Indications and Clinical Outcomes of Transoral Robotic Surgery and Free Flap Reconstruction

SIMPLE SUMMARY: Transoral robotic surgery (TORS) with spontaneous healing is associated with improved quality of life as compared to traditional open surgery in small pharyngeal tumors. Improved surgeon experience allows very large or very complex resections, such as in a previously irradiated field where spontaneous healing is functionally insufficient or is at high risk of postoperative complications. We demonstrated very satisfactory feasibility and postoperative outcomes with a free flap microvascular reconstruction in this category of patients. TORS and free flap reconstruction has a place as a standard of care in a number of complex situations. ABSTRACT: We reviewed the indications, peroperative feasibility, and postoperative clinical outcomes of our first 50 consecutive patients who underwent free flap reconstruction after TORS for complex pharyngeal defects at our institution. We analyzed indications according to previous radiotherapy, the size of the resection, and the transoral exposure of critical structures. We reviewed surgical data, postoperative complications, and functional outcomes comprising tracheostomy and alimentation management. Indications were upfront surgery (34%), a second primary surgery after radiotherapy (28%), or salvage surgery after chemoradiotherapy failure (38%). Localizations were the tongue base (44%), tonsillar fossa (28%), pharyngeal wall (22%), and soft palate (6%). T-classifications were T1 (6%), T2 (52%), T3 (20%), and T4 (22%). The mean length of the surgery was 574 min. Two patients were intraoperatively converted to a conventional approach at the beginning of the learning curve. In conclusion, TORS and free flap reconstruction in complex situations were associated with low rates of postoperative complications and satisfactory functional outcomes. They were, however, associated with a renewed learning curve.