had cameras that are uni-directional,” Kain said. To use the new robot for this procedure, the surgeon sits at a console in front of a control panel with his head in the 3D goggles. The surgeon’s fingers are placed in rings, so he has the natural dexterity and movement of his own hands and fingers. In many ways, the robot’s movements are better than the human hand because it has movement reductions and precise turns that make up for the fallibility of the human hand. A handful of surgeons typically keep up with the technology and perform a few procedures robotically to prove it can be done, but the technique has never caught on as the best way to do it because, as Kain says, “it is fairly nuanced.”
An MRI depicts the parapharyngeal tumor
Symptoms include a bulge in the throat, vocal cord paralyses, swallowing dysfunction and nerve paralysis. The tumors sit directly adjacent to the blood supply to critical cranial nerves and to the vascular supply to the brain and skull. Typically, the tumors themselves are mostly benign but causing compression on surrounding structures. The robotic approach is all done through the mouth with no external scarring. It also provides shorter operating times with two hours versus six to eight hours with the traditional approach. "Patients leave the hospital swallowing and are back on a regular diet in two to three weeks after surgery," Kain said. “I want to see this be something we can offer very broadly,” Kain said. “We can expand the number of patients we’re able to treat directly but also provide education on this technique so that this becomes a more widespread approach to these types of tumors. “I’d hope to see, 15 to 20 years from now, we’re hardly ever doing a big open approach for these types of tumors,” he adds.
Two of Kain’s recent patients have come from other countries where this technology doesn’t exist. He said they came specifically to Houston Methodist to be spared the possible morbidities of the traditional method of treatment in their own countries. Even in the US, the vast majority of ENT surgeons may not be familiar enough with this option well enough to use it. For the better part of last half century, the traditional approach has entailed long incisions on face and neck, moving tissues along cheek and jaw to gain access to this very specific area. “It’s like traveling miles and miles of really hard roads to get to a very small town in the center of the country. There’s a lot of collateral that goes along with that destination and, ultimately, over 90 percent of the time these are benign tumors. There’s really not even easy and feasible ways to get biopsies,” he said. Patients typically would go through surgery to get a benign result and live the rest of their days with that result and its consequences, Kain added. Worst case scenario is facial paralysis, with permanent long-lasting affects. Other risks include stroke, bleeding, malocclusion or dental problems and malunion or bones healed in abnormal positions. The tumors are located in the skull base where all of the neurovascular structures of the brain and neck meet together. “Now we have a camera that’s completely and fully under the control of the surgeon the whole time. It is flexible and can move along with the steps of the operation into different spaces at different times. It’s as if you’re walking through the territory rather than just standing there gazing upon it. “We’ve really developed a nice work flow. We’ve only had a small amount of patients, but each of those patients have had great outcomes and outcomes we can be proud of and the patients are happy about,” Kain said. The surgery itself is usually less than two to three hours where the traditional approach is more along the lines of six to eight hours. The surgeon goes in through the mouth, and an incision is made in the pallet. The incision continues along the side of the pallet, very similar to tonsillectomy scar would be. "Patients can still be a candidate for this surgery after a tonsillectomy,” Kain said. “There is really a sweet spot where patients have a nice, well defined, small benign tumor, and we can easily approach it through this means. We are pushing the boundaries of how large the tumor can be safely approached. “Each successive patient, just by happenstance, has gone a little bit larger every time. Luckily, the technique comfort has risen right alongside that so that boundary is ever evolving,” Kain said. Patients include those who’ve had the tumor for over 10 years and patients who’ve noticed a problem for less than a year. There is a lot of variation in the growth rate of the tumor. Most recently, Kain removed the largest tumor he has seen — more than five centimeters or the size of a typical lemon.