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Robotic surgeon can help cancer patients avoid chemotherapy

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A new type of robotic surgery for head and neck cancer increases survival rates.

Professor Michael Thick, 71, a former transplant surgeon (and chief clinical officer of the NHS National Program for IT) tells Angela Epstein how it saved his life.

The patient

After I found a large lump (about 3 cm) on the left side of my neck in 2009, I was diagnosed with oropharyngeal cancer.

It was a terrifying discovery—as a physician who had worked in a head and neck cancer ward early in my training, I had seen patients undergo radical surgery to remove tumors that caused terrible, often fatal, bleeding.

Things had moved on, but I was still dealing with the trauma of surgery, followed by daily radiotherapy for six weeks and three rounds of chemotherapy.

It took its toll on my health – the radiotherapy affected my lung function, I lost a lot of weight and my recovery was slow. It took more than a year to get back to work. When I finally came back, I naturally hoped I was cured. But I also knew there was a chance the cancer would return, as happens with up to 60 percent of head and neck cancers.

So when I noticed in 2018 that my tongue felt sore when swallowing and that the surface felt a little uneven, warning bells started ringing in my head.

Professor Michael Thick, 71, a former transplant surgeon (and chief clinical officer of the NHS National Program for IT) tells Angela Epstein how it saved his life

Tests revealed a 2 cm tumor which, considering the base of the tongue is just under 5 cm, was significant. I was terrified.

Conventional tongue cancer surgery is brutal and involves splitting the jaw to reach the tumor, followed by major facial reconstruction. But then I had the opportunity to undergo a groundbreaking robotic procedure at the Royal Marsden Hospital in London.

Tumors in the neck or throat are often impossible for surgeons to access by mouth using surgical hand tools.

As a result, conventional open surgery involves cutting large areas of skin, muscles, and bones — often resulting in a scar that runs from the lower lip all the way to the throat.

But robot-assisted surgery, using the Da Vinci robot, is performed through the open mouth — without the need for incisions or stitches — using small instruments at the end of a robot’s three long, thin arms.

Operated remotely by a surgeon across the room, these provide an accuracy not possible with the human hand alone.

As a former liver transplant surgeon, I was aware of innovations in robotic surgery and its many benefits, not least the shorter recovery time and reduced risk of infection, bleeding and complications because there was no need to split the jaw or undergo facial reconstruction.

I didn’t hesitate to take up the offer, mainly because it also meant that I didn’t have to undergo radiotherapy or chemotherapy this time.

After a series of CT scans to determine the exact location of the tumor, I had surgery in July 2018.

After that I had a whisper, and could not eat or drink anything for a few days; after a few days I could go home.

My wife Catherine was great she made me puree or mixed food. At first I was in pain, but after about three months I switched to ‘normal’ food. My speech also returned quickly and soon I was doing it again in public.

Now I have a full and busy life again, with flying, sailing and keeping bees in my spare time.

My only real adjustment is to never eat more than two courses – it takes me longer than most people to eat, just because it takes time to eat it all.

The radiation treatment for my first cancer caused long-lasting scars and a dry mouth. But I am cancer free and I feel fantastic.

Having had both types of surgery, I am grateful for this new technology and the skill of the team. It is thanks to them that I am here today, enjoying the wonderful sense of normalcy.

The surgeon

Professor Vinidh Paleri is a consultant head and neck surgeon with The Royal Marsden NHS Foundation Trust in London.

Head and neck cancer is an umbrella term for tumors of the nose, mouth, throat, larynx, thyroid and salivary glands.

It has traditionally been treated with radical and potentially disfiguring surgery, and some patients undergoing such invasive surgeries are at risk of losing the ability to talk, eat, or taste.

That is why transoral robotic surgery (TORS) is such an innovation for mouth and throat cancer.

A minimally invasive technique, introduced in 2013, gives patients with recurrent mouth and throat cancer a greater chance of survival. A new study from the Royal Marsden showed they had a 72 percent survival rate at two years, compared to an average of 52 percent with open surgery.

In addition, it is much shorter and less likely to affect the patient’s ability to speak and eat because it prevents cutting through the neck and other tissues, as well as splitting the jaw to get to the cancer.

While the patient is under general anesthesia, we expose the cancer using specialized gags to keep the mouth open.

Head and neck cancer is an umbrella term for tumors of the nose, mouth, throat, larynx, thyroid and salivary glands.  It has traditionally been treated with radical and potentially disfiguring surgery, and some patients undergoing such invasive surgeries are at risk of losing the ability to talk, eat, or taste.  A stock photo is used above

Head and neck cancer is an umbrella term for tumors of the nose, mouth, throat, larynx, thyroid and salivary glands. It has traditionally been treated with radical and potentially disfiguring surgery, and some patients undergoing such invasive surgeries are at risk of losing the ability to talk, eat, or taste. A stock photo is used above

I sit at a console in the operating room five feet from the patient, using my hands and feet to guide the device through the mouth to the cancer.

The robot has three arms: one holds a 3D camera in the patient’s mouth, which gives a good view of the area (the location of the tumor is determined by means of scans); the others hold small instruments, one for cutting out the cancer and one for cauterizing (sealing) the wound.

I move these arms, based on what I see on my camera screen, bend and twist them to perform the surgery.

In Michael’s case, I then used the small electric knife on the end of one of the arms to cut out the tumor, as well as a 5mm margin of tissue in case cancer cells started to spread to nearby tissue.

After I cut the tumor off the tongue, it fell down the throat – but because the patient lay flat and didn’t swallow while under anesthesia, it didn’t go down the throat.

My assistant, who had been standing next to Michael during the surgery, pulled it out with pliers.

Then I used another arm with a small probe on the end that generated an electrical current to cauterize the blood vessels that had been dissected.

With conventional surgery in this part of the body, there can be a lot of bleeding that can cause problems if blood leaks into the lungs. Significant blood loss can also impair heart function. But the robotic surgery didn’t require stitches, as the tumor simply left a small dimple in the tongue, which will heal within three months. If it affects talking, it will do so to a much lesser degree than traditional surgery.

As an extra precaution against bleeding, I also make a 1-inch cut in one side of the neck at the start of surgery and (permanently) tie off a pair of blood vessels supplying the tongue with small clips. The tongue can easily survive with blood from the other side.

TORS is an excellent option for early stage recurrent cancers of the tonsils or back of the tongue – with later stage disease, the tumor will be larger and there is a greater risk of bleeding and complications.

But for many, it can improve quality of life because it doesn’t affect speech or the ability to eat. I am delighted that Michael has returned to his busy life so quickly and I am delighted that we can offer patients this alternative.

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