IMAGE-GUIDED ENDOSCOPIC SINUS SURGERY Over the last two decades advances in computer processing and optics technology has led to a significant improvement in visualisation during functional endoscopic sinus surgery (FESS). High definition camera heads and monitors, LED light sources, infrared technology, multi-angled scopes and voice-activation functions are now readily available. Similarly, the endoscopic instrumentation has improved dramatically to facilitate safer dissection particularly within areas close to the orbit and skull base. Paralleling these advances has been the advent of image guided surgery (IGS). Its application to endoscopic sinus surgery has been revolutionary. For cases including advanced sinonasal polyposis, revision ESS, and sinus surgery for both benign and malignant neoplasms of the sinonasal cavities and skull base, IGS has helped to improve patient safety and outcomes and in some cases opened up a world of endoscopic options in patients who may have had traditional open transfacial surgical procedures. Earlier methods of IGS relied on line-of-sight infrared technology, however more recent systems now use electromagnetic technology. This is much more convenient in the head and neck region due to avoidance of instrument registration problems that can occur with the crowding of large amounts of equipment into a small surgical field. With the electromagnetic systems, several of the “work horse” sinus instruments such as the microdebrider and the endoscopic drills now also have image guided functions, which provide for a safer, and faster, surgical dissection. MICROVASCULAR FREE FLAP IMPLANTABLE DOPPLER MONITORING Reconstruction of defects within the head and neck region often require free tissue transfers. In principle, defects are reconstructed with the simplest possible option that restores form and function, but in head and neck cases involving high volume tissue loss or both bone and soft tissue requirements, often the only viable option is a free flap. Traditionally the monitoring of free tissue transfers has been via transcutaneous handheld doppler. This allows monitoring of arterial supply, with venous monitoring generally performed by inspecting the colour of the flap which is most often a paddle of cutaneous tissue. In cases where the flap is “buried” (ie, pharyngeal reconstruction) the surgical method of monitoring has been to have a portion of the flap brought to the skin surface for monitoring. These methods, although reasonably reliable, have had issues. They require the flap to be constantly palpated which can create issues with healing. They also require a reusable handheld doppler which has raised issues with regards to infection control. Additionally, monitoring for venous congestion relies on experienced staff being present to be able to appreciate the subtle early signs of venous congestion which is by far a greater risk than loss of arterial supply. Implantable doppler probes largely solve the issues mentioned above with the non-implantable monitoring options. A simple silicone cuff, which has a doppler probe attached, is placed around the vessel at the time of surgery. This can be placed on both the donor artery and vein. The doppler leads are then brought through the skin and secured to the patient’s neck. During the postoperative course these leads can be attached to the processing unit which gives both an auditory and visual reading of blood flow in the monitored vessel. The use of this simple but ingenious technology has been steadily increasing. Implantable dopplers are reliable, relatively inexpensive, and potentially critical to providing the opportunity to salvage a free flap in the rare instance of vascular failure. TRANSORAL ROBOTIC SURGERY Transoral robotic surgery (TORS) was developed in the mid-2000s. The initial feasibility studies were performed in Philadelphia (USA) and since this time its application to the treatment of both benign and malignant conditions of the head and neck has been ever increasing. There are various aspects of this unique technology that facilitate its use in transoral surgery. The dual endoscope creates threedimensional imagery at the surgical console and allows for unrivalled visualisation within the narrow laryngopharyngeal conduit. Angled scopes and magnification options can improve this visual access even further. Combined with the freedom of movement of the instrument arms, this creates safe surgical access to areas beyond what was previously possible with lineof sight surgical options such as transoral laser microsurgery. With a bedside surgeon able to pass instruments around the robot, two-surgeon access is effectively created. The bedside surgeon helps with tissue manipulation and adjustment of robot positioning. The robotic endowrists articulate in 270 degrees throughout seven different planes and can have their movements both scaled as well as tremor filtrated. This precision of movement is particularly important in head and neck surgery given the close approximation of many critical neurovascular structures in close approximation. In Queensland the TORS program was founded in 2013. Tonsil and base of tongue cancers have primarily been the treatment focus with surgical management in these cases aiming to save the patient requiring high-dose radiotherapy or chemoradiotherapy. Additionally, benign conditions of the head and neck can potentially be treated with TORS including tongue base and supraglottic surgery for the management of obstructive sleep apnoea. 72 Pindara Magazine 2017
Pindara Private Hospital Magazine - Issue Ten
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