Previous. Chemo-radiation.
In some departments of certain hospitals where minimal approach surgery is not commonly practised, a traditional surgical approach known as the open trans-mandibular approach is typically offered. This method involves splitting the lip and the mandible along the midline and opening them to gain access to the oropharynx through the floor of the mouth. A lateral oropharyngectomy, along with a neck dissection, is then performed.
This open surgical approach entails several consequences. Due to the unreliable airway immediately after surgery, a tracheostomy is necessary during the postoperative period. Additionally, the patient will be unable to consume food orally for a certain period, thus requiring the insertion of a nasogastric feeding tube. The surgical defect needs to be covered with a flap. The standard flap for this type of defect is a radial forearm free flap. Depending on the expertise of the surgical team the duration of surgery will vary, but it generally remains a lengthy procedure. The functional outcomes related to swallowing will also vary depending on various factors. It is important to note that the flap covers the defect where the mucosal lining and the pharyngeal constrictor muscle are gone, but it is an inert flap. So, swallowing will be impaired, potentially in the long term. Hospitalization time will also vary, but tends to be prolonged. Finally, there are obvious cosmetic sequelae.
Indeed, reconstructive surgery of the oropharynx has historically played a significant role in managing many situations and has significantly enhanced the quality of life of numerous patients.
But in the present day there are very few clinical scenarios that necessitate this type of surgery. Minimal access surgery provides the same oncologic results with a better functional outcome. Minimal access surgery offers equivalent oncologic outcomes while providing superior functional results. The associated morbidities are notably lower with no requirement of tracheostomy or feeding tube in most cases, shorter hospital stays, better of normal swallowing, better aesthetics and reduced costs. From a cost-effectiveness standpoint this situation represents a dominant strategy leaving no justiciable reason to overlook the option of minimal approach surgery.
Therefore, it is crucial to carefully consider and dismiss the possibility of minimal approach surgery before offering open surgery in this particular case.
So, let us consider minimal access surgery…
J Granell, June 2023