How does it differ from other minimally invasive surgical approaches in the head and neck?
Transoral laser microsurgery is also considered a minimally invasive approach with similar indications. It differs in that the field of surgeon view is more restrictive because it is performed through a laryngoscope and at a greater distance from the target site. Since the surgical view is line of sight only through a narrow opening, the technique requires cutting through tumor in pieces to accomplish removal. Orientation of the parts thereby becomes more challenging. As a consequence of this, the learning curve for this technique is very steep.
What are the advantages and disadvantages of the TORS approach?
The greatest advantage of TORS is the ability to closely approach selected tumors with wide exposure using a three-dimensional camera providing an excellent view of the surgical bed. Precise tremor-free surgery can be accomplished with wristed instruments providing seven degrees of motion. Angled telescopes eliminate line-of-sight issues seen with transoral laser surgery. Compared with open surgical approaches, TORS offers the patient numerous potential benefits that include:
- avoidance of a jaw split approach
- avoidance of tracheotomy
- quicker return to normal speech and swallowing
- significantly less pain
- less blood loss
- shorter hospital stay
- minimal scarring
- minimization or elimination of need for chemoradiation therapy
Who are candidates for this approach?
Candidates for TORS generally include early tumors (T1 or T2) of the oropharynx (base of tongue and tonsil) and laryngopharynx (supraglottis and pharyngeal wall).
Who are not candidates for TORS?
Standard contraindications for head and neck surgery, both conventional and minimally invasive, include:
- Presence of medical conditions contraindicating general anaesthesia or transoral surgical approaches.
- Inability to adequately visualize anatomy to perform the diagnostic or therapeutic surgical procedure transorally.
- Unresectability of involved neck nodes.
Specific contraindications for TORS procedures regardless of region or procedure include:
- Jaw bone invasion.
- Anticipated tongue base involvement requiring removal of more than 50%.
- Anticipated pharyngeal wall involvement requiring removal of more than 50%.
- Presence of trismus (inability to open jaw easily).
- Carotid artery involvement.
- Fixation of tumor to prevertebral fascia (layer in front of spine).
How does TORS compare against primary radiation or combined chemoradiation in terms of functional outcomes?
If statistically significant risk to the neck for spread of tumor exists, or if clinically evident neck nodal disease is present, neck dissection is usually performed 1 to 3 weeks after the TORS procedure. Based on the margin status of the primary tumor and nodal status of the neck, radiation alone or combined chemoradiation may be indicated. If radiation is used, it is typically given in a lower dose as adjuvant treatment than it otherwise would have been given for primary treatment. Since does is related to tissue injury and complication rates (acute and chronic), this is an advantage to the patient. Since chemotherapy intensifies the toxicity of radiation therapy, side effects are greater than radiation alone. It has been shown that 19-30% of patients treated in this way still retain a gastrostomy tube at the end of 1 year, due to swallowing dysfunction. With a TORS neck dissection approach, about 70% of patients can be spared chemotherapy and approximately 30% can avoid radiation treatment based on histologic findings.
Who can I contact for more information on TORS or make an appointment to discuss possible treatment?
Information can be discussed by phone or by patient appointment with Dr. Richard Arden. Office location and phone numbers are posted on this web site.