Concurrent neck dissection and transoral robotic surgery

1) Determine the incidence of pharyngocutaneous fistula associated with transoral robotic oropharyngectomy with concurrent neck dissection. 2) Discuss prevention and treatment of pharyngocutaneous fistulization as a consequence of transoral oropharyngeal surgery with concurrent neck dissection.

Retrospective, single-institution chart review of 148 consecutive patients who underwent transoral robotic surgery with synchronous neck dissection for oropharyngeal neoplasia April 2007 to February 2010.

Forty-two of 148 (29%) patients were identified as having an orocervical communication intraoperatively. All were managed with some combination of primary closure, local tissue advancement, fibrin glue application, and cervical drain placement. Of these, six (4%) developed a subcutaneous pharyngeal fluid accumulation requiring postoperative management via controlled incision and drainage with daily packing placement. All the patients had aesthetic and functional results comparable to those patients who did not have/develop an orocervical communication. No patients experienced a delay from their operative treatment that prevented them from initiating recommended adjuvant therapy on schedule.

Transoral robotic surgery is emerging as a primary treatment modality for oropharyngeal malignancies. Neck dissection is a required portion of operative therapy in many of these patients, and many surgeons delay neck dissection to prevent pharyngocutaneous fistula. Pharyngeal communication with the neck is a common occurrence during transoral surgery when it is combined concurrently with neck dissection, but persistent fistula formation is an uncommon, preventable, but potentially problematic, complication resulting from this operative technique. Prompt recognition and intervention are of paramount importance in preventing acute, long-term functional impairment.