Robot opens new surgical possibilities
July 03--John Ayers kicked cancer, but was left with an uncomfortable souvenir: After six weeks of chemo and radiation therapy, so much scar tissue had built up in his throat he couldn't swallow and, on occasion, struggled to breathe.
Ayers, 70, suffered through two tracheotomies and countless awkward dinner parties. A feeding tube inserted into his stomach provided Ayers his own provisions, leaving him the odd dinner guest with an empty plate.
Then, after more than three years of waiting for his scar tissue to break down on its own, a doctor at Stanford offered a solution. He could use a surgical robot to enter Ayers' throat through his mouth and attempt to remove the scar tissue.
The Portola Valley resident had two other options: endure an intense, 18-hour surgery that would reconstruct his throat using a portion of his intestine and remove his voice box -- allowing him to swallow but rendering him speechless -- or he could do nothing and possibly spend a lifetime staring at the steak on his wife's dinner plate, tantalized.
To Ayers, the robot seemed like the way to go.
In an initial operation, Dr. Edward J. Damrose, a head and neck surgeon at Stanford, used the robot -- known as the da Vinci -- to open up Ayers' throat, exposing the airway and the esophagus.
The da Vinci looks a little like something out of science fiction -- a giant surgical spider hovers over a patient, its arms crawling around inside the cavities of the patient's body (or in this case, his mouth) as a surgeon plays pilot from a cockpit of sorts.
It hit the market in 1999 and was cleared by the Food and Drug Administration for general laparoscopic surgeries in 2000. It is only in recent years, that the robot has been used for head and neck procedures, what has been dubbed transoral robotic surgery, or TORS.
There are more than 2,500 da Vinci units in more than 2,000 hospitals worldwide, according to Intuitive Surgical, the Sunnyvale company that makes the robot. Stanford and UCSF are among the few medical institutions, though, that use the da Vinci for head and neck procedures such as Ayers'. More commonly, it is used as a minimally invasive alternative in procedures elsewhere in the body, such as hysterectomies or gastric bypass.
Less complex procedure
The da Vinci's most frequent use in transoral procedures is in head and neck cancers. By operating through the mouth, surgeons can remove tumors in places that previously might have required much more complex procedures, such as breaking the jaw to get a good enough look.
The robot has four arms -- three that can hold typical surgical tools, and a fourth that holds an endoscopic camera, giving a surgeon a full view of the patient's insides.
"You get an almost panoramic view," said Damrose. "It's as if you were miniaturized and in someone's throat looking around."
The da Vinci was first used on a human for a head and neck procedure in 2005 at the University of Pennsylvania. An update to the robot made the experiment possible, when slimmer tools were developed for the robot that might more easily fit inside the mouth. (Even with the smaller tools, working inside someone's throat can be a tight squeeze, depending on the patient.)
Stanford and UCSF both began performing the operations in 2011, and have done upward of 30 procedures each since then.
For Ayers' surgery, the da Vinci was used to essentially chip away at the tough scar tissue lining his throat after cancer on his tongue. The opening was already small, but a common cold had caused a slight swelling in Ayers' airway, making it nearly impossible for him to breathe. The initial robotic surgery successfully opened up the airway and the hole into his esophagus. Subsequent surgeries widened the esophagus, allowing Ayers to drink and eat some soft foods. In January, he was finally able to ditch the feeding tube, subbing in smoothies, soups, ice cream and the occasional bite of something like mashed potatoes.
Aside from being uncomfortable, the feeding tube had become a serious annoyance: He stopped flying after an airport security agent spent hours examining his tube before letting him onto his flight, and he quit riding BART to work, for fear someone would accidentally yank the tube out of his stomach -- as he did three times, accidentally, himself.
He recalled before the surgeries attending his 9-year-old grandson's birthday, during which he spent the family meal watching TV in a bedroom while his family dined, emerging only for cake and presents. The tempting smell of his wife's homemade tacos was unbearable.
No residual pain
Ayers said he missed only two days of work as a computer systems manager for each procedure. There was no residual pain, and after some of the surgeries he was able to leave the hospital the same day as the procedure.
The da Vinci's safety has been called into question recently after complications in other procedures, but surgeons underscore its positive effects in head and neck surgeries.
"If we're able to operate through the mouth, we can avoid a lot of downsides to different approaches," Damrose said, pointing to surgeries that involve breaking the jaw.
"Patients recover faster. They look better. They can swallow better," he said. "It's helping us a lot to accomplish procedures endoscopically where a few years ago these things would likely not have been possible."
Since Stanford started its robotic surgery program, three more surgeons have been added to the program, and three fellows have been trained in the technique.
With the da Vinci, Damrose said, it might have been possible to avoid doing the chemo and radiation therapy on Ayers that wound up causing his post-cancer condition in the first place.
"We can really apply the same principles of surgery, but do it in a way that's much less invasive," said Dr. Steven Wang, an associate professor at UCSF in the Department of Otolaryngology.
Ayers had one last surgery on Friday, a surgery he hoped would finally open up his throat enough to eat whatever he wanted. He was so excited for the prospect, he cooked up a meal of spaghetti Bolognese for his family, anticipating it would be one of the final times he would watch them eat without joining in.
"After this Friday, I figure I am going to be eating," Ayers said before the procedure.
On Monday, he recounted the good news: The opening in his throat had been opened to double its previous size, meaning that once the swelling goes down in a week or two he will probably be "back to normal."
He already had his first meal picked out: an In-N-Out burger.
Kristen V. Brown is a San Francisco Chronicle staff writer. E-mail: firstname.lastname@example.org Twitter: @kristenvbrown
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