A robotic surgeon can help cancer patients avoid chemotherapy

A new type of robotic surgery for head and neck cancers is increasing survival rates.

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

The patient

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

It was a chilling discovery – as a doctor 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 were causing bleeding terrible, often deadly.

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 a toll on my health – the radiotherapy had an impact on my lung function, I lost a lot of weight and my recovery was slow. It took over a year to get back to work. When I finally came back, I hoped, of course, that I had been healed. But I also knew there was a chance the cancer would come back, as is the case with up to 60% of head and neck cancers.

So in 2018, when I noticed my tongue hurt when swallowing and the surface was a bit uneven, alarm bells rang in my head.

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

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

Conventional surgery for tongue cancer is brutal and involves splitting the jaw to reach the tumor, followed by extensive facial reconstruction. But then I was offered the opportunity to have a pioneering robotic procedure at the Royal Marsden Hospital in London.

It is often impossible for surgeons to properly access neck or throat tumors through the mouth using hand-held surgical tools.

As a result, conventional open surgery involves cutting large areas of skin, muscle, and bone, often resulting in a scar extending from the lower lip down 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 tiny instruments at the end of the three long, slender arms of a robot.

These are operated remotely by a surgeon across the room and provide a level of precision not possible with the human hand alone.

As a former liver transplant surgeon, I was familiar with the innovations in robotic surgery and its many benefits, including reduced recovery time and reduced risk of infection, bleeding and complications since it was not no need to split the jaw or have a facial reconstruction.

I had no hesitation in accepting the offer, especially since it also meant not having to undergo radiotherapy or chemotherapy this time around.

Following a flurry of CT scans to locate the exact location of the tumor, I had surgery in July 2018.

Then I had a whispering voice and couldn’t eat or drink anything for a few days; after a few more days, I was able to go home.

My wife Catherine was wonderful, making pureed or mixed foods for me. I was in pain at first, but moved on to a “normal” diet after about three months. My speech came back quickly too, and soon I started speaking in public again.

Now I am back to a full and busy life, which includes, in my free time, flying, sailing and beekeeping.

My only real adaptation is to never eat more than two dishes – I take longer to eat than most people simply because it takes time to take it all in.

Radiation therapy for my first cancer caused long term scarring and dry mouth. But I’m 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 normality.

The surgeon

Professor Vinidh Paleri is a consultant in head and neck surgery at the Royal Marsden NHS Foundation Trust in London.

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

It has traditionally been treated with radical and potentially disfiguring surgery, and some patients undergoing such invasive operations may risk losing the ability to speak, eat or taste.

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

A minimally invasive technique, introduced in 2013, it gives patients with recurrent mouth and throat cancer a better chance of survival. A new study from Royal Marsden showed they had a two-year survival rate of 72%, compared to an average of 52% with open surgery.

Also, since it avoids cutting the neck and other tissues, as well as splitting the jaw, to reach the cancer, it is much shorter and less likely to affect the patient’s ability to speak and eat.

With the patient under general anesthesia, we expose the cancer using specialized gags to hold the mouth open.

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

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

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

The robot has three arms: one holds a 3D camera inside the patient’s mouth, which gives a good view of the area (the location of the tumor has been pinpointed using scanners); the others hold tiny instruments, one to cut the cancer and one to cauterize (seal) the wound.

I move these arms, depending on what I see on my screen from the camera, bending them and rotating them to perform the operation.

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

Once I cut the tumor from the tongue it fell down the throat – but since the patient was lying flat and not swallowing under anesthesia it did not go down the throat.

My assistant, who was standing next to Michael during the operation, pulled him out with forceps.

Then I used another arm with a small probe on the end that generated an electric 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 which can cause problems if blood leaks into the lungs. Severe blood loss can also impair heart function. But the robot surgery meant there was no need for stitches as the tumor simply left a small dimple in the tongue, which will heal within three months. If it affects speech, it will do so to a much lesser extent than traditional surgery.

As an extra precaution against bleeding, I also make a 1 inch incision on one side of the neck at the start of the operation and (permanently) tie off a few blood vessels that supply the tongue, using small clips . The tongue can easily survive with blood on the opposite side.

TORS is a great option for recurrent early-stage cancers of the tonsils or the back of the tongue – with advanced 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 won’t affect speech or the ability to eat. I am delighted that Michael has returned to his full life so quickly and I am happy that we can offer this alternative to patients.

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