Lateral palatal flap approach to the nasopharynx and parapharyngeal space for transoral robotic surgery: a cadaveric study

Abstract

The da Vinci surgical robot has been used for minimally invasive surgery of the head and neck region including resection of tumors in the nasopharynx. Access to and vision of the nasopharynx with the robot are difficult. A pure transoral approach and midline palatal split approach have been described. The disadvantage of these approaches is the limited lateral access to the parapharyngeal space. The objective of this study was to investigate the feasibility of accessing the nasopharynx and parapharyngeal space with a lateral palatal flap. Two complete nasopharyngectomies with resection of the parapharyngeal space and exposure of the internal carotid artery and branches of the mandibular nerves were performed on two fresh cadavers with the da Vinci surgical robot. The set up of the robot, the surgical procedure of elevating the lateral palatal flap, and robotic resection of the nasopharynx and parapharyngeal space are described.

Keywords: Nasopharyngectomy; Recurrent nasopharyngeal cancer; Robotic surgery.

Fig. 1

Schematic diagram of the incision for the lateral palatal flap

Fig. 2

View of the nasopharynx after retraction of the palatal flap to the contralateral side

Fig. 3

Close up view of the nasopharynx. F denotes the fossa of Rosenmuller. E denotes the posterior cushion of the Eustachian tube

Fig. 4

Photograph of the resected specimen. E denotes the right Eustachian tube opening. MT denotes the upper part of the right medial pterygoid muscle. LN is the resected parapharyngeal lymph node

Fig. 5

Exposure of the right internal carotid artery (ICA) and branches of right mandibular nerve (V3) after resection

Fig. 6

Suturing of the fasciocutaneous flap to the nasal cavity and nasopharynx by use of robotic instruments