Arm 2 and 3: Trans-oral Surgeries
tumor, bleeding, fistula, primary tumor, bipolar
TUMOR, BLEEDING, POSITIVE, SECONDARY, PRIMARY TUMOR, PATHOLOGY, COMPLICATIONS
Trans-oral surgeries can be performed by TLM or by TORS. The choice of the technique will be made during the local MTB and depending the local expertise.Surgery must be performed within the 4 weeks after pathological confirmation of SSCC with primary tumor biopsy.A good surgical field exposure is mandatory. The use of an appropriate mouth gag is recommended. The exposure will be evaluated before the main surgery during a rigid panendoscopy. In case of doubt, the mouth gag needs to be tested during this procedure.1/ Trans-oral laser microsurgery (TLM).A microscope with a COThe best adapted laryngoscope to the patient anatomy should be used for an adequate exposition.The hemostasis can be performed by a monopolar of the use of clips.During the procedure, the superior laryngeal arteries should be ligated or clipped.2/ Trans-oral robotic surgery (TORS).TORS will be carried out using the Da Vinci Surgical robot (Intuitive Surgical, CA, USA). Surgeons on the main console and at the bedside should have adequate training and an experience of minimum 20 cases. The spatula cautery will be used to remove the tumor and perform hemostasis at the same time. The hemostasis and bleeding prevention should be made with the bipolar or using clips. During the procedure, the superior laryngeal arteries should be ligated or clipped.3/ Handling of Surgical Margins.The surgeon should try to achieve a minimum of 1 cm gross visual margins with > 3 mm microscopic margins. The resection needs to completely remove the tumor and During the surgery, circumferential margins will be evaluated by frozen section peroperative analysis. These margins will be oriented as followed: superior, inferior, lateral, medial and deep. If needed, further resections will be performed until negative margins are obtain. The resected specimen should be oriented with the help of a schematic view on the cork-board.Definition of the margins [Clear margins (R0): when margins are > 3 mm on the final pathology specimenClose margins: when they are between 1 and 3 mm.Positive margins (R1) when they are < 1 mmIf a positive (R1) or close margin is found on the final pathology analysis, an attempt to clear the margin may be performed within 2 weeks after the original resection in order to obtain an R0-status with the help of a new trans-oral resection in the closed/positive margins area. If clear margins cannot be obtained, postoperative radiotherapy ± chemotherapy will be administered (see below).4/ Neck dissection.In both surgical arms (Arms 2 and 3), all patients will undergo standard elective neck dissections (END) for the lymph node areas at risk on the same day of the main surgery, or differed for a maximum of 2 weeks, at the discretion of the surgeon [About the side:- any lesion more than 5 mm away from the midline, a unilateral same side END is sufficient.- for lesions closer or equal than 5 mm to the midline, a bilateral END will be done.The END should be oriented or separately partitioned in order to identify the level of the lymph involved on the final pathology [
5/ Reconstruction.Healing of the defect is generally by secondary intention. In some rare cases, a primary closure is performed by trans-oral approach. In these T1 and T2 cases, the reconstruction with flaps can generally be avoided [In case of complications likes communication between the neck dissection site and the tumor resection bed or pharyngo-cutaneous fistula, a reconstruction with flaps can be used. The choice of the subtype of flaps (pectoralis; forearm free-flap, anterolateral thigh free-flap, etc.) is left at the discretion of the surgeon or the plastic surgeon and depends on his expertise.6/ Post-operative care.Extubation: can be performed the same day or the day after the surgery, at the surgeons’ and anesthetists’ discretion [The use of nasogastric tube or gastrostomy: is necessary at the end of the procedure. The choice of the type of interventions is left at the discretion of the surgeon and depends of the patient swallowing capabilities before the surgery. The use of nasogastric tube is preferred. The number of days and the type of support should be collected in the study [In case of bleeding after the surgery: the management needs to be optimal and the safest for the patient [