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Transoral Robotic Repair of Recurrent Oronasal Fistula FollowingComposite Facial Transplantation

Matthew M. Dedmon1,2,3, Kyle J. Chambers1,2,3, Ahmad R. Sedaghat1,2,3, Daniel S. Roberts1,2,3,Bohdan Pomahac4, Donald J. Annino2,3

1Department of Otolaryngology, Massachusetts Eye & Ear Infirmary, Boston, MA 2Division of Otolaryngology, Brigham & Women’s Hospital, Boston, MA

3Department of Otology & Laryngology, Harvard Medical School, Boston, MA4Division of Plastic Surgery, Brigham & Women’s Hospital, Boston, MA

ABSTRACTABSTRACT

REFERENCESREFERENCES

Persistent oronasal fistula is a complication commonly associated with midface reconstruction, occurring in approximately 4% of patients following cleft palate repair and 10-12% of patients following reconstruction of maxillectomy defects. Oronasal fistulas cause significant patient morbidity by impairing speech, deglutition, and breathing. By diameter, fistulas are classified as small (1-2mm), medium (3-5mm), and large (>5mm). Fistula sites are categorized into 7 anatomic locations by the Pittsburgh Fistula Classification System, of which type IV (hard palate) and type III (junction of hard and soft palate) are most common. Location of the fistula correlates with repair failure rates, with type IV/V fistulas having the highest risk of recurrence. Numerous approaches to fistula repair have been described including primary repair, layered closure with local flaps, insertion of allograft materials, and microvascular free flaps. Regardless of the reconstruction method employed, the key principle to fistula repair is a tensionless closure.

RESULTSRESULTS

Introduction:Oronasal fistula represents a challenging problem resulting in speech difficulties, velopharyngeal insufficiency, and aberrant nasal drainage. While commonly associated with cleft palate defects, oronasal fistula may also arise with any maxillofacial reconstruction due to asymmetry between donor and native tissue. Repair of oronasal fistulas in this setting can be particularly difficult due to post-operative sequelae, such as trismus, restricting transoral exposure of the palate. In such cases, a transoral robotic approach may be advantageous.

Study Design: We report a case of recurrent oronasal fistula in a patient following composite facial transplantation secondary to mismatch between donor maxilla and native palate.

Methods: Initial attempts at transoral closure of this 2 x 0.5cm midline palatal fistula were limited by incomplete exposure due to trismus. Subsequent fistula recurrence was addressed with a transoral robotic approach for improved palatal access. Maryland forceps and monopolar cautery were used to raise a submucosal flap on the soft palate posterior to the fistula. Subperiosteal dissection was then used to raise an opposing bipedicled flap on the hard palate anterior to the defect. A two-layered closure was achieved whereby the soft palate flap spanned the fistula to form the nasal lining while the hard palate flap recreated the oral mucosa.

Results: Transoral robotic repair achieved complete closure that remains intact at one-month follow-up.

Conclusions: This case highlights the utility of robotic surgery in repair of defects with difficult oral exposure. Such approaches may be required with increasing frequency as composite facial transplantation techniques become more widespread.

CASECASEA 59 year-old female sustained severe facial, eye, and limb injuries secondary to chimpanzee mauling. She underwent debridement and primary repair of her facial injuries; however, numerous areas became necrotic in the setting of recurrent infection and required extensive debridement and numerous graft repairs over the next year. This was complicated by the subsequent development of severe trismus. Composite facial transplantation was performed and was well-tolerated. Unfortunately she developed a 3 x 7mm oronasal fistula, likely secondary to mismatch between donor maxilla and native palate. Her symptoms of nasal regurgitation and hypernasal speech were extremely bothersome. Primary repair was attempted twice over 4 months yielding a persistent but smaller 2 x 0.5mm fistula. Unfortunately, the patient’s symptoms continued to impact her quality of life, and the decision was made to repair the residual fistula via layered transposition of local flaps.

APPROACHAPPROACH

Achieving adequate surgical exposure in the oral cavity can be challenging, particularly in the setting of severe trismus. In this case, the patient had very limited mouth opening due to multiple reconstructive surgeries preceding composite facial transplantation. This inhibited fistula closure methods other than simple primary repair, which did not yield complete fistula closure. The decision was made to employ a robotic approach to improve surgical exposure and visualization of the defect. In addition, the use of 5 mm articulating endowrist instruments made possible the raising of local flaps to perform a layered, tensionless closure.

RESULTSRESULTS

RESULTSRESULTS

A

B

ATransoral robotic fistula repair was durable at one-month follow-up with symptomatic improvement

A B

INTRODUCTIONINTRODUCTION

Anatomic classification of fistulas according to the Pittsburgh Fistula Classification System. Figure from Smith et. al. Cleft Palate Craniofac. J. 2007 Nov;44(6):590-4.

(A) A typical robotic setup is shown including primary surgeon and assistant consoles with stereoscopic high definition video. The procedure is facilitated by a third assistant at the bedside to position instruments in the field and provide additional retraction and suction. (B) Endowrist instruments provide provide 540 degrees of motion, tremor-filtration and motion scaling to facilitate precise bimanual tissue manipulation in areas with difficult surgical exposure such as the oral cavity and oropharynx.

(A) The patient was positioned supine with a Dingman mouth gag and protective goggles. A 30-degree high-defninition endoscope, as well as Maryland forceps and monopolar cautery were brought into the field. Sheath instrument guards were used to protect the teeth. (B) A third surgeon at the head of the bed positioned the instruments appropriately and provided suction.

(A) Robotic Maryland forceps and (B) monopolar cautery were used to raise opposing flaps. An incision was made in the soft palate approximately 1cm from the posterior edge and elevated anteriorly towards the oronasal fistula. Next an incision was made 1.5cm from the edge of the hard palate and a bipedicled flap was elevated posteriorly.

Dissection proceeded in an anterior to posterior fashion in the subperiosteal plane. Of the hard palate. The bilateral blood supply from the greater palatine artery was carefully preserved. Upon reaching the edge of the hard palate, the resulting flap was mobile and could be easily slid posteriorly to facilitate a tension free closure. The mucosa of the hard palate was then separated to create free edges for flap attachment. Four 3-0 Vicryl sutures were placed through the soft palate flap and then attached to the superior portion of hard palate anterior to the fistula. These sutures were tied down to extend the soft palate flap across the fistula. This resulted in single layer closure with the soft palate flap forming the new nasal lining.

Vicryl sutures were then placed in the free edge of the bipedicled hard palate flap and then passed through the initial soft palate incision. These were tied down so that the hard palate flap spanned the fistula, thereby forming the new oral lining. This represented the second layer of the closure.

A two-layer complete closure of the oronasal fistula was thereby achieved by transposition of opposing flaps. The remaining exposed areas were left to granulate in. This resulted in a tension free fistula repair, which as desribed above is the crucial component of maximizing the chance of successful closure.

RESULTSRESULTS

RESULTSRESULTS

CONCLUSIONSCONCLUSIONS

• Oronasal fisula is a challenging surgical problem and can result from mismatches between donor and native palatal bone following reconstructive procedures

• Transoral robotic approaches can provide improved exposure for oral cavity and oropharyngeal lesions in the setting of profound trismus

• Endowrist robotic instruments allow for enhanced tissue manipulation in confined surgical spaces and facilitate the development of local flaps for improved coverage of defects.