The temporalis muscle flap for reconstruction of soft palate and lateral oropharyngeal wall after transoral robotic surgery

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The

temporalis

muscle

flap

for

reconstruction

of

soft

palate

and

lateral

oropharyngeal

wall

after

transoral

robotic

surgery

Giuseppe

Meccariello

a

,

Filippo

Montevecchi

a,

*,

Alberto

Deganello

b

,

Giovanni

D’Agostino

a

,

Chiara

Bellini

a

,

Ermelinda

Zeccardo

a

,

Claudio

Vicini

a

a_Department_of_Head-Neck_Surgery,_{Otolaryngology,}_Head-Neck_and_Oral_Surgery_Unit,_Morgagni_Pierantoni_Hospital,_Azienda_USL_della

Romagna,Forlı`,Italy

b_Department_of_Surgery_and_{Translational}_Medicine,_University_of_Florence,_largo_Brambilla_10,_50134,_Florence,_Italy

1. Introduction

Trans Oral Robotic Surgery (TORS) has emerged as a techniquethatallowsheadandnecksurgeonstosafelyresect evenlargeoropharyngealtumorswithoutdividingthelipand/or the mandible. The resulting defect is usually left to heal by secondary intention; however some defects are large and complex enough to benefit soft-tissue coverage. To enhance safe healing minimizing complications, TORS with recon-struction (whether using free flaps, local flaps, or primary closure)appearstobeasuperiorapproachinselectedcases,and holds the promise of expanding indications for minimally invasive reconstructive procedures [1]. However, surgical defects following TORS provide a reconstructive challenge becausethe physical access andvisualization of the surgical

fieldisseverelyrestricted,makingthecontouringandinsertion ofthereconstructivetissuemoredifficult.Here,wereportour reconstructivesolutionusingthetemporalismuscleflap(TMP) following a TORS resection of a squamous cell carcinoma (SCC)oftheofthelateraloropharyngealwallextendingtothe soft palate.

2. Technicaldescription

A 65 year-old male patient with a cT2N1 SCC p16-, involvingtheleftanteriorpillarextendingtothesoftpalateat the left side (Fig. 1A), was referred to our Institution. The history revealed smoking and light drinking habits, no significant comorbidities. The Magnetic Resonance Imaging confirmedasuperficiallesionwithpartial involvementofthe softpalate,withasuspiciouslymphnodeatlevelII.Thepatient wasscheduledforTORSandSelectiveNeckDissection(SND) of levelsI–IV.

A tracheostomy was performed before proceeding the robotic surgery. Then, a Feyh-Kastenbauer retractor (Gyrus Medical Inc., Maple Grove, MN) was used to expose the

AurisNasusLarynxxxx(2016)xxx–xxx

ARTICLE INFO Articlehistory: Received5October2016 Accepted28November2016 Availableonlinexxx Keywords:

Transoralroboticsurgery Reconstruction

Cancer Palate Flap

ABSTRACT

Trans Oral Robotic Surgery (TORS) is a prominent surgical approach for the resection of oropharyngealtumorswithoutdivisionofthelipandmandible.SomedefectsfollowingTORSare largeandcomplexenoughtobenefitsoft-tissuecoverage.Thepedicledtemporalismuscleflapisa versatileandreliableflapandmaybeavalidoptiontoreconstructdefectsofthelateralpharyngeal wallandpartialsoftpalate.

ß2016ElsevierIrelandLtd.Allrightsreserved.

* Correspondingauthor.at:DepartmentofHead-NeckSurgery, Otolaryngol-ogy,Head-NeckandOralSurgeryUnit,MorgagniPierantoniHospital,Azienda USLdellaRomagna,VialeForlanini34,47100Forlı`,Italy.

Fax:+390543735660.

E-mailaddress:filippomontevecchi72@gmail.com(F.Montevecchi).

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ANL-2215;No.ofPages3

Pleasecitethisarticleinpressas:MeccarielloG,etal.Thetemporalismuscleflapforreconstructionofsoftpalateandlateraloropharyngeal wallaftertransoralroboticsurgery.AurisNasusLarynx(2016),http://dx.doi.org/10.1016/j.anl.2016.11.011

ContentslistsavailableatScienceDirect

Auris

Nasus

Larynx

j our na l ho me p a ge : w ww . e l se v i e r . com / l oc a te / a n l

http://dx.doi.org/10.1016/j.anl.2016.11.011

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operativefield.The tumormarginswereobserved intraopera-tively with a 0 or 308 8mm Hopkins Scopes (Karl Storz, Germany) using white light then with the Narrow Band Imaging(NBI) high-definitionvideo-endoscopy system (CV-260SLprocessor,CVL-260SLlightsource,OlympusOptical Co.,Ltd.,Japan).Theedgesofsurgicalexcisionweremarked withmonopolarcauteryandcontrolledwithNBI[2](Fig.1B). The daVinci1 Surgical Robotic System (Intuitive Surgical, Sunnyvale,CA)waspositioned308angledontherightsideof thepatient.A0or3088.5mmendoscopeswereusedwithtwo 5-mmsidearmsMarylanddissectorsandcautery(Fig.1C).All vesselsencounteredduringtheresectionwereclippedpriorto transaction.Thewholesurgicalspecimenwasorientedandthen submittedtothepathologistforintraoperativeassessmentofthe margin status with frozen sections. Then the SND was performed. Once neck dissection was completed and clear margins confirmed by the pathologist, the TMP was easily harvested[3]andtransposedtoresurfacethedefect(Fig.2).A nasogastric tube was placed. Tracheotomy was closed on postoperativeday5andthepatientresumedoralfeedingonday 7anddischargedonday9withnormaldiet.Thepathological report was consistent with a pT2N0 R0 SCC p16-. No indicationsfor adjuvant treatmentswere posed at multidisci-plinarytumorboard.

3. Discussion

Althoughthe currentpracticefollowingTORS istoallow the defect to heal by secondary intention, many defects are

large andcomplexenough tobenefit soft-tissuecoverage.In fact,when thecarotidsheathisexposedbyacommunication betweentheoropharynxandtheneck,whenavelopharyngeal compromiseisanticipated,andwhenaconsiderableresection of tongue base tissue has occurred, the transposition of vascularized tissue seems to be beneficial for anatomical restoration and appropriate long-term function. For these situations,thetransoralinsetofafreeflaporofapedicledflap usingroboticsurgicalvisualizationandprecisionwouldbean appealing reconstructivestrategy [4].In such cases, accurate sutureplacementforflapinsettinginaconfinedworkingspace remains difficult even using the robot. Therefore, a highly pliableflap,easytoharvestandtotranspose,mightbeavalid optiontominimizetheseissues.

In our case, the transposition of the TMF restored a competent velopharyngeal sphincter and a watertight seal betweenthepharynxandneck,resultingintimelyhealingwith enhanced postoperative functional results. The TMP is a versatileandreliableflapthatisoftenoverlookedinheadand neckreconstructivesurgery,neverthelessitappearsmostuseful fordefectsinwhichtheidealflapisaflexible,tailoredmuscle with moderate thickness, resulting particularly suitable for upper defects, i.e. following radical tonsillectomy and soft palate resections [3,5]. These characteristics fit well in the TORS framework. The minimally invasive surgery requires, wheneverpossible,areconstructiveapproachofthesameentity inordertorespectthepeculiaritiesofthistypeofsurgery.To the best of our knowledge, thisis the first report describing the reconstructive use of TMP after TORS. In terms of

Fig.1.(A)Endoscopicviewofthetumor.(B)CheckingofthesurgicaledgeswithNBI.(C)Endoscopicviewofsurgicalfieldaftercompletedtumorresection.

Fig.2.(A)Thetemporalismuscleflaponthefifthpostoperativeday.(B)Endoscopicviewoftheleftlateralpharyngealandsoftpalatereconstructedwithtemporalis muscleflapafteronemonth.

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cost-effectiveness,theuseofalternativepedicledflapsinTORS framework probably reduced the risks of postoperative complications, with consequent expenditure restraints. The use of microvascular techniques for these patients might haveledtoanincreaseinproductioncostslinkedtothegreater complexityoftheprocedureinitselfwithincreaseoftreatment costsarisingfromoperatingroomdurationanddoublesurgical team[5].

In conclusion, the TMPin TORS mightrepresent a valid option rather than free flaps, especially in elderly patients andpatientswithsignificantcomorbiditiesor vesseldepleted neck.

Disclosurestatement

ClaudioViciniandFilippoMontevecchiareconsultantsand proctorsforIntuitiveSurgicalInc.

References

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[2] ViciniC,MontevecchiF,D’AgostinoG,VitoDEA,MeccarielloG.A novelapproachemphasisingintra-operativesuperficialmargin enhance-ment of head-neck tumours with narrow-band imaging in transoral roboticsurgery.ActaOtorhinolaryngolItal2015;35:157–61.

[3] HanasonoMM,UtleyDS,GoodeRL.Thetemporalismuscleflapfor reconstruction afterheadandneckoncologic surgery.Laryngoscope 2001;111:1719–25.

[4] deAlmeidaJR,ParkRCW,GendenE.M.Reconstructionoftransoral roboticsurgerydefects:principlesandtechniques.JReconstrMicrosurg 2012;28:465–72.

[5] DeganelloA,GittiG,ParrinelloG,MuratoriE,LarotondaG,GalloO. Cost-analysis inoral cavityand oropharyngeal reconstructions with microvascularandpedicledflaps.ActaOtorhinolaryngolItal2013;33: 380–7.

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