Transoral Robot-Assisted Surgery in Supraglottic and Oropharyngeal Squamous Cell Carcinoma: Laser Versus Monopolar Electrocautery

Background: Monopolar electrocautery (EC) is the surgical cutting and haemostatic tool most commonly used for transoral robotic surgery (TORS). The aim of this study was to retrospectively compare EC efficacy in the treatment of patients affected by T1 or T2 oropharyngeal and supraglottic squamous cell carcinomas with the more recently introduced laser fibres. Methods: We considered all TORS patients admitted to our department from January 2010 to June 2019. The outcomes of patients treated with Thulium: yttrium aluminium garnet (YAG) laser (TY-TORS), CO2 laser (CO2-TORS) and EC (EC-TORS) were analysed in order to assess surgical performances, functional outcomes and postoperative complications. Results: Twenty patients satisfied the enrolling criteria, of which nine underwent laser-TORS, and the remaining 11 underwent EC-TORS. In all candidates, TORS procedures were completed without the need for microscopic/open conversion. Close or positive margins were significantly more frequent in EC-TORS (p = 0.028). A considerable difference was found in overall functional parameters: times of nasogastric tube and tracheostomy removal and time of hospital discharge were significantly shorter in laser-TORS (p = 0.04, p = 0.05, p = 0.04, respectively). Conclusions: Laser-TORS showed better results in comparison with EC-TORS in term of tumour resection margins and patient functional outcomes. Our findings can be justified with the greater tissue thermal damage caused by EC-TORS, despite prospective randomized trials and increased patient numbers being needed to confirm these preliminary conclusions.

Curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery: description of use and review of the relevant literature

Objective:The use of lasers in cholesteatoma surgery is common and well accepted. The most commonly used laser fibres are straight and non-adjustable; these have several limitations. This paper describes the use of an alternative laser fibre.Method:This ‘How I Do It’ paper describes and illustrates the use of an alternative curved adjustable fibre-optic diode laser in microscopic cholesteatoma surgery.Results:The curved, adjustable laser fibre allows accurate and atraumatic disease removal when the use of a straight laser fibre may be less effective or accurate. It reduces potential damage to delicate structures without the need for extra drilling or bone removal.Conclusion:It is suggested that the curved adjustable laser fibre is superior to the traditional straight fibre for cholesteatoma surgery.

Intracorporeal techniques of stone fragmentation

The use of intracorporeal lithotripsy for the management of larger ureteral and intrarenal calculi has dramatically improved. Although the choice of intracorporeal fragmentation is frequently based on the location and composition of the stone to be treated, the experience of the clinician and availability of equipment often dictates this decision. Several different modalities of intracorporeal lithotripsy are currently available. Ultrasonic lithotripsy is mainly used for the fragmentation of large renal calculi during percutaneous nephrolithotripsy procedures. Ultrasound is used rarely via an ureteroscopic approach. Significant advances in laser fibres and power generation systems have propelled laser lithotripsy to the treatment of choice for fragmentation of most ureteral stones. Pneumatic lithotripsy consists of a pneumatically driven piston which will fragment stones by direct contact.

Retained laser fibre: insights and management

Objectives: To describe a case of retained endovenous laser fibre. To review the literature and Food and Drug Administration device failure reports. To suggest protocols for avoiding this complication and a method of removal. Methods: A case of retained fibre removal is described. Fibre removal techniques in vivo and ex vivo in a bovine model on the laboratory bench are presented. Results: Successful in vivo and ex vivo fibre removal was performed using duplex ultrasound scan guided phlebectomy techniques. Unexplained measured fibre-length discrepancies due to misleading manufacturer's packaging was discovered. Conclusions: Simple ultrasound-guided micro-phlebectomy techniques can be used to remove retained laser fibres in the office environment. Laser fibre length measurements before and after treatment are recommended. Some preventive guidelines are described to avoid, or at least diagnose immediately, this complication, such as the ‘Laser Eclipse Sign’.