9例经口入路机器人手术在口腔颌面外科应用报道

目的: 总结口腔颌面外科机器人手术的应用经验。方法: 解放军总医院口腔科应用达芬奇机器人手术系统对9例位于口腔深部肿瘤患者行经口入路机器人手术（transoral robotic surgery, TORS）,总结手术经验与体会。结果: 患者均顺利完成手术,摆位及术区暴露用时20~90 min,平均42.2 min;手术时间5~90 min,平均40.9 min。除1例双侧颈淋巴清扫术患者外,其余纯口腔入路患者8例,术后平均住院日3.25 d,术后均顺利出院,平均住院天数7.75 d。结论: 达芬奇机器人手术系统可以独立完成口腔深部肿瘤手术,但在特殊患者如舌根肿瘤手术上仍有一定困难,主要是术区暴露时间较长。     

经口腔机器人手术在头颈外科中的应用

经口腔机器人手术(transoral robotic surgery,TORS)是近年来国际上头颈外科领域引人注目的一大进展,目前已成功应用于头颈-颅颌面肿瘤切除及游离皮瓣重建术。它突破了传统外科医师手术的概念,提高了手术质量,减小了手术创伤,极大地满足了患者的安全与美观需求,在头颈外科中的应用已被初步证实具有可行性和安全性。本文就TORS的组成、优点、应用现状及发展前景作一综述。     

Transoral robotic surgery of parapharyngeal space tumours: a series of four cases

Tumours arising from the parapharyngeal space (PPS) represent less than 1% of all head and neck tumours. Salivary gland tumours account for 40–50% of PPS lesions and are located in the pre-styloid parapharyngeal space. Pleomorphic adenomas represent 80–90% of salivary tumours in the PPS. Recently, transoral robotic surgery (TORS) has become common in head and neck surgery as a minimally invasive procedure. Four cases of benign PPS tumour treated with TORS are presented here. Preoperative diagnosis was conducted by fine needle aspiration biopsy and magnetic resonance imaging, and the results were used to plan the correct surgical approach. One case required a change of approach to conventional transoral blunt dissection. Patients required pain control and reported dysphagia symptoms for a period of weeks, but no nasogastric tube was needed at any time. This case series indicates that TORS is a safe surgical procedure for the excision of benign tumours of the PPS in selected cases.     

Oncological and functional outcomes of transoral robotic surgery for oropharyngeal cancer

In this prospective study we analysed the oncological and functional results of transoral robotic surgery (TORS) to find out if it was suitable as a minimally invasive treatment for oropharyngeal cancer. Between April 2008 and September 2011, 39 patients with oropharyngeal cancer were treated by TORS. We assessed overall and disease-free survival by the Kaplan–Meier test, and we used videopharyngography and the functional outcome swallowing scale (FOSS) to evaluate swallowing. We used nasometry to estimate hypernasality, and acoustic waveform analysis to evaluate the voice. Thirty-seven patients (95%) had histologically clear margins of resection. Overall survival at 2 years was 96% and disease-free survival 92%. An oral diet was tolerable after a mean of 6 (range 1–18) days. No serious swallowing difficulties were seen on the videopharyngogram. Thirty-six of 38 patients could swallow well (97%) with FOSS scores ranging from 0 to 2 (1 patient had a poor score but was able to take an oral diet after postural training). Voices were maintained close to the normal range on the acoustic waveform analysis. The oncological and functional results of TORS were quite acceptable for the treatment of oropharyngeal cancer. TORS is a valid treatment for selected patients with oropharyngeal cancer.     

Robotic surgery in oral and maxillofacial,craniofacial and head and neck surgery: A systematic review of the literature

A systematic review of the literature concerning robotic surgery in oral and maxillofacial (OMF), craniofacial and head and neck surgery was performed. The objective was to give a clear overview of the different anatomical areas of research in the field of OMF, craniofacial and head and neck surgery, in all its fields (pre-clinical and clinical). The present indications are outlined and the critical reader is invited to assess the value of this new technology by highlighting different relevant parameters. A PubMed and Cochrane library search yielded 838 papers published between 1994 and 2011. After screening the abstracts, 202 articles were considered clinically or technically relevant and were included. These full papers were screened in detail and classified as articles on synopsis (n = 41), educational aspects (n = 3), technical/practical aspects (n = 11) and clinical papers (n = 147). Regarding clinical feasibility this systematic review revealed the following main indications: transoral robotic surgery (TORS) for upper digestive and respiratory tract lesions; TORS for skull base surgery; and TORS for trans-axillary thyroid and endocrine surgery. Regarding functional outcome, this systematic review revealed a promising reduction of morbidity in patients with cancer of the upper digastric and respiratory tract.     

Transoral robotic surgery for hilo-parenchymal submandibular stones: step-by-step description and reasoned approach

The conservative transoral approach to hilo-parenchymal submandibular stones has been proposed as an alternative to traditional sialadenectomy. The main purpose is to preserve the gland and eliminate the risk of a cervical scar and damage to the marginal mandibular branch of the facial nerve. The spread of transoral robotic surgery has favoured its application not only in the oropharynx, but also in the anterior oral cavity. This article describes a transoral robotic approach for hilo-parenchymal submandibular stones. In January 2019, two patients with a right and a left hilo-parenchymal submandibular stone of 15 mm and 8 mm, respectively, underwent removal of the stone with transoral robotic surgery using the Si Da Vinci surgical robot. The procedure was performed successfully and tolerated well, with a one-night hospitalization. There were no complications such as lingual nerve damage, painful gland swelling, infection, or ranula. The patients were followed up clinically and ultrasonographically for the first 3 months to verify symptom relief and persistence of stones; no symptoms or stones were found. The transoral robotic surgical approach seems to be safe and adequate for the conservative management of large hilo-parenchymal submandibular stones. An adequate diagnosis together with proper docking and an appropriate approach to the oral floor is mandatory.     

Morbidity related to the lip-split mandibulotomy approach: a systematic and narrative review

The lip-split mandibulotomy (LSMA) is an access procedure that has been used in head and neck (H&N) surgery as an aid to surgical resection of inaccessible tumours of the postertior oral cavity and oropharynx. Anecdotal evidence suggests that it has significant morbidity. Voices of concern within the H&N surgical community suggest that it has been abandoned in favour of technological advances such as robotic surgery. We report here the first (to our knowledge) registered systematic review of its kind, documenting the safety and efficiency of LSMA in H&N surgery. We performed a PRISMA-guided systematic review (PROSPERO-registered) and identified reports using a search algorithm in MEDLINE/EMBASE. LSMA-related surgical complications were recorded using the Clavien-Dindo classification. Secondary outcomes included swallowing dysfunction, facial cosmesis, and patient satisfaction recorded in health-related quality of life questionnaires (HRQoL). From 125 studies identified, 54 met the inclusion criteria (3872 patients). The LSMA mortality rate was 0%; we did not identify a single case of perioperative death. The median rate of osteoradionecrosis was 5.4%, whereas fistula formation was 5.7%. Malunion was noted in 4.9%. Other complications (surgical site infection, plate exposure) were around 5%. There was significant between-study variation with regards to swallowing assessment tools, but overall there was no significant difference in outcomes. This was also the case for the HRQoL questionairres. LSMA is a safe procedure with an acceptable rate of complications, and should definitely remain in the armamentarium of H&N surgery.     

Surgically repaired cleft lips depicted in paintings of the late Gothic period and the Renaissance

Paintings and drawings by Lucas Moser, Leonardo da Vinci, Albrecht Dürer, and Jacob Cornelisz van Oostsanen suggest that they employed people who had had cleft lips operated on as models for their works of art. Created between 1431 and 1520, the portraits show diagnostic facial profiles with a curved nasal dorsum, short columella, maxillary retrusion, and pseudoprogenia. The first medical illustration of cleft lip surgery was published in 1564 by Ambroise Paré. It was therefore late Gothic and Renaissance artists who depicted the conspicuous signs of surgically treated patients with cleft lip more than 130 years before the surgeons.     

Schwannoma of the mental nerve: usefulness of preoperative imaging: a case report

Schwannoma of the head and neck region is relatively uncommon. We report a case of schwannoma arising from the left mental nerve. A 21-year-old male presented at our hospital with a painless swelling of the left cheek. Because the lesion had rapidly increased in size, a malignant tumor was suspected. Magnetic resonance imaging (MRI), computed tomography, and ultrasonography were performed. MRI and ultrasonography revealed that the tumor was connected to the mental nerve. Both MRI and ultrasonography were found to be useful in making a preoperative diagnosis. It was possible to determine prior to surgery that this was a peripheral nerve sheath tumor. The lesion was completely resected. The pathological diagnosis was Antoni type A schwannoma. There has been no sign of recurrence 1 year after surgery.     

舌下腺舌神经鞘瘤临床病例报告及分析

本文通过对经诊治的1例左侧舌下腺舌神经鞘瘤患者进行临床病例报告及分析。发现对于神经鞘瘤这种生长缓慢、包膜完整的良性肿瘤,沿包膜外完整切除,术后3个月复诊创口愈合良好,舌感觉及运动无异常,未见复发。所以在对于舌下腺肿瘤的临床诊断及治疗时,舌神经鞘瘤应予以鉴别诊断。     

Loss of lingual sensitivity and slightly increased size signaling schwannoma in a patient with mixed conjunctive tissue disease

The purpose of this study was to describe an unusual case of a lingual schwannoma associated with a mixed connective tissue disease (MCTD). A case report. A lingual schwannoma with loss of lingual sensitivity and slightly increased size in an 18‐year‐old patient with MCTD was correctly diagnosed through a biopsy and no reoccurrence was observed one year after the surgical removal of the tumor and sensitivity returned 3 months after surgery. This case was considered uncommon, making the clinical diagnosis challenging in view of the diversity of possibilities for its differential diagnosis, thus showing the importance of a biopsy to confirm the diagnosis and long term follow up in such cases.     

Robotic sialoadenectomy of the submandibular gland via a modified face-lift approach

The purpose of this study was to describe and analyse the advantages and disadvantages of submandibular gland (SMG) resection using a robotic surgical system through a modified face-lift approach. The authors performed robotic sialoadenectomy of the SMG on 5 patients using the daVinci robot system through a modified face-lift approach. Three robotic arms were inserted through a modified face-lift incision; a face-down 30-degree endoscopic arm and two operative arms. The right arm was equipped with a harmonic scalpel and the left arm with a Maryland forceps. In all patients, robotic sialoadenectomy of the SMG was completed successfully. Diagnoses were sialolithiasis in two patients, pleomophic adenoma in two patients, and ranula in one patient. The mean robotic operative time was 90.2 min (range 62–185 min) and that for setting the robotic system was 8.2 min (range 5–15 min). No significant intra-operative or postoperative complications were observed. All patients were satisfied with the outcome and especially the cosmetic results at their last follow-up visit. In the authors opinion robotic sialoadenectomy of the SMG is technically feasible and secures a better cosmetic outcome than endoscopic submandibular resection.     

The effect of soft palate reconstruction with the da Vinci robot on middle ear function in children: an observational study

Cleft palate is associated with a high prevalence of middle ear dysfunction, even after palatal repair. The aim of this study was to evaluate the effects of robot-enhanced soft palate closure on middle ear functioning. This retrospective study compared two patient groups after soft palate closure with a modified Furlow double-opposing Z-palatoplasty technique. Dissection of the palatal musculature was performed using a da Vinci robot in one group and manually in the other. Outcome parameters were otitis media with effusion (OME), tympanostomy tube use, and hearing loss during 2 years of follow-up. At 2 years post-surgery, the percentage of children with OME had reduced significantly to 30% in the manual group and 10% in the robot group. The need for ventilation tubes (VTs) decreased significantly over time, with fewer children in the robot group (41%) than those in the manual group (91%) needing new VTs during postoperative follow-up (P = 0.026). The number of children presenting without OME and VTs increased significantly over time, with a faster increase in the robot group at 1 year post-surgery (P = 0.009). Regarding hearing loss, significantly lower hearing thresholds were recorded in the robot group from 7 to 18 months postoperatively. To conclude, beneficial effects of robot-enhanced surgery were recorded, suggesting a faster recovery when the soft palate was reconstructed using the da Vinci robot.     

Schwannoma of the Cheek: Clinical Case and Literature Review

Introduction

Schwannoma is a relatively uncommon benign tumor that apparently originates from Schwann cells of peripheral nerves. The most common intraoral site is the tongue followed by the palate, floor of mouth, buccal mucosa, lips and the jaws. The preoperative diagnosis is often difficult, and in the majority of cases, the diagnosis can only be made during surgery and by histological study. The immunohistochemistry reveals that the schwannoma cells test positive for S-100 protein.

Case Report

The authors report here a case of an intraoral schwannoma situated in the cheek, treated by complete surgical excision. In the present case the schwannoma presented as a slow growing, circumscribed swelling without any particular features to distinguish it from other benign soft-tissue lesions. The final diagnosis was established based on the clinical, histopathologic and immunohistochemical findings.

Conclusion

The presence of schwannoma calls for the careful search for nerve tumors in other parts of the body, although in most cases none may be found. The differentiation of schwannoma from neurofibroma is essential, because an apparently solitary neurofibroma may be a manifestation of neurofibromatosis.     

Schwannoma arising from intramasseteric region

Schwannoma in the head and neck is usually arising in the parapharyngeal space, but intramasseteric schwannoma is very rare. We report a schwannoma arising from masseter muscle in a middle-aged woman, who presented with a history of a painless right cheek mass for 3 years. Computed tomography scan suggested that the mass was located within the masseter muscle. Fine-needle aspiration was performed and showed spindle neoplastic cells, which were suspected to be of mesenchymal tissue origin. The mass was completely resected under general anesthesia. It was a well-circumscribed and lobulated mass, 4 × 3 × 2 cm in size. Histological examination gave the diagnosis of schwannoma, which was also confirmed by immunohistochemical stainings for S-100 and vimentin. Neurologic sequelae and recurrence were not found at 2 years after surgery.     

Gland-preserving robotic surgery for benign submandibular gland tumours: a comparison between robotic and open techniques

Benign tumours of the submandibular gland are usually treated surgically. Gland-preserving techniques, which can be used to completely remove the tumour, preserve the function of the gland and reduce complications, but conventional open operations result in obvious scars on the neck. We aimed to investigate the feasibility and efficacy of gland-preserving robotic surgery using a hairline approach. We compared robotic with open techniques for gland-preserving operations to remove benign tumours of the submandibular gland. Patients were matched for age and sex (4 in each group). All patients in the robotic surgery group had their tumours removed successfully through hairline approaches. No patient had operative complications or postoperative functional nerve deficit, and an aesthetically pleasing outcome was achieved by concealing the scars within the hairline. Robotic operations took longer than open operations. No recurrence was noted during follow-up. Gland-preserving robotic surgery is a feasible alternative to conventional techniques and has potential advantages for safety and aesthetic outcome.     

累及相邻器官的晚期舌癌的手术治疗:附1例报告

报告1例晚期舌癌患者实施多器官联合切除同期双游离瓣修复术,术中切除全舌、双侧口底、右下颌骨及左下颌骨颏部、部分右上颌骨、右软腭、右扁桃体、会厌、舌骨及全喉,制备右腓骨肌瓣、左腹直肌肌皮瓣移植修复软硬组织复合缺损,临床疗效满意。推荐对晚期口腔癌患者施行救治性外科及重建。     

腮腺内面神经鞘瘤的临床病理分析

目的 探讨腮腺内面神经鞘瘤的临床特点及病理特征。方法 收集2015—2020年江苏大学附属医院口腔颌面外科收治的5例腮腺内面神经鞘瘤病例,分析患者的临床资料、影像资料、病理资料、术前诊断、治疗方式及术后神经损伤情况等。结果 5例患者均为男性,年龄33~70岁。临床表现仅为境界清楚的无痛性腮腺区肿物,均不伴面神经瘫痪等症状。2例术前诊断为混合瘤,3例术前诊断为腺淋巴瘤。治疗方式为肿瘤合并神经切除后神经端端吻合术。术后随访4例患者面神经功能基本正常,仅一例患者存在H-BⅡ级面神经功能障碍症状,随访10~72个月未见复发病例及恶变。镜下肿瘤细胞呈长梭形,呈编织状排列。免疫组化示肿瘤细胞S-100蛋白在5例患者的细胞核和细胞质中呈弥漫性强阳性表达,Vimentin在5例患者胞质中均呈强阳性表达,Sox10在4例患者胞核中呈阳性表达,3例患者局灶表达CK7,细胞增殖能力标记物Ki-67阳性指数均小于3%,AE1、EMA、P63、SMA在全部病例中均呈阴性表达。结论 腮腺内面神经鞘瘤的临床表现及辅助检查均无特异性,术前确诊较为困难,需要依赖病理诊断,S-100、Vimentin可辅助诊断腮腺内面神经鞘瘤。     

Robotic compared with open operations for cancers of the head and neck: a systematic review and meta-analysis

To compare the effectiveness and safety of robotic surgery with that of open operations for patients with cancers of the head and neck we made an electronic search of the CENTRAL, MEDLINE, EMBASE, CNKI, CBM, Opengray and Sciencepaper Online databases, and then made a manual search of specific online databases and the reference lists of relevant papers. Our most recent searches were made on 18 July 2018, and we included randomised controlled trials (RCT), case-control studies, cohort studies, and cross-sectional surveys in which robotic was compared with open surgery for cancer of the head and neck. Data from all the studies included were extracted by two independent workers. The risk ratio was chosen to measure dichotomous effects of treatment for prospective studies including RCT or cohort studies, while the odds ratio was chosen for case-control or cross-sectional studies. The weighted mean difference or standard mean difference was chosen to summarise continuous effects. A random-effects model was used for all data analyses. Thirteen studies were included: one RCT, nine cohort studies, and three cross-sectional studies. Robotic surgery was associated with fewer invaded resection margins, lower recurrence, less need for intraoperative tracheostomy, and less need and shorter duration of postoperative nasal feeding than open operations. Robotic surgery is a safe and feasible approach with remarkable superiority over open surgery for the treatment of cancers of the head and neck.     

Swallowing rehabilitation after oro-pharyngeal resection for squamous cell carcinoma

The resection of even relatively small tumours that involve the base of tongue can lead to problems with swallowing. Free tissue transfer has improved the functional results and reduced the complications of head and neck surgery. The outcome after ablative operations depends on the site and extent of the resection, and in cases where the tongue base is involved, swallowing can be severely impaired. Aspiration in a patient with swallowing difficulties is of particular concern, however, there is a range of techniques that can be introduced during videofluoroscopy to reduce or eliminate aspiration. It is during the rehabilitation phase that procedures and techniques to improve swallowing and prevent aspiration should be incorporated. The efficacy of adaptive manoeuvres needs further evaluation, and in this study we aim to assess the effectiveness of compensatory procedures and therapy techniques (chin tuck and supraglottic swallow) in eliminating aspiration. We report on a study of the swallow function of 13 patients following surgical resection of the oropharynx including the base of tongue. Postoperative assessment by videofluoroscopy was carried out at 2 weeks, 1 month, 3 months, and 6 months according to a standard protocol. Subjects were analysed in two groups depending on the degree of resection of the tongue base resection (less than 1/4,1/4 or more).Patients' swallowing disorders were related to the extent of the resection and the consistency of the bolus. Those with involvement of a quarter of the tongue base or more generally had greater impairment, and radiotherapy tended to exacerbate these problems. Compensatory procedures and therapy techniques were effective in 50% of patients who aspirated, and tended to be more effective between the one month and 6 month follow-up in patients with smaller resections.