Stanford Medicine Newsletter Updates For the Local Community


Transoral robotics

Extraordinary solution for an extraordinary problem

John Ayers is back to enjoynig normal activities with his wife, tjanks to an innovative robotic surgery to treat his cancer.


John Ayers didn’t hesitate to pursue the chemotherapy and radiation recommended to treat his Stage IV tongue cancer. But after the treatment, he developed further problems that called for an extraordinary solution: the use of slender robotic fingers directed by a master surgeon at Stanford Hospital & Clinics.

Ayers’ tissues were more than typically scarred by the effects of radiation, narrowing his throat to less than 10 percent of normal size. When he developed a cold, his throat would swell closed, and he couldn’t breathe. He couldn’t eat, either, because the scar tissue prevented food from passing.

That left Ayers with just one option: a feeding tube implanted in his stomach. He tolerated that for three years until he was diagnosed with a new health problem: thyroid cancer.

But the obstruction from his throat’s scar tissue made surgery to remove the new cancer problematic. By this time, he had been in conversation with Edward Damrose, MD, associate professor of otolaryngology and chief of Stanford Hospital’s Division of Laryngeal Surgery.
Damrose has a special interest in using surgical robots to remove tumors through the mouth, a practice known as transoral robotic surgery.

“We had cured his first cancer,” said Damrose, “but we had left him with a set of problems that were quite serious. This new cancer forced our hand.”

Damrose and his team had to find a way to allow surgery on the thyroid cancer despite the scar tissue and restore Ayers’ ability to eat and reliably breathe.

Surgery conducted through the mouth has advanced greatly in the last five years with the aid of robotic devices that are significantly smaller and nimbler and are optically superior. Moreover, with a robotic-supported fiber optic laser and harmonic scalpel, surgeons can minimize the amount of heat required to remove tissue so that more healthy tissue is protected and more function is preserved.

“Advances in transoral robotic surgery allow us to do things through the mouth that previously required extensive incisions,” Damrose said. “Now we can approach these lesions entirely through the mouth with no incisions. Blood loss is minimized. Hospitalization is shorter. Complications are lower. It’s truly a win-win for the patient.”

When Damrose first mentioned the robot, Ayers said, “I’m used to new technology, but my faith was not in the robot—it was in the doctor. You could tell me all you want about the robot, but what’s going to make it run is the person. I said to myself, ‘This is the man I want to go to because he knows what he’s talking about.’”

To expedite Ayers’ care, Damrose and the Stanford team devised a plan to insert a tracheotomy tube for the thyroid surgery, which would be conducted traditionally, with large incisions from the outside. Then, by inserting the slender endoscopic tools through the patient’s mouth and down his esophagus, the surgeons could remove the scar tissue there and use stretchers to return it to a normal size. Damrose controlled the robotic arms while seated at a console and looking through a scope-like device with an almost 3-D image quality.

Ayers “healed beautifully,” Damrose said. He said the procedure also helped advance the field.

“Working through these problems gave us new ideas about how we could apply transoral robotic surgery technology to others,” Damrose said. “As we discover what we can do, the process is prompting people to investigate new ways to use the device. The traditional answer for John would have been radical surgery—and that just wasn’t a palatable option, especially when you take into account the added risks of operating in a previously radiated field. And I don’t know how much longer he would have been able to go on the way he was.”

Following an additional treatment, Ayers now has complete freedom to eat.

“The most important message I’d like to get out there is that you don’t give up,” Ayers said. “No matter what anybody says—you don’t give up.”

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