This article reviews current advances in surgical treatment of head and neck cancers such as sentinel node biopsy, stereolithic modelling, transoral robotic surgery and intra-operative imaging of tumour margins. Sentinel node biopsy has been found to be especially useful for patients with melanoma or Merkel cell carcinoma as they require specific immunohistochemical staining. The authors believe that this allows close analysis of the sentinel nodes paving the way for more accurate staging. A large study performed by the University of Michigan found sentinel node biopsy to not only have a 95.8% negative predictive value for melanoma but also provides an indication of prognosis (disease free recurrence and survival). Sentinel node biopsy may have a role in cases of T1/T2 oropharynx and oral cavity SCC where it may help identify at risk nodes which may have been missed in a traditional selective neck dissection. Another advancement being discussed is preoperative 3D virtual planning with sterolithic modelling – this allows construction of preformed titanium plates, cranioplasty plates and osteotomy design which could aid in bony free tissue transfer. Operative time and accuracy unsurprisingly improved with this. Another surgical innovation which has been gaining in popularity is robotic surgery. The first transoral robotic surgery for oropharyngeal cancer was performed in 2006 by O’Malley and colleagues and since then, robotic surgery has been described for thyroidectomy, neck dissection, skull base surgery and removal of parapharyngeal space lesions.

Robotic surgery allows for better visualisation, minimal access and tremor damping. However, its limitations include the cost, lack of haptic feedback and also its size. Eight ‘Ts’ have been described as limiting factors for transoral robotic surgery – teeth, trismus, tori, transverse dimensions of the mandible, previous treatment, tongue, tilt and tumour factors.

There have also been discussions about specific training and credentialing of robotic surgeons in the future. Finally, dynamic optical contrast imaging may be one for the future to help delineate tumour margins intra-operatively. 

New frontiers in surgical innovation.
Jackson RS, Schmalbach CE.
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Wai Sum Cho

Queens Medical Centre, Nottingham, UK.

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