TORS

Benefits of TORS

• • alternative to mandibulotomy/tracheostomy

  • quicker recovery and reduced hospital stay v open surgery

Risks of TORS

• • Post-op bleeding, highest chance on day 10

    • media injury --> aneurysm --> rupture

  • Dysphagia

  • Fistula

  • Nasopharyngeal reflux/Velopharyngeal insufficiency

Evaluation

• • It's essential to confirm by both endoscopy and imaging that a patient's anatomy (and the tumor itself) are amenable to the robotic approach. This is most critical for approaches to the supraglottic larynx

  • Rule of T's

    • • Tongue (relative macroglossa)

      • Tumor

      • Trismus

      • Transverse dimension (mandible)

      • Tori

      • Tilt (head extension)

  • Preoperative CT scan - identify aberrant vascular anatomy, especially medialized carotid

Anesthesia preop discussion: 

Intubation:  Tonsillectomy -use armored tube oral or nasal Rae; BOT -use nasal Rae.  If using nasal Rae, the larger diameter tubes are longer which avoids accidental extubation with manipulating head, neck.

Full relaxation(paralysis)

Instruments for TORS

Tonsillectomy: need TORS tray, Floseal

BOT: need TORS tray, clear soft plastic tooth guard vs Thermasplint, FK retractor, Floseal

Procedure:

Intubation: Tonsillectomy armored tube oral or nasal; BOT nasal

Turn bed 180

EUA, possible DL, placement of oral retractor to obtain maximum exposure.  If FK is used, need a tooth guard (clear preformed soft plastic vs Thermasplint. When using thermasplint make sure hot water is available)

Attach retractor holder arm to side rail and then to retractor.  May augment stability with Lewy or ring suspension arm or stack of towels

Dock robot

Stow arm 1 (use arms 2,3,4)

Attach trocars into arms 2,3,4

Insert camera and arms (Maryland forceps on contralateral side of tumor location, spatula monopolar cautery on ipsilateral side)

Place camera and arm into oral cavity.  For BOT need 30 degree camera. Tip of trocar with the instrument arms should be at the plane of the retractor.  Camera trocar can be out a bit further to avoid collisions.

Radical Tonsillectomy:

Dissect and divide styloglossus (usually a small arterial branch is just deep to the styloglossus).

Medial pterygoid is always seen in the superior lateral aspect of the dissection.and is a landmark for the superior lateral aspect of the dissection.  Mandible is not commonly exposed. 

• POST OP ORDERS

  • For large BOT resection plan to keep patients AT LEAST 48 hours. 

  • Yankaeur oral suction to opposite side of surgery only

  • DIET

    • • NPO except for meds day of surgery --> Clear Liquid Diet POD 1

      • On POD 1, start with clear thickened liquids and gelatin.  

        • Teach patient to tuck chin down toward the side of the resection when swallowing.  

        • Advance to regular soft diet as able. Swallow twice. Small amounts to start.  Stop if significant, strong coughing.

  • Pain meds during admission

    • • Decadron 10 mg Q8H until discharge

      • IV tylenol 24H then change to oral 1000 mg Q6H (crushed)

      • Oxycodone liquid 5-10 mg Q6H scheduled 

      • IV dilaudid 0.2 mg breakthrough pain

  • Pain meds at discharge

    • • Tylenol pills (crush) 1000mg Q6H

      • Oxycodone 5-10mg Q6H scheduled

      • Dilaudid 2mg Q4H breakthrough pain

      • Prednisone dose pack:

        • 30BID 2d

        • 20BID 2d

        • 10 BID 1d

• • • No post-op Lovenox or heparin, only SCD for dvt ppx. encourage ambulation POD 0

Postop pain instructions (please copy and paste the instructions exactly):

You will be prescribed 3 different pain medications: Tylenol, Oxycodone, and Dilaudid. 

It is important to follow a schedule to keep your pain controlled while you are healing. An example schedule, maximizing your pain control with all 3 medications, would be as follows:

7am: Take two Tylenol 500mg pills (1000mg)

10am: Take Oxycodone (5mg if pain level is 3-6 out of 10, 10mg if pain level is 6-10 out of 10)

1pm: Take two Tylenol 500mg pills (1000mg)

4pm: Take Oxycodone (5mg if pain level is 3-6 out of 10, 10mg if pain level is 6-10 out of 10)

7pm: Take two Tylenol 500mg pills (1000mg)

10pm: Take Oxycodone (5mg if pain level is 3-6 out of 10, 10mg if pain level is 6-10 out of 10)

If your pain level reaches 8-10, take 2mg Dilaudid. You are able to take this medication in addition to the Tylenol and Oxycodone up to every 4 hours if your pain continues to be severe. 

You may need to set an alarm to take pain medication overnight. You may take one additional dose of tylenol and additional oxycodone only as prescribed (eg., every 6 hours).

Do not exceed more than 4000mg Tylenol per 24 hours.